业务学习 肾肿瘤

1、Kidneys肾脏Diagnostic approach to a renal mass肾脏占位性病变的诊断方法Renal mass protocol multiphase CT肾脏占位性病变的多时相的CT扫描标准 A renal mass protocol CT consists of at least three phases of data acquisition, with each phase providing important information to aid in the diagnosis of a renal mass.肾脏占位性病变的CT扫描标准至少包括三个时相的数

2、据收集，每一个时相对于帮助诊断都提供了重要的信息。 Unenhanced phase: Necessary as a baseline to quantify enhancement.平扫：对于增强扫描是必须的对比检查。 Nephrographic phase (100 second delay): The nephrographic phase is the critical phase for evaluating for enhancement, comparing to the unenhanced images.肾实质期（100秒后）：肾实质期对于强化后的评估是很重要的期相。 Pye

3、lographic phase (15 minute delay; also called the excretory phase): The pyelographic phase is helpful for problem solving and to diagnose potential mimics of cystic renal masses. 肾盂期（15分钟后，又称做分泌期）：肾盂期有助于诊断隐匿的肾脏囊性病变。The pyelographic phase can distinguish between hydronephrosis (will show dense opacif

4、ication in the pyelographic phase) and renal sinus cysts (will not opacify).肾盂期可以鉴别肾盂积水（肾盂期时变得浑浊）和肾窦囊肿（不会变得不透明）。Reflux nephropathy may cause a dilated calyx that can simulate a cystic renal mass on the nephrographic phase. The pyelographic phase would show opacification of the dilated calyx.反流性的肾病可以

5、导致肾盏的扩大，在肾实质期与肾脏囊性病变很类似。而在肾盂期扩张的肾盏会变的浑浊。The pyelographic phase is also useful to demonstrate a calyceal diverticulum and to show therelationship of a renal mass to the collecting system for surgical planning. 肾盂期也可以很好的显示肾盂憩室，也可以显示肾脏占位性病变与肾集合系统的关系，为外科手术提供帮助。 Optionally, a vascular phase can be perfor

6、med for presurgical planning. 视情况而定，外科手术前需做血管造影检查。Evaluating enhancement (CT and MRI)CT和MRI增强检查的表现 The presence of enhancement is the most important characteristic to distinguish between a benign and malignant non-fat-containing renal mass (a lesion containing intralesional fat is almost always a be

7、nign angiomyolipoma, even if it enhances). 在鉴别非含脂的肾脏占位性病变中（含脂肪的多数为血管平滑肌脂肪瘤，尽管有强化），强化后的表现是非常重要的一个特征。 On CT, enhancement is quantified as the absolute increase in Hounsfield units on postcontrastimages, compared to pre-contrast: <(less than)10HU， No enhancement；1019 HU，Equivocal enhancement.；（great

8、er than or equal to）20 HU， Enhancement. 增强前后的图像CT值对比：小于10hu为无强化；10-19hu为疑似强化；大于等于20hu为强化。 On MRI, enhancement is quantified as the percent increase in signal intensity as measured on post-contrast images: <15%: No enhancement. 1519%: Equivocal enhancement. 20%: Enhancement. MRI增强检查，前后对比，小于15%为无强化

9、；15-19%疑似强化；大于等于20%为强化。 Lesions are considered “too small to characterize” if the lesion diameter is smaller than twice the slice thickness. For instance, using 3 mm slices, a lesion less than 6 mm cannot be accurately characterized based on attenuation or enhancement. 如果病灶小于两个层面时，没有特征性的表现。例如，3毫米层厚时

10、，小于6毫米的病灶基于减弱或者增强时，就不能准确的诊断。Renal mass biopsy肾脏占位性病变的活组织切片检查 After full imaging workup is complete, there are several well-accepted indications for percutaneous renal mass biopsy: 所有的影像学检查结束后，有几个被广泛接受的适应症，可以进行肾脏占位性病变的经皮穿刺活检。Indications for renal mass biopsy穿刺活检的适应症 To distinguish renal cell carcinom

