腎竇病變的影像診斷

1、腎竇病變的影像診斷,,,【解剖】從腎門進(jìn)入為一擴(kuò)大的腔隙，叫做腎竇，外周為腎實(shí)質(zhì)。為腎動(dòng)，靜脈血管的分支、腎盂和腎大盞、腎小盞所占據(jù)，中間充填以脂肪組織。另外還有植物性神經(jīng)系統(tǒng)的神經(jīng)纖維，淋巴管和不同數(shù)量的.纖維組織。所以腎竇病變可以來(lái)自于其組成成分的任何組織，另外，腎竇還可以被腎實(shí)質(zhì)病變及腹膜后病變所累及。,,腎竇的正常結(jié)構(gòu)組成,,腎竇的正常CT解剖,,腎竇病變可以被分為腫瘤性病變和非腫瘤性病變，非腫瘤性病變包括腎竇脂肪過(guò)多癥，腎

2、竇囊腫，血管性病變。腫瘤性病變分為四類：a: tumors of the renal pelvis, 腎盂腫瘤 b: primary tumors of mesenchymal origin,原發(fā)間葉組織腫瘤 c: tumors of the renal parenchyma that project into the renal sinus, 腎實(shí)質(zhì)腫瘤類及腎竇and d: retroperitoneal tumors that ex

3、tend to the renal sinus. 腹膜后腫瘤擴(kuò)展到腎竇。,,診斷腎竇病變方法包括泌尿系造影術(shù), ultrasonography (US), CT, MRI, 和血管造影等。泌尿系造影術(shù)可用于評(píng)估腎臟收集系統(tǒng)的累及情況。超聲檢查可用于囊腫和實(shí)性腫塊的區(qū)別。CT是評(píng)估腎臟和廣泛的腎竇病變最敏感的，最有效地，最全面的影像方法。最近多排CT的發(fā)展提供了更快的掃描時(shí)間，更薄的層厚獲得更高的空間分辨率。多方位重建能夠更精確的確

4、定復(fù)雜的腎竇病變的范圍。一般來(lái)說(shuō)，冠狀位是觀察腎竇病變的最有用的 。MRI能夠顯示復(fù)雜的腎竇病變的組織特異性，直接的多方位圖像能夠使軸位，失狀位，冠狀位具有同樣的圖像分辨率。并且能夠用于腎衰患者和造影劑過(guò)敏的患者。,,,【非腫瘤性病變】1------脂肪過(guò)多癥正常腎竇內(nèi)含有脂肪，并包裹其他的組織，正常腎竇脂肪含量隨著年齡和肥胖程度逐漸的增加。腎竇脂肪的增加而發(fā)生不正常和引起腎組織的破壞和萎縮，以及內(nèi)源性，外源性類固醇激素的增加相

5、關(guān)聯(lián)。腎竇脂肪過(guò)多癥指脂肪顯著增生而發(fā)生占位效應(yīng)影響腎臟收集系統(tǒng)。腎竇脂肪過(guò)多癥占位效應(yīng)很少引起臨床癥狀是因?yàn)閱渭兊闹具^(guò)多癥不會(huì)引起腎盞梗阻。 泌尿系造影能夠顯示腎竇的透亮區(qū)和拉伸的腎漏斗。超聲能夠顯示腎竇的擴(kuò)大。CT和MRI能夠直接顯示腎竇脂肪過(guò)多癥的脂肪成分。,,76歲，男性，無(wú)癥狀。雙側(cè)腎竇脂肪過(guò)多癥 Excretory urogram shows diffuse elongation and attenuation o

6、f the renal pelvis and infundibula of both kidneys.,,Axial contrast-enhanced CT scan shows proliferation of fat (arrows) in both renal sinuses, a finding suggestive of renal sinus lipomatosis.,,2-------腎竇囊腫腎竇囊腫是一種常見疾病，據(jù)

7、報(bào)道尸檢發(fā)生率為1.28%-- 1.5%。腎盂周圍囊腫，腎盂旁囊腫，腎盂旁淋巴囊腫和淋巴管擴(kuò)張是用來(lái)描述發(fā)生在腎竇內(nèi)的單發(fā)或多發(fā)囊腫得不同形式。有兩種不同的形式，一種形式：多發(fā)的，小的，融合的囊腫，被稱為腎盂周圍囊腫和腎實(shí)質(zhì)外的良性囊腫。他們被認(rèn)為是淋巴源性的，很少引起臨床癥狀，通常是雙側(cè)的。,,在泌尿系造影中腎盂周圍囊腫和腎竇脂肪瘤樣病很難鑒別。在超聲和非增強(qiáng)CT和腎盂積水很難區(qū)別，但是腎盂周圍囊腫不是相互連通的，并且不會(huì)延伸至輸尿

