业务学习 肾肿瘤

2021年2月26日发(作者：肾病药物)
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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. < br>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。

?

Pyelographic
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
opacification
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 the
relationship 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 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
postcontrast
。

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images, compared to pre-contrast: <(less than)10HU
，
No enhancement
；
10
–
19 HU
，
Equivocal enhancement.
；≥（
greater 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.
15
–
19%:
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 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，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 carcinoma 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 been
performed), which may represent a benign angiomyolipoma with minimal fat versus a
renal cell
carcinoma.

最终诊断同肾肿瘤同样强化的高密度病变，< br>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。

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Solid 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 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。

?
Renal cell carcinoma (RCC) is a relatively uncommon tumor that arises from the
renal
tubular
cells.
It
represents
2
–
3%
of
all
cancers.
Risk
factors
for
development
of RCC include smoking, acquired cystic kidney disease, von Hippel
–
Lindau (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。

?
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%
。

。

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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 Hippel
–
Lindau.
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 80
–
90%.
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，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 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
characterizes
fascial extension and vascular/lymph node involvement. Stages I
–
III 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
extends
out
of
the
renal
capsule
but
remains
confined
within
Gerota
’
s
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 involvement.
IIIC
：静脉和淋巴结转移。

Stage IVA: Tumor growth through Gerota
’
s fascia;
IVA
期：肿瘤突破肾前筋膜生长。

Stage IVB: Distant metastasis.
IVB
：远处转移。

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167













Angiomyolipoma (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 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。


intra-abdominal fat.

Axial T1-weighted MRI shows that the lesion is predominantly isointense to
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。

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Axial early arterial post-contrast T1-weighted fat suppressed image shows slight
enhancement of the
soft 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
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 (
≥
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 a
non-calcified renal lesion. The non fat-containing portion enhances
avidly and
homogeneously. Calcification is almost never present.
。

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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 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 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< br>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 RCC (papillary type) or
AML with
minimal fat. Although an AML typically would enhance more avidly than a papillary RCC,
biopsy is
warranted 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
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。

168

Oncocytoma
嗜酸细胞瘤


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Oncocytoma.
Noncontrast
CT
(left
image)
shows
an
isodense
renal
mass
(yellow
arrows)
containing
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
be
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
subtype.
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:
。

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