11、a from metastasis in a patient with a known primary. 鉴别肾细胞性肾癌还是转移性肿瘤。 To distinguish between renal infection and cystic neoplasm. 鉴别感染还是囊性的病变。 To definitively diagnose a hyperdense, homogeneously enhancing mass (after MRI has beenperformed), which may represent a benign angiomyolipoma with minimal f

12、at versus a renal cellcarcinoma. 最终诊断同肾肿瘤同样强化的高密度病变，代表的有含有很少脂肪的血管平滑肌脂肪瘤与肾细胞肾癌。 To definitively diagnose a suspicious renal mass in patient with multiple comorbidities for whom nephrectomy would be high risk. 在具有高风险的肾脏切除手术并伴有多发并发症的病人，可以最终明确疑似的肾肿瘤性病变。 To ensure correct tissue diagnosis prior to renal

13、mass ablation. 在占位性病变切除前明确病理组织诊断。166Solid renal masses肾脏实性占位Renal cell carcinoma (RCC)肾细胞性肾癌Renal cell carcinoma, stage 3A: Coronal (left image) and axial post-contrast fat-suppressed T1-weighted MRI shows a heterogeneously enhancing mass (yellow arrows) replacing and expanding most of the left kidn

14、ey. Contiguous to the mass there is expansion and heterogeneous enhancement of the left renal vein (red arrows), representing tumor thrombus and extension of the renal carcinoma into the renal vein. 3A期的肾细胞肾癌：冠状位（左）和轴位T1WI压脂后的增强图像示：大部分的左侧肾脏被不均匀强化的肾肿瘤（黄箭头）取代，邻近肿块的是扩张和不均匀强化的左肾静脉（红箭头），表示左肾静脉癌栓形成和受累。 Re

15、nal cell carcinoma (RCC) is a relatively uncommon tumor that arises from the renal tubular cells. It represents 23% of all cancers. Risk factors for development of RCC include smoking, acquired cystic kidney disease, von HippelLindau (VHL), and tuberous sclerosis. 肾细胞肾癌是起源于肾小管细胞的不是很常见的肿瘤。在所有肿瘤中占2-3%

16、。危险因素包括吸烟、继发于肾脏囊性病变、“希佩尔- 林道综合征”和结节性硬化。 Clear cell is the most common RCC subtype (75%), with approximately 55% 5-year survival.75%的肾癌为透明细胞癌，其5年存活率接近55%。Clear cell RCC tends to enhance more avidly than the less common subtypes.透明细胞肾癌相对于其它亚型的肿瘤强化明显。Clear cell can be sporadic or associated with von Hi

17、ppelLindau.透明细胞可以是散发的或者和“希佩尔- 林道综合征”相关。 Papillary RCC is a hypovascular subtype, with a 5-year survival of 8090%.乳头状透明细胞癌是少血供的类型，其5年生存率为80-90%。Papillary RCC tends to enhance only mildly due to its hypovascularity.乳头状透明细胞癌因为其少血供，表现为轻微强化。A renal “adenoma” is frequently seen on autopsy specimens and is

18、 a papillary carcinoma 5 mm.肾脏腺瘤通常在尸检标本中发现，死小于5mm的乳头状肾癌。 Chromophobe is the subtype with the best prognosis, featuring a 90% 5-year survival.嫌色细胞癌是一种预后最好的亚型，5年存活率为90%。 Collecting duct carcinoma is rare and has a poor prognosis.集合管癌是少见并预后不良。 Medullary carcinoma is also rare, but is known to affect mo

19、stly young adult males with sickle cell trait. Medullary carcinoma is an extremely aggressive neoplasm, with a mean survival of 15 months, not helped by chemotherapy.髓样癌也是少见的，主要发生于具有镰刀型细胞性质的年轻人。髓样癌是非常有侵袭性的肿瘤，不进行化疗的存活期为15月。 Staging of renal cell carcinoma is based on the Robson system, which characte

20、rizes fascial extension and vascular/lymph node involvement. Stages IIII are usually resectable, although the surgical approach may need to be altered for venous invasion (stages IIIA and IIIC).肾癌的分级是基于罗布森系统，包括筋膜的受累、血管及淋巴结的转移。1-3级的通常可以切除，因为静脉的受累，手术入迳常常需要更改。Stage I: Tumor confined to within the renal