8、管。在腎盂期泌尿系造影和增強(qiáng)CT中兩者區(qū)別是很明顯的。水樣密度的腎竇囊腫勢(shì)增強(qiáng)的腎臟收集系統(tǒng)受壓移位。長(zhǎng)期隨訪直徑?jīng)]有變化，沒有癥狀的腎盂周圍囊腫不需要密切的功能和形態(tài)監(jiān)測(cè)。,,53歲，男性，無(wú)癥狀。腎竇囊腫 Axial contrast-enhanced CT scan obtained during the nephrographic phase shows low-attenuation cystic lesions (ar

9、rows) in the left renal sinus; this finding could be misinterpreted as hydronephrosis.,,Axial contrast-enhanced CT scan obtained during the excretory phase shows the cysts (arrows) in the renal sinus, an appearance diffe

10、rent from that of hydronephrosis. The enhanced calices are stretched and attenuated but not obstructed by the cysts.,,另外一種形式：腎竇內(nèi)單發(fā)的，較大的囊腫。非常像來(lái)自于鄰近地腎實(shí)質(zhì)。被稱為腎盂旁囊腫。通常單發(fā)或者少數(shù)的，偶爾較大的腎盂旁囊腫因?yàn)閴浩妊芟到y(tǒng)和收集系統(tǒng)出現(xiàn)癥狀如高血壓，血尿，局限性腎盂積水。,,54歲，男

11、性，無(wú)癥狀。腎竇囊腫 Excretory urogram shows splaying of the calices and compression of the right renal pelvis (arrows), findings suggestive of a focal lesion.,,Axial contrast-enhanced CT scan shows a single, well-defined, water

12、-attenuation cyst (arrows) protruding into the renal sinus. It has the same appearance as the more common renal cortical cyst (arrowhead).,,但是兩種形式的任何一種都不是臨床和病理研究的重點(diǎn)，故缺乏病理-放射學(xué)相關(guān)資料。腎竇囊腫被推薦用來(lái)描述任何在腎竇內(nèi)發(fā)現(xiàn)的液性密度的囊腫。,,3-----血管病變

13、血管病變，例如腎動(dòng)脈瘤，動(dòng)靜脈吻合，腎靜脈曲張。這些血管性質(zhì)能夠很容易的被彩色多普勒超聲，增強(qiáng)CT, MRI, 和血管造影發(fā)現(xiàn)。,,47歲，男性，重度血尿，腎動(dòng)脈瘤Coronal reformatted CT scan obtained during the corticomedullary phase shows a small saccular aneurysm (arrow) in the right renal sinus.,

14、,腎動(dòng)脈瘤最常見的原因是動(dòng)脈粥樣硬化。動(dòng)脈粥樣硬化的腎動(dòng)脈超過(guò)50%發(fā)生環(huán)形鈣化。在做體外沖擊波碎石術(shù)之前，區(qū)別鈣化的腎動(dòng)脈瘤和腎結(jié)石是非常重要的。對(duì)比增強(qiáng)CT和血管造影腎動(dòng)脈瘤根據(jù)瘤體內(nèi)血栓的多少可發(fā)生不同程度的強(qiáng)化，彩色多普勒超聲能夠發(fā)現(xiàn)具有流體特性的腫塊。,,67歲，男性 ，有高血壓，腎動(dòng)脈瘤內(nèi)部分形成血栓，邊緣鈣化。 Axial unenhanced CT scan shows a large, lobulated, ma

15、sslike lesion with soft-tissue attenuation and rim calcifications (arrows) in the right renal sinus.,,Axial contrast-enhanced CT scan shows that the lesion is vascular (arrows) with a nonenhancing area suggestive of thro

16、mbus (T).,,Direct right renal arteriogram shows the large, saccular, bilobed aneurysm.,,有三種形式的動(dòng)靜脈吻合：先天性動(dòng)靜脈畸形，獲得性動(dòng)靜脈瘺，---腎活檢或其他操作，外傷，惡性腫瘤（多數(shù)為腎細(xì)胞癌），先天性動(dòng)靜脈瘺。獲得性動(dòng)靜脈瘺最常見，占70%–80%，腎活檢是最常見原因。大部分動(dòng)靜脈瘺 臨床癥狀陰性。但是他們可以出現(xiàn)以下任何一種癥狀：重度血尿

17、，腹部雜音，高輸出量心力衰竭，高血壓，腹痛。,,48歲，女性，突發(fā)血尿和右側(cè)腰部疼痛。Retrograde pyelogram shows nonopacification of the lower pole calices and irregular tortuous filling defects in and around the interpolar calices and pelvis (arrows). The pelvi

18、caliceal system is mildly dilated.,,Axial contrast-enhanced CT scan obtained during the corticomedullary phase shows tortuous, dilated, enhancing vascular structures (arrow) in the right renal sinus. Note the mildly dila

19、ted right renal pelvis and the double-J catheter (arrowhead) in the renal pelvis.,,Coronal contrast-enhanced T1-weighted MR image (repetition time msec/echo time msec = 111/4.1) shows the tortuous vascular structures wit

