腹部讀片腎臟淋巴瘤

1、2014091720140917腹腹 部部 讀讀 片片王莉教授王莉教授邊邊 云云 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史介紹？病理描述和結(jié)果鏡檢：瘤內(nèi)為淋巴樣細(xì)胞，體積較小，核類圓，排列密集，呈浸潤(rùn)性生長(zhǎng)（左側(cè)）腎臟惡性淋巴瘤（彌漫大B細(xì)胞型）原發(fā)淋巴瘤腎臟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(rèn)為不存在腎臟原發(fā)淋巴瘤有人認(rèn)為來源于腎包囊的淋巴組織慢性炎癥刺激引起腎實(shí)質(zhì)產(chǎn)生淋巴組織，繼而演變?yōu)榱馨土隼^發(fā)淋巴瘤占淋巴瘤尸檢病理的30%-60%占結(jié)

2、外淋巴瘤3%-8% Yasunaga1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(shí)為淋巴瘤 就診時(shí)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腎臟淋巴瘤分型腎臟淋巴瘤腎臟淋巴瘤多結(jié)節(jié)型30-50%單結(jié)節(jié)型25-30%腹膜后浸潤(rùn)型腎周型少見彌漫型少見腫瘤細(xì)胞浸潤(rùn)后再增殖可形成單側(cè)多個(gè)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(shí)無法顯示多發(fā)病灶；增強(qiáng)：皮髓交界期輕度強(qiáng)化-確定病變性質(zhì) 實(shí)質(zhì)期最佳時(shí)期-確定病變數(shù)目、形態(tài)、邊界、均勻度MRT1WI：呈低信號(hào)、等信

3、號(hào)或稍高信號(hào);T2WI：呈等或低信號(hào); 腫瘤信號(hào)相對(duì)均勻、壞死少見，無包膜;DWI：顯著高信號(hào)（與水分子運(yùn)動(dòng)受限有關(guān)）;增強(qiáng)：輕度強(qiáng)化多結(jié)節(jié)型30-50%多結(jié)節(jié)型腎淋巴瘤多結(jié)節(jié)型腎淋巴瘤多結(jié)節(jié)型腎淋巴瘤多結(jié)節(jié)型腎淋巴瘤Figure 1. Large B-cell lymphoma in a 41-year-old HIV-positive man. (a) Unenhanced CT scan of the midabdomen shows a soft-tissue mass (arrowhead) in the region of the great vessels, a finding

4、that is suspicious for retroperitoneal adenopathy. The kidneys do not demonstrate any abnormality in contour. (b) Contrast-enhanced CT scan of the midabdomen shows bilateral soft-tissue renal masses (arrows). Note that these masses do not deform the contour of the kidneys. The paraaortic retroperito

5、neal adenopathy (arrowhead) is much more clearly depicted than in a.Figure 2. High-grade B-cell lymphoma in a 38-year-old human immunodeficiency virus (HIV)positive woman who presented with abdominal pain and distention. (a) Contrast materialenhanced CT scan of the midabdomen shows a very large soft

6、-tissue mass (arrows) infiltrating the mesentery and omentum and displacing the small bowel and colon. (b) Contrast-enhanced CT scan shows hypoenhancing soft-tissue masses (arrows) in both kidneys. Note also the retroperitoneal adenopathy (arrowhead). (c) Photomicrograph of a specimen obtained at fi

7、ne-needle aspiration biopsy shows hypercellularity with a uniform population of malignant lymphocytes. Numerous aptotic cells are also seen(200 HE)多結(jié)節(jié)型腎淋巴瘤多結(jié)節(jié)型腎淋巴瘤Figure 3. Magnetic resonance imaging of the kidneys. (A) T1-weighted imaging reveals two slightly hypointense or isointense signal masses

8、 in the right kidney and one hypointense signal mass in the left kidney. (B) T2-weighted imaging reveals hypointense signal in the bilateral renal masses shown in (A). (C) Contrast-enhanced T1-weighted imaging reveals poor enhancement of the bilateral renal masses shown in (A).多結(jié)節(jié)型腎淋巴瘤多結(jié)節(jié)型腎淋巴瘤腫瘤呈灶性增

9、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(qiáng)：強(qiáng)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(rùn)，形成包膜尾征單結(jié)節(jié)型25-30%單結(jié)節(jié)型腎淋巴瘤單結(jié)節(jié)型腎淋巴瘤Figure 4. Large B-cell lymphoma in a 72-year-old man with a history of prostate cancer. Contrast-en- hanced CT scan of the kidneys shows a well-defined expansile mass (arrow) in the left kidney. N