21、 capsule.1期：肿瘤局限于肾包膜内。Stage II: Tumor extends out of the renal capsule but remains confined within Gerotas fascia.2期：肿瘤突破肾包膜，但仍然局限于肾前筋膜。Stage III: Vascular and/or lymph node involvement.3期：血管和/或淋巴结转移。IIIA: Renal vein involvement or IVC involvement.IIIA期：深静脉受累或者下腔静脉受累。IIIB: Lymph node involvement.III

22、B：淋巴结转移。IIIC: Venous and lymph node involvement.IIIC：静脉和淋巴结转移。Stage IVA: Tumor growth through Gerotas fascia; IVA期：肿瘤突破肾前筋膜生长。Stage IVB: Distant metastasis.IVB：远处转移。167Angiomyolipoma (AML)血管平滑肌脂肪瘤Axial non-contrast CT shows an exophytic mass (arrow) in the right kidney containing macroscopic fat. Th

23、ere are a few linear strands of soft tissue within the lesion.轴位平扫可见右肾含脂肪的外生性肿块，病灶内含有一些少许软组织密度影。Axial T1-weighted MRI shows that the lesion is predominantly isointense to intra-abdominal fat.轴位T1加权MRI示：病灶为主要表现为同腹腔脂肪相等的信号。Axial early arterial post-contrast T1-weighted fat suppressed image shows sligh

24、t enhancement of thesoft tissue components.动脉增强早期T1脂肪抑制图像示：软组织成分的轻微强化。Late arterial post-contrast T1-weighted fat suppressed image shows more prominent enhancement of the soft tissue components of the lesion.动脉晚期示：病变内软组织成分明显强化。 Angiomyolipoma (AML) is the most common benign renal neoplasm, composed

25、of fat, smooth muscle, and disorganized blood vessels. The majority are sporadic, but 40% are associated with tuberous sclerosis (where AMLs are bilateral, with multiple renal cysts). 血管平滑肌脂肪瘤是最常见的肾脏良性肿瘤，由脂肪、平滑肌和不规则的血管组成。大多数是散在的，但是40%和结节性硬化有关（病灶为双侧，伴有多发肾囊肿）。 AML has a risk of hemorrhage when large (

26、4 cm), thought to be due to aneurysmal change of the vascular elements. Small, asymptomatic AMLs are not typically followed or resected.血管平滑肌脂肪瘤大于4cm时有出血的风险，认为是由于血管原因的血管瘤。小的，无症状的血管平滑肌脂肪瘤通常不需要随访和手术切除。 A early pathognomonic imaging finding is the presence of macroscopic fat in anon-calcified renal les

27、ion. The non fat-containing portion enhances avidly andhomogeneously. Calcification is almost never present.典型的征象是在无钙化的肾脏病灶内发现脂肪。不含脂肪的成分明显强化，钙化基本看不见。 On MRI, the fat component will follow retroperitoneal fat on all sequences and will saturate out on fat-saturated sequences. Intracytoplasmic lipid is

28、 not a feature of AML, so there should be no significant signal drop-out on dual-phase MRI. 磁共振图像，脂肪部分同腹膜后的脂肪一样在stir序列表现为信号降低。胞质内的脂肪并不是血管平滑肌脂肪瘤的特点，因此在双期磁共振上没有重要的信号减低。 Approximately 4% of AMLs will not contain visible macroscopic fat and will appear as a hyperdense enhancing mass. MRI is the next ste

29、p, with the T2-weighted images the most useful to distinguish from renal cell carcinoma in some cases.大约4%的血管平滑肌脂肪瘤不含有脂肪，只表现为增强后高信号肿块。在有些病例可以通过MRI的T2图像来和肾癌鉴别。A T2 hyperintense mass suggests RCC (clear cell subtype) and the patient can proceed to surgery.T2高信号肿块提示为肾癌（透明细胞），建议病人手术。A T2 hypointense mas

