业务学习 肾肿瘤Word文件下载.docx

1、 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 opacification in the pyelographic phase

2、） 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

3、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 performed for presurgical planning. 视情况

4、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 benign angiomyolipoma, even if it e

5、nhances）. 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.；（greater than or equal to）20 HU， Enhancemen

6、t. 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；15-19%疑似强化；大于等于20%为强化。 Lesions are consid

7、ered “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，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 bio

8、psy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 carcinoma from metastasis in a patient with a know

9、n 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 fat versus a renal cellcarcinoma. 最终诊断同肾肿瘤同

10、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 mass ablation. 在占位性病变切除前明确病理组织诊断。166Solid

11、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 kidney. Contiguous to the mass there is expans

12、ion 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。 Renal cell carcinoma （RCC） is a relatively u

13、ncommon 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%。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。 Cl

14、ear 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 HippelLindau.透明细胞可以是散发的或者和“希佩尔- 林道综合征”相关。 Pa

15、pillary 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 a papillary carcinoma 5 mm.肾脏腺瘤通常在尸检标本中发现

16、，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 mostly young adult males with sickle cell tr

17、ait. 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 characterizes fascial extension and vascular/lymph

18、 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 capsule.1期：肿瘤局限于肾包膜内。Stage II: Tumor exte

19、nds 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.IIIB：淋巴结转移。IIIC: Venous and lymph node involv

20、ement.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. There are a few linear strands of soft tissu

21、e 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 slight enhancement of thesoft tissue components

22、.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 of fat, smooth muscle, and disorganized bl

23、ood 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 （4 cm）, thought to be due to aneurysmal cha

24、nge 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 lesion. The non fat-containing portion enhanc

25、es 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 not a feature of AML, so there should be

26、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 step, with the T2-weighted images the most us

27、eful 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 mass is nonspecific and can represent either

28、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 ultrasound, although up to 1/3 of renal ce

29、ll 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 a central punctate focus of hyperattenuat

30、ion （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。 Oncocyt