10、o other solid renal masses are seen, but the right psoas muscle (arrowhead) is enlarged. The diagnosis was established with US-guided percutaneous biopsy of the renal mass.單結(jié)節(jié)型腎淋巴瘤單結(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(shí)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(qiáng)：輕中度強(qiáng)化; 動(dòng)態(tài)增強(qiáng)呈進(jìn)行性延遲強(qiáng)化，腫瘤內(nèi)依稀可分辨腎門，腎門血 管走形、形態(tài)正

11、常腹膜后浸潤(rùn)型腹膜后浸潤(rùn)型腎淋巴瘤腹膜后浸潤(rùn)型腎淋巴瘤Figure 5. Low-grade B-cell lymphoma in a 60-year-old man. The patient underwent abdominal CT for necrotizing pancreatitis. (a) Venous phase contrast-enhanced CT scan shows a large soft-tissue mass (arrow) infiltrating the retroperitoneum, encasing the left renal vessels, a

12、nd extending into the perinephric space. Note the fluid collection (arrowhead) in the pancreatic bed, a finding that is consistent with the patients history of pancreatitis. (b) Excretory phase contrast-enhanced CT scan shows a pararenal mass (arrow) with soft-tissue attenuation. Note also the absen

13、ce of hydronephrosis. Although pancreatitis commonly affects the perirenal and pararenal spaces, the soft-tissue attenuation of the mass in this case led to the correct diagnosis of lymphoma. The diagnosis was confirmed with US-guided biopsy腹膜后浸潤(rùn)型腎淋巴瘤腹膜后浸潤(rùn)型腎淋巴瘤Figure 6. Large B-cell lymphoma in a 52

14、-year-old man with a history of chronic lymphocytic leukemia.Contrast-enhanced CT scan shows bulky retroperitoneal adenopathy (black arrows). A soft-tissue mass (white arrow) is seen in the right renal sinus fat and the perinephric space. Note the delayed enhancement of the right kidney.腹膜后浸潤(rùn)型腎淋巴瘤腹膜

15、后浸潤(rùn)型腎淋巴瘤腫瘤沿著腎周筋膜生長(zhǎng);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(qiáng)：可侵犯或不侵犯腎臟皮質(zhì)，增強(qiáng)有助于鑒別兩者關(guān)系腎周型少見腎周型腎淋巴瘤腎周型腎淋巴瘤Figure 7. Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left p

16、araaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. (c) Photomicrograph of a specimen o

17、btained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow) (100; HE). Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing

18、the left renal vein. 腎周型腎淋巴瘤腎周型腎淋巴瘤Figure 8. B-cell lymphoma in a 62-year-old man with a history of follicular lymphoma. Routine follow-up CT was performed. (a) Portal venous phase contrast-enhanced CT scan shows a mildly enhancing mass (arrow) in the right anterior pararenal space. The mass represe

19、nted a new finding. (b) Portal venous phase contrast-enhanced CT scan shows stranding in the mesenteric fat (arrows), a finding that suggests a “misty mesentery.” This finding was also new. US-guided biopsy of the perirenal mass demonstrated aggressive B-cell lymphoma.腎周型腎淋巴瘤腎周型腎淋巴瘤CT平掃：腎臟體積彌漫性增大，但形

20、態(tài)正常，密度減低；增強(qiáng)：輕中度不均勻強(qiáng)化 彌漫型腫瘤細(xì)胞沿著沿著腎臟間質(zhì)組織支架呈浸潤(rùn)性生長(zhǎng);腎臟體積增大但形態(tài)正常;彌漫型腎淋巴瘤彌漫型腎淋巴瘤MRT1WI：呈低信號(hào)、等信號(hào)或稍高信號(hào);T2WI：呈等或低信號(hào);增強(qiáng)：增強(qiáng)早期腎皮質(zhì)相對(duì)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Figure 9. Primary renal lymphoma in a 41-year-old HIV-positive man who presented with renal failure. Nephrographic phase contrast-enhanced CT scan of the

21、 kidneys shows bilateral renal enlargement. Heterogeneously decreased enhancement of the renal parenchyma is also seen. The diagnosis of Burkitt-like lymphoma was established with renal biopsy.彌漫型腎淋巴瘤彌漫型腎淋巴瘤Figure 10. Infiltrative renal lymphoma in a 44-year-old woman. Cont|rast-enhanced CT scan shows the kidneys as diffusely enlarged and replaced by tumor.The lobulated appearance of the tumor reflects the transition to a more focal expansile mass as it compresses and destroys renal parenchyma.彌漫型腎淋巴瘤彌漫型腎淋巴瘤影像學(xué)診斷難點(diǎn)影像學(xué)診斷難點(diǎn)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(shí)際工作中有“