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1、2014091720140917腹腹 部部 读读 片片王莉教授王莉教授边边 云云男性，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
2、3%-8%Yasunaga1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肾脏淋巴瘤分型肾脏淋巴瘤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;T2
3、WI：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多结节型肾淋巴瘤多结节型肾淋巴瘤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 that is s
4、uspicious 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 retroperitoneal aden
5、opathy (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-tissue m
6、ass (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 fine-needle
7、 aspiration biopsy shows hypercellularity with a uniform population of malignant lymphocytes. Numerous aptotic cells are also seen(200 HE)多结节型肾淋巴瘤多结节型肾淋巴瘤Figure 3. Magnetic resonance imaging of the kidneys. (A) T1-weighted imaging reveals two slightly hypointense or isointense signal masses in the r
8、ight 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).多结节型肾淋巴瘤多结节型肾淋巴瘤肿瘤呈灶性增殖，一般形成单侧单
9、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%单结节型肾淋巴瘤单结节型肾淋巴瘤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. No other so
10、lid 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.单结节型肾淋巴瘤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
11、肾淋巴瘤腹膜后浸润型肾淋巴瘤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, and extending
12、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 absence of hydrone
13、phrosis. 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腹膜后浸润型肾淋巴瘤腹膜后浸润型肾淋巴瘤Figure 6. Large B-cell lymphoma in a 52-year-old man
14、 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.腹膜后浸润型肾淋巴瘤腹膜后浸润型肾淋巴瘤肿瘤沿着肾
15、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肾周型肾淋巴瘤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 paraaortic lymp
16、h 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 obtained at cor
17、e 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 the left renal
18、 vein. 肾周型肾淋巴瘤肾周型肾淋巴瘤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 represented a new fin
19、ding. (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.肾周型肾淋巴瘤肾周型肾淋巴瘤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
20、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 kidneys shows b
21、ilateral renal enlargement. Heterogeneously decreased enhancement of the renal parenchyma is also seen. The diagnosis of Burkitt-like lymphoma was established with renal biopsy.弥漫型肾淋巴瘤弥漫型肾淋巴瘤Figure 10. Infiltrative renal lymphoma in a 44-year-old woman. Cont|rast-enhanced CT scan shows the kidneys a
22、s 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.弥漫型肾淋巴瘤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总 结结鉴别诊断肾脏良性肿瘤肾脏恶性肿
23、瘤肿瘤样病变炎症之间可提示诊断1.肿瘤双侧发生2.肿瘤与肾脏交界面模糊，瘤肾互穿插3.肿瘤沿薄膜爬行生长4.肿瘤样密度，炎症样模糊边缘5.肿瘤巨大但坏死少见或者坏死区很小6.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总 结结1. Yasunaga Y, Hoshida Y, Hashimoto M, Miki T, Okuyama A, Aozasa K. Malignant lymphoma of the kidney. Journal of surgical oncology. 1997;64(3):207-11.2.Sheth S, Ali S, Fishman E. Ima
24、ging of renal lymphoma: patterns of disease with pathologic correlation. Radiographics : a review publication of the Radiological Society of North America, Inc. 2006;26(4):1151-68.3.Urban BA, Fishman EK. Renal lymphoma: CT patterns with emphasis on helical CT. Radiographics : a review publication of the Radiological Society of North America, Inc. 2000;20(1):197-212.参考文献参考文献THANK YOU