30、s is nonspecific and can represent either RCC (papillary type) or AML withminimal fat. Although an AML typically would enhance more avidly than a papillary RCC, biopsy iswarranted for definitive diagnosis.T2为低信号肿块没有特异性，可以是肾癌（乳头状肾癌）或者血管平滑肌脂肪瘤。尽管血管平滑肌脂肪瘤比乳头状瘤强化更明显，病例始终是金标准。 AML appears hyperechoic on

31、ultrasound, although up to 1/3 of renal cell carcinomas may also be hyperechoic and ultrasound is thus unreliable to distinguish AML from RCC. 血管平滑肌脂肪瘤在超声上是强回声，1/3的肾癌也是强回声，因此超声用来鉴别肾癌并不可靠。168Oncocytoma嗜酸细胞瘤Oncocytoma. Noncontrast CT (left image) shows an isodense renal mass (yellow arrows) containing

32、 a central punctate focus of hyperattenuation (red arrow). The contrast-enhanced pyelographic phase CT (right image)demonstrates that the mass enhances. There is a faint suggestion of a central focus of nonenhancement (red arrow), corresponding to a central scar.嗜酸细胞瘤，平扫CT（左图）表现为等密度肿块（黄色箭头），包含一个中央的点

33、状高密度（红色箭头），增强扫描肾盂期（右图）肿块强化，中心小点状的无强化可以轻微的提示此病，表现为中心瘢痕。 Oncocytoma is the most commonly resected benign renal mass and has overlapping imaging findings with renal cell carcinoma.嗜酸细胞瘤是肾脏良性肿瘤的很常见的，和肾细胞癌图像表现有相似。 Imaging features can suggest oncocytoma, but imaging features are not specific and cannot b

34、e reliably differentiated from RCC. The imaging features suggestive of oncocytoma are homogeneous enhancement and a central scar.典型的图像特征可以提示嗜酸细胞瘤，但并没有特异性，将其和肾细胞癌区分开来不是很可靠。其图象特征为均匀一致的强化，和中心瘢痕。 Complicating the pathologic diagnosis, oncocytic cells can sometimes be found in the rare chromophobe RCC su

35、btype. The pathologist can usually distinguish oncocytoma from the more common clear cell and papillary renal cell carcinoma subtypes.病理学诊断，嗜酸细胞常常在嫌色细胞癌里发现，病理学家常常将嗜酸细胞瘤同普通的肾细胞癌和乳头状肾细胞癌区分开来。Renal lymphoma肾淋巴瘤 Primary renal lymphoma is rare, as the kidneys do not contain native lymphoid tissue.原发的肾淋巴瘤

36、很少见，因为肾脏没有淋巴组织。However, the kidneys may become involved from hematogenously disseminated disease or spread from the retroperitoneum.尽管如此，肾脏仍然可以通过血行转移和腹膜后病灶的邻近转移受累。 Renal involvement of lymphoma has several patterns of disease:肾淋巴瘤的受累有多种类型：Multiple lymphomatous masses (most common pattern; seen in 50

37、% of cases of renallymphoma).肾脏多发肿块（最常见的类型，见于50%的肾淋巴瘤）。Solitary renal mass.单发的肿块。Diffuse lymphomatous infiltration, causing nephromegaly.淋巴瘤的侵犯导致肾脏的肿大。Direct extension of retroperitoneal disease.腹膜后病变的直接侵犯。Non-neoplastic solid renal masses非肿瘤性的肾脏占位 When evaluating a potential renal mass, its importa

38、nt to always consider that anapparent solid renal mass may represent a non-neoplastic lesion.当评估肾脏可疑占位时，考虑其为非肿瘤性的病变是很重要的。 Infection, especially focal pyelonephritis, can masquerade as a solid renal mass. Renalabscess may be difficult to differentiate on imaging from a cystic renal cell carcinoma.感染，

39、特别是局灶性的肾盂肾炎，很像一个肾实质性的肿块。在图像上肾脓肿很难和囊性的肾细胞癌鉴别。 Renal arteriovenous malformation (AVM ) will avidly enhance and can mimic ahypervascular renal mass. One clue to the presence of an AVM would be asymmetricenhancement of the renal vein on the affected side, due to early shunting of venous blood.肾脏的动静脉畸形是明

