腹部读片肾脏淋巴瘤课件.ppt

20140917腹部读片 男性 46岁 已婚 汉患者2周前在当地体检发现左肾占位患者自发病以来无尿频 尿急 尿痛 腰痛 发热等症状无体重变化 大小便正常 睡眠良好 病史介绍 病理描述和结果镜检 瘤内为淋巴样细胞 体积较小 核类圆 排列密集 呈浸润性生长 左侧 肾脏恶性淋巴瘤 弥漫大B细胞型 原发淋巴瘤 肾脏淋巴瘤 肾脏为结外淋巴瘤好发的部位之一 正常肾脏没有淋巴组织 有学者认为不存在肾脏原发淋巴瘤 有人认为来源于肾包囊的淋巴组织 慢性炎症刺激引起肾实质产生淋巴组织 继而演变为淋巴瘤 继发淋巴瘤 占淋巴瘤尸检病理的30 60 占结外淋巴瘤3 8 Yasunaga 1 等提出肾脏原发性淋巴瘤诊断标准肾脏肿物经病理证实为淋巴瘤就诊时无淋巴结以及内脏器官等淋巴瘤肾外侵犯无白血病性血象以及骨髓抑制表现 肾脏淋巴瘤 肾脏淋巴瘤分型 肾脏淋巴瘤 多结节型30 50 单结节型25 30 腹膜后浸润型 肾周型少见 弥漫型少见 肿瘤细胞浸润后再增殖可形成单侧多个病灶或双侧病灶可位于肾皮质 髓质无包膜边界清 病灶呈圆形或类圆形 或融合状无论结节大小 占位效应不显著 CT平扫 等 低 稍高密度 有时无法显示多发病灶 增强 皮髓交界期轻度强化 确定病变性质实质期最佳时期 确定病变数目 形态 边界 均匀度 MRT1WI 呈低信号 等信号或稍高信号 T2WI 呈等或低信号 肿瘤信号相对均匀 坏死少见 无包膜 DWI 显著高信号 与水分子运动受限有关 增强 轻度强化 多结节型30 50 多结节型肾淋巴瘤 多结节型肾淋巴瘤 Figure1 LargeB celllymphomaina41 year oldHIV positiveman a UnenhancedCTscanofthemidabdomenshowsasoft tissuemass arrowhead intheregionofthegreatvessels a ndingthatissuspiciousforretroperitonealadenopathy Thekidneysdonotdemonstrateanyabnormalityincontour b Contrast enhancedCTscanofthemidabdomenshowsbilateralsoft tissuerenalmasses arrows Notethatthesemassesdonotdeformthecontourofthekidneys Theparaaorticretroperitonealadenopathy arrowhead ismuchmoreclearlydepictedthanina Figure2 High gradeB celllymphomaina38 year oldhumanimmunode ciencyvirus HIV positivewomanwhopresentedwithabdominalpainanddistention a Contrastmaterial enhancedCTscanofthemidabdomenshowsaverylargesoft tissuemass arrows in ltratingthemesenteryandomentumanddisplacingthesmallbowelandcolon b Contrast enhancedCTscanshowshypoenhancingsoft tissuemasses arrows inbothkidneys Notealsotheretroperitonealadenopathy arrowhead c Photomicrographofaspecimenobtainedat ne needleaspirationbiopsyshowshypercellularitywithauniformpopulationofmalignantlymphocytes Numerousaptoticcellsarealsoseen 200HE 多结节型肾淋巴瘤 Figure3 Magneticresonanceimagingofthekidneys A T1 weightedimagingrevealstwoslightlyhypointenseorisointensesignalmassesintherightkidneyandonehypointensesignalmassintheleftkidney B T2 weightedimagingrevealshypointensesignalinthebilateralrenalmassesshownin A C Contrast enhancedT1 weightedimagingrevealspoorenhancementofthebilateralrenalmassesshownin A 多结节型肾淋巴瘤 肿瘤呈灶性增殖 一般形成单侧单发病灶 平扫 等 低 稍高密度 境界欠清 增强 强化方式多样 可为富血管 中等血供 少血供 位于肾包膜下孤立结节可沿包膜浸润 形成包膜尾征 单结节型25 30 单结节型肾淋巴瘤 Figure4 LargeB celllymphomaina72 year oldmanwithahistoryofprostatecancer Contrast en hancedCTscanofthekidneysshowsawell de nedexpansilemass arrow intheleftkidney Noothersolidrenalmassesareseen buttherightpsoasmuscle arrowhead isenlarged ThediagnosiswasestablishedwithUS guidedpercutaneousbiopsyoftherenalmass 单结节型肾淋巴瘤 腹膜后巨大软组织肿块侵犯附近肾脏 包绕肾门和肾血管 平扫 形态不规则 实变 坏死 囊变 出血少见 肾脏病灶与腹膜后肿块可分开也可融合 增强 轻中度强化 动态增强呈进行性延迟强化 肿瘤内依稀可分辨肾门 肾门血管走形 形态正常 腹膜后浸润型 腹膜后浸润型肾淋巴瘤 Figure5 Low gradeB celllymphomaina60 year oldman ThepatientunderwentabdominalCTfornecrotizingpancreatitis a Venousphasecontrast enhancedCTscanshowsalargesoft tissuemass arrow in ltratingtheretroperitoneum encasingtheleftrenalvessels andextendingintotheperinephricspace Notethe uidcollection arrowhead inthepancreaticbed a ndingthatisconsistentwiththepatient shistoryofpancreatitis b Excretoryphasecontrast enhancedCTscanshowsapararenalmass arrow withsoft tissueattenuation Notealsotheabsenceofhydronephrosis