腹部讀片-腎臟淋巴瘤

20140917腹部讀片 男性 46歲 已婚 漢患者2周前在當(dāng)?shù)伢w檢發(fā)現(xiàn)左腎占位患者自發(fā)病以來無尿頻 尿急 尿痛 腰痛 發(fā)熱等癥狀無體重變化 大小便正常 睡眠良好 病史介紹 病理描述和結(jié)果鏡檢 瘤內(nèi)為淋巴樣細胞 體積較小 核類圓 排列密集 呈浸潤性生長 左側(cè) 腎臟惡性淋巴瘤 彌漫大B細胞型 原發(fā)淋巴瘤 腎臟淋巴瘤 腎臟為結(jié)外淋巴瘤好發(fā)的部位之一 正常腎臟沒有淋巴組織 有學(xué)者認為不存在腎臟原發(fā)淋巴瘤 有人認為來源于腎包囊的淋巴組織 慢性炎癥刺激引起腎實質(zhì)產(chǎn)生淋巴組織 繼而演變?yōu)榱馨土?繼發(fā)淋巴瘤 占淋巴瘤尸檢病理的30 60 占結(jié)外淋巴瘤3 8 Yasunaga 1 等提出腎臟原發(fā)性淋巴瘤診斷標(biāo)準(zhǔn)腎臟腫物經(jīng)病理證實為淋巴瘤就診時無淋巴結(jié)以及內(nèi)臟器官等淋巴瘤腎外侵犯無白血病性血象以及骨髓抑制表現(xiàn) 腎臟淋巴瘤 腎臟淋巴瘤分型 腎臟淋巴瘤 多結(jié)節(jié)型30 50 單結(jié)節(jié)型25 30 腹膜后浸潤型 腎周型少見 彌漫型少見 腫瘤細胞浸潤后再增殖可形成單側(cè)多個病灶或雙側(cè)病灶可位于腎皮質(zhì) 髓質(zhì)無包膜邊界清 病灶呈圓形或類圓形 或融合狀無論結(jié)節(jié)大小 占位效應(yīng)不顯著 CT平掃 等 低 稍高密度 有時無法顯示多發(fā)病灶 增強 皮髓交界期輕度強化 確定病變性質(zhì)實質(zhì)期最佳時期 確定病變數(shù)目 形態(tài) 邊界 均勻度 MRT1WI 呈低信號 等信號或稍高信號 T2WI 呈等或低信號 腫瘤信號相對均勻 壞死少見 無包膜 DWI 顯著高信號 與水分子運動受限有關(guān) 增強 輕度強化 多結(jié)節(jié)型30 50 多結(jié)節(jié)型腎淋巴瘤 多結(jié)節(jié)型腎淋巴瘤 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 多結(jié)節(jié)型腎淋巴瘤 Figure3 Magneticresonanceimagingofthekidneys A T1 weightedimagingrevealstwoslightlyhypointenseorisointensesignalmassesintherightkidneyandonehypointensesignalmassintheleftkidney B T2 weightedimagingrevealshypointensesignalinthebilateralrenalmassesshownin A C Contrast enhancedT1 weightedimagingrevealspoorenhancementofthebilateralrenalmassesshownin A 多結(jié)節(jié)型腎淋巴瘤 腫瘤呈灶性增殖 一般形成單側(cè)單發(fā)病灶 平掃 等 低 稍高密度 境界欠清 增強 強化方式多樣 可為富血管 中等血供 少血供 位于腎包膜下孤立結(jié)節(jié)可沿包膜浸潤 形成包膜尾征 單結(jié)節(jié)型25 30 單結(jié)節(jié)型腎淋巴瘤 Figure4 LargeB celllymphomaina72 year oldmanwithahistoryofprostatecancer Contrast en hancedCTscanofthekidneysshowsawell de nedexpansilemass arrow intheleftkidney Noothersolidrenalmassesareseen buttherightpsoasmuscle arrowhead isenlarged ThediagnosiswasestablishedwithUS guidedpercutaneousbiopsyoftherenalmass 單結(jié)節(jié)型腎淋巴瘤 腹膜后巨大軟組織腫塊侵犯附近腎臟 包繞腎門和腎血管 平掃 形態(tài)不規(guī)則 實變 壞死 囊變 出血少見 腎臟病灶與腹膜后腫塊可分開也可融合 增強 輕中度強化 動態(tài)增強呈進行性延遲強化 腫瘤內(nèi)依稀可分辨腎門 腎門血管走形 形態(tài)正常 腹膜后浸潤型 腹膜后浸潤型腎淋巴瘤 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 腹膜后浸潤型腎淋巴瘤 Figure6 LargeB celllymphomaina52 year oldmanwithahistoryofchroniclymphocyticleukemia Contrast enhancedCTscanshowsbulkyretroperitonealadenopathy blackarrows Asoft tissuemass whitearrow isseenintherightrenalsinusfatandtheperinephricspace Notethedelayedenhancementoftherightkidney 腹膜后浸潤型腎淋巴瘤 腫瘤沿著腎周筋膜生長 可侵犯或不侵犯腎臟皮質(zhì) CT平掃 淋巴瘤主要位于腎臟周圍 形成腫塊或不規(guī)則軟組織腫塊 腎臟被腫瘤 封入 增強 可侵犯或不侵犯腎臟皮質(zhì) 增強有助于鑒別兩者關(guān)系 腎周型少見 腎周型腎淋巴瘤 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 腎周型腎淋巴瘤 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 腎周型腎淋巴瘤 CT平掃 腎臟體積彌漫性增大 但形態(tài)正常 密度減低 增強 輕中度不均勻強化 彌漫型 腫瘤細胞沿著沿著腎臟間質(zhì)組織支架呈浸潤性生長 腎臟體積增大但形態(tài)正常 彌漫型腎淋巴瘤 MRT1WI 呈低信號 等信號或稍高信號 T2WI 呈等或低信號 增強 增強早期腎皮質(zhì)相對正常 腎皮髓交界相延遲 后期皮髓交界相消失 腎臟輪廓增大 Figure9 Primaryrenallymphomaina41 year oldHIV positivemanwhopresentedwithrenalfailure Nephrographicphasecontrast enhancedCTscanofthekidneysshowsbilateralrenalenlargement Heterogeneouslydecreasedenhancementoftherenalparenchymaisalsoseen ThediagnosisofBurkitt likelymphomawasestablishedwithrenalbiopsy 彌漫型腎淋巴瘤 Figure10 Infiltrativerenallymphomaina44 year oldwoman Cont rast enhancedCTscanshowsthekidneysasdiffuselyenlargedandreplacedbytumor Thelobulatedappearanceofthetumorreflectsthetransitiontoamorefocalexpansilemassasitcompressesanddestroysrenalparenchyma 彌漫型腎淋巴瘤 影像學(xué)診斷難點與腎臟其它疾病表現(xiàn)有重疊性 出現(xiàn) 四象 和 四不像 的特征介于良性腫瘤 惡性腫瘤 腫瘤樣病變 炎癥之間實際工作中