40、显强化的很像富血供的肾脏肿瘤。动静脉畸形的一个征象为患侧的肾静脉不均匀强化，由于静脉的分流。169Renal pseudotumors肾脏假肿瘤征 Renal pseudotumors are normal variations of renal morphology that may mimic arenal mass.肾脏假肿瘤是肾脏的一种正常变异，类似于肾脏肿瘤。 Hypertrophied column of Bertin: The columns (septa) of Bertin are normal structuresthat anchor the renal cortex t

41、o the hilum and create the separations between the renal pyramids. When hypertrophied, the columns of Bertin may mimic a renal mass.肾柱肥大：肾柱是正常的结构，为肾皮质深入相邻肾锥体之间的部分。当其增生时同肾肿瘤很像。 Persistent fetal lobation/lobulation: In normal fetal development, the fetal kidneys are divided into discrete lobes. Occasi

42、onally these lobulations persist in adulthood, producing an indentation of the renal cortex.永存性的肾胚胎分叶：正常胎儿肾脏发育为相互独立的肾小叶。少数情况下这些肾小叶间沟持续存在直到成年，表现为肾皮质的切迹。 This indentation can cause an adjacent focal bulge that simulates a renal mass. This pseudomass can usually be distinguished from a true mass by the

43、 presence of septa of Bertin on either side.这些切迹可以使相邻的肾实质局限性隆起，而类似于肾脏肿瘤。这些假肿瘤征象可以通过相邻的肾柱间分隔鉴别出来。Syndromes with renal masses (all have increased risk of RCC )肾脏多发肿块综合征 von HippelLindau (VHL)希佩尔-林道综合征 von HippelLindau (VHL) is an autosomal dominant multiorgan syndrome caused by a mutation in the VHL t

44、umor suppressor gene on chromosome 3, which leads to cysts and neoplasms in multiple organs.希佩尔-林道综合征是常染色体显性遗传额多脏器受累的综合征，是3好染色体的肿瘤抑制因子突变，表现为多脏器的囊肿和肿瘤。 The primary manifestation of VHL in the genitourinary system is bilateral or multifoca renal cell carcinomas, most commonly the clear-cell subtype.林道

45、综合征的在泌尿系统最常见的表现是双侧的多发肾细胞癌，最多见于透明细胞癌。 Other genitourinary manifestations of VHL include multifocal pheochromocytoma and renal cysts.其他的泌尿系统最常见的是多发嗜铬细胞瘤和肾囊肿。 Central nervous system manifestations of VHL include hemangioblastoma of the brainstem, cerebellum, or spinal cord.中枢神经系统最常见的表现是脑干、小脑和脊髓的血管母细胞瘤。

46、 Pancreatic and hepatic manifestations include malignant neuroendocrine pancreatic tumor, pancreatic serous cystadenoma (a benign neoplasm), and pancreatic/hepatic cysts.胰腺和肝脏的表现包括恶性的胰腺神经内分泌肿瘤，胰腺的浆液囊腺瘤（良性肿瘤），和胰腺、肝脏的囊肿。BirtHoggDubeBHD综合征 BirtHoggDube is an autosomal dominant syndrome of dermatologic

47、lesions, cystic lung disease, and multiple renal oncocytomas and renal cell carcinomas.BHD综合征是常染色体显性遗传的皮肤病变的综合征，肺囊肿、多发的肾脏嗜酸细胞瘤和肾细胞癌。Tuberous sclerosis (TS)结节硬化 Tuberous sclerosis is an autosomal dominant neurocutaneous disease caused by a tumor suppressor gene mutation. It manifests clinically with

48、seizures, developmental delay, and (mostly) benign tumors in multiple organ systems.结节硬化是常染色体显性遗传疾病，由肿瘤抑制基因突变造成。其临床表现为癫痫、发育迟缓，和多器官的良性肿瘤。 The most common renal manifestation of tuberous sclerosis is multiple bilateral rena angiomyolipomas (AMLs). Approximately 50% of patients with TS will have at lea