Althoughpancreatitiscommonlyaffectstheperirenalandpararenalspaces thesoft tissueattenuationofthemassinthiscaseledtothecorrectdiagnosisoflymphoma Thediagnosiswascon rmedwithUS guidedbiopsy 腹膜后浸润型肾淋巴瘤 Figure6 LargeB celllymphomaina52 year oldmanwithahistoryofchroniclymphocyticleukemia Contrast enhancedCTscanshowsbulkyretroperitonealadenopathy blackarrows Asoft tissuemass whitearrow isseenintherightrenalsinusfatandtheperinephricspace Notethedelayedenhancementoftherightkidney 腹膜后浸润型肾淋巴瘤 肿瘤沿着肾周筋膜生长 可侵犯或不侵犯肾脏皮质 CT平扫 淋巴瘤主要位于肾脏周围 形成肿块或不规则软组织肿块 肾脏被肿瘤 封入 增强 可侵犯或不侵犯肾脏皮质 增强有助于鉴别两者关系 肾周型少见 肾周型肾淋巴瘤 Figure7 Perinephricdiseaseina66 year oldmanwithanincidental ndingofaleftrenalmass a UnenhancedCTscanshowsmarkedenlargementoftheleftkidney arrows Leftparaaorticlymphnodes arrowhead areseenencasingtheleftrenalvein b Corticomedullaryphasecontrast enhancedCTscanshowsalargehypovascularmass arrows locatedprimarilyintheperinephricspace Themassappearstoinvadetheleftrenalparenchyma c Photomicrographofaspecimenobtainedatcorebiopsyshowsnumerouslymphocyteswithfocalnuclearcrushartifactin ltratingdense broustissue arrow 100 HE Notethatthereisnosigni cantenhancementdelayintheleftrenalparenchymarelativetotherightkidney Arrowheadindicatesparaaorticlymphnodesencasingtheleftrenalvein 肾周型肾淋巴瘤 Figure8 B celllymphomaina62 year oldmanwithahistoryoffollicularlymphoma Routinefollow upCTwasperformed a Portalvenousphasecontrast enhancedCTscanshowsamildlyenhancingmass arrow intherightanteriorpararenalspace Themassrepresentedanew nding b Portalvenousphasecontrast enhancedCTscanshowsstrandinginthemesentericfat arrows a ndingthatsuggestsa mistymesentery This ndingwasalsonew US guidedbiopsyoftheperirenalmassdemonstratedaggressiveB celllymphoma 肾周型肾淋巴瘤 CT平扫 肾脏体积弥漫性增大 但形态正常 密度减低 增强 轻中度不均匀强化 弥漫型 肿瘤细胞沿着沿着肾脏间质组织支架呈浸润性生长 肾脏体积增大但形态正常 弥漫型肾淋巴瘤 MRT1WI 呈低信号 等信号或稍高信号 T2WI 呈等或低信号 增强 增强早期肾皮质相对正常 肾皮髓交界相延迟 后期皮髓交界相消失 肾脏轮廓增大 Figure9 Primaryrenallymphomaina41 year oldHIV positivemanwhopresentedwithrenalfailure Nephrographicphasecontrast enhancedCTscanofthekidneysshowsbilateralrenalenlargement Heterogeneouslydecreasedenhancementoftherenalparenchymaisalsoseen ThediagnosisofBurkitt likelymphomawasestablishedwithrenalbiopsy 弥漫型肾淋巴瘤 Figure10 Infiltrativerenallymphomaina44 year oldwoman Cont rast enhancedCTscanshowsthekidneysasdiffuselyenlargedandreplacedbytumor Thelobulatedappearanceofthetumorreflectsthetransitiontoamorefocalexpansilemassasitcompressesanddestroysrenalparenchyma 弥漫型肾淋巴瘤 影像学诊断难点与肾脏其它疾病表现有重叠性 出现 四象 和 四不像 的特征介于良性肿瘤 恶性肿瘤 肿瘤样病变 炎症之间实际工作中有 四象 和 四不像 要考虑到本病的可能 总结 鉴别诊断肾脏良性肿瘤肾脏恶性肿瘤肿瘤样病变炎症之间 可提示诊断肿瘤双侧发生肿瘤与肾脏交界面模糊 瘤肾互穿插肿瘤沿薄膜爬行生长肿瘤样密度 炎症样模糊边缘肿瘤巨大但坏死少见或者坏死区很小肿瘤密实 但占位效应相对不明显 瘤内可见相对正常血管 总结 1 YasunagaY HoshidaY HashimotoM MikiT OkuyamaA AozasaK Malignantlymphomaofthekidney Journalofsurgicaloncology 1997 64 3 207 11 2 ShethS AliS FishmanE Imagingofrenallymphoma patternsofdiseasewithpathologiccorrelation Radiographics areviewpublicationoftheRadiologicalSocietyofNorthAmerica Inc 2006 26 4 1151 68 3 UrbanBA FishmanEK Renallymphoma CTpatternswithemphasisonhelicalCT Radiographics areviewpublicationoftheRadiologicalSocietyofNorthAmerica Inc 2000 20 1 197 212 参考文献 THANKYOU