49、st one AML.最常见的肾脏病变是双侧多发的血管平滑肌脂肪瘤，50%的结节硬化的病人至少有有一个血管平滑肌脂肪瘤。 Renal cysts can be seen in 25%.25%的有多发肾囊肿。 The relative risk of renal cell carcinoma is increased in patients with TS, and occurs inapproximately 23% of patients. Diagnosis of renal cell carcinoma is complicated by the abnormal kidneys tha

50、t may have multiple cysts and/or AMLs.约2-3%结节硬化的病人有患肾癌的风险，在那些并发多发肾囊肿和血管平滑肌脂肪瘤的患者。 In the heart, the most common neoplasm is a rhabdomyoma. A cardiac rhabdomyoma may be present during fetal life and can be detected by fetal ultrasound.在心脏，最常见新生物是横纹肌瘤，通常在胎儿时可以通过胎儿超声发现。 In the lung, a process of smooth

51、 muscle proliferation identical to lymphangioleiomyomatosis can occur, causing cystic replacement of lung parenchyma.在肺组织，会发生与淋巴管平滑肌增生症相同的平滑肌增生，导致囊肿取代肺组织。It has been suggested that the abnormal smooth muscle in the lung in patients with TS represents genetically identical metastatic smooth muscle fr

52、om a renal angiomyolipoma.发生在结节性硬化病人肺的异常平滑肌增生，被认为和肾脏血管平滑肌脂肪瘤的基因相同。170Approach to a cystic renal mass囊性肾肿瘤性病变的诊断方法 A cystic renal mass may be neoplastic or infectious; the two most common entities to cause a cystic renal mass are renal cell carcinoma and renal abscess.囊性肾肿瘤性病变可以是肿瘤或者感染引起的；最常见的是肾细胞癌和肾

53、脓肿。Neoplastic differential of a cystic renal mass囊性肾肿瘤性病变和肿瘤新生物的鉴别 Cystic renal cell carcinoma. Although renal cell carcinoma most commonly presents as a solid renal mass, it can also manifest as a cystic renal mass.囊性肾细胞癌：尽管肾细胞癌最常见表现为实质性肿块，也可以表现为囊性的肾肿块。 Multilocular cystic nephroma is a benign cyst

54、ic neoplasm with enhancing septa that occurs in a bimodal age distribution in baby boys and middle-aged women. 多房囊性肾细胞瘤是一个分隔强化的良性肾脏囊性病变，主要发生在小男孩和中年女性。A characteristic but nonspecific feature is the propensity to herniate into the renal pelvis, causing hydronephrosis.其非特异性的一个征象是向内压迫肾盂，而造成肾盂积水。In adul

55、ts, multilocular cystic nephroma can be indistinguishable from cystic renal cell carcinoma.在成人，多房囊性肾细胞瘤和囊性肾细胞癌鉴别困难。In children, multilocular cystic nephroma can be indistinguishable from cystic Wilms tumor.在儿童，多房囊性肾细胞瘤和囊性Wilms瘤鉴别困难。 Mixed epithelial and stromal tumor (MEST ) is a benign neoplasm com

56、posed of epithelial and mesenchymal elements, typically found in middle-aged women. MEST may appear as either a solid or cystic mass.混合上皮间质性肿瘤是一个良性的肿瘤，包含有上皮和间叶细胞，最常见于中年女性。可以表现为囊性或者实性肿块。Non-neoplastic differential of a cystic renal mass囊性肾肿瘤性病变和非肿瘤性新生物的鉴别 Renal abscess is a contained purulent collect

57、ion within the kidney.肾脓肿是肾脏脓液的一个聚集。 Hemorrhagic renal cyst, which will not have any enhancing component.出血性囊肿，没有强化部分。Role of MRI in evaluation of a complex cystic renal massMRI在诊断复杂囊性肾肿瘤性病变中的价值 MRI has a limited role in the evaluation of a cystic renal mass. The key advantage of MRI is more accurat

58、e enhancement characterization, as MRI does not suffer from the CT phenomenon of pseudoenhancement due to beam hardening from adjacent, densely enhancing renal parenchyma.MRI在诊断囊性肾肿瘤方面有点局限性，他最重要的优点是增强的准确性，不会受到像CT图像上邻近的高密度强化的肾实质的干扰。The increased accuracy of MRI to characterize enhancement is most useful to d