20、h signal void (arrows) along the dilated collecting system.,,Right renal arteriogram shows the entangled vessels of the arteriovenous communication (arrows), which is sometimes referred to as a cirsoid aneurysm, in the l

21、ower polar area of the right kidney.,,4----炎性病變盡管原發(fā)于腎竇內(nèi)炎性病變很少見，但是腎臟炎性病變累及腎竇和腎周并非罕見。有時(shí)炎性病變聚集于腎竇內(nèi)形成假性腫瘤征象。,,18歲，急性白血病患者，發(fā)熱，左側(cè)腰部疼痛。腎臟曲霉菌病 Axial unenhanced CT scan shows a lobulated masslike lesion (arrows) with focal int

22、ernal high attenuation, a finding suggestive of intralesion hemorrhage.,,Coronal reformatted contrast-enhanced CT scan obtained during the excretory phase shows the poorly enhancing, low-attenuation, masslike renal paren

23、chymal lesion extending to the renal sinus (arrow). Analysis of the nephrectomy specimen demonstrated a hemorrhagic mass due to focal invasive aspergillosis. Aspergillosis causes vascular occlusion and multiple renal inf

24、arcts. However, as in this case, differentiation from a tumor is not always easy. （圖片見下頁(yè)）,,,,【腫瘤性病變】1------腎盂腫瘤腎盂惡性腫瘤僅占尿路新生物的5%。移行細(xì)胞癌占約90%，剩余10%為鱗狀上皮細(xì)胞癌。腫瘤起自腎盂中心，侵及腎竇脂肪和腎實(shí)質(zhì)。尿路造影原發(fā)腎盂腫瘤因?yàn)槟[瘤或出血出現(xiàn)充盈缺損，因?yàn)閻盒云茐某霈F(xiàn)腎盞中斷。超聲顯示腎竇內(nèi)

25、脂肪被腫瘤替代。CT和MRI，I和II期的早期移行細(xì)胞癌顯示腎竇內(nèi)脂肪受壓移位，相反，III和IV期侵襲性移行細(xì)胞癌侵犯腎竇內(nèi)脂肪 和侵襲周圍腎實(shí)質(zhì)，引起腎輪廓的改變。,,65歲，男性，左側(cè)腰痛和間歇性血尿一月，移行細(xì)胞癌 Axial contrast-enhanced CT scan obtained during the nephrographic phase shows an ill-defined low-attenuat

26、ion mass (arrow) in the central portion of the left kidney.,,Coronal maximum intensity projection CT scan obtained during the excretory phase shows a large filling defect with an irregular margin (arrows) in the pelvical

27、ices of the left kidney, thus clearly demonstrating the extent of the tumor.,,影像不能區(qū)別移行細(xì)胞癌和鱗狀上皮細(xì)胞癌，鱗狀上皮細(xì)胞癌與腎結(jié)石和尿道上皮細(xì)胞的慢性刺激有關(guān)。腎竇內(nèi)腎結(jié)石的存在提示鱗狀上皮細(xì)胞癌的可能。,,50歲，男性，有慢性腎結(jié)石病史和左側(cè)腰痛---鱗狀上皮細(xì)胞癌 Axial unenhanced CT scan shows a high-

28、attenuation stone (arrow) in the left renal pelvis. A tiny amount of air (arrowhead) due to previously performed percutaneous nephrostomy is seen in the renal sinus.,,Axial contrast-enhanced CT scan obtained during the e

29、xcretory phase shows an infiltrative mass (arrows) in the renal pelvis that extends to the renal parenchyma. Note the metastatic lymph nodes (arrowhead) in the paraaortic space.,,2----原發(fā)間葉組織腫瘤原發(fā)間葉組織腫瘤比較罕見，可以同樣發(fā)生于腎竇，腎包膜和

30、腎實(shí)質(zhì)。良性腫瘤有血管瘤，纖維瘤，平滑肌瘤，血管肌脂瘤，神經(jīng)源性腫瘤，和畸胎瘤。原發(fā)間葉組織的惡性腫瘤有平滑肌肉瘤，纖維肉瘤，脂肪肉瘤，血管外皮細(xì)胞瘤，和惡性纖維組織細(xì)胞瘤。 平滑肌肉瘤是最常見的。,,33歲，男性，重度血尿，左側(cè)腰痛，腎竇靜脈血管瘤。 Axial unenhanced CT scan shows a well-defined high-attenuation lesion (arrows) adjacent t

31、o the left renal pelvis.,,Axial contrast-enhanced CT scan shows that the mass (arrows) has low attenuation and poor enhancement. Because of the possibility of malignancy, left nephrectomy was performed. At pathologic exa

32、mination, the lesion was composed of multiple vascular channels of variable sizes beneath the pelvic mucosa. Renal hemangioma is seldom diagnosed preoperatively but should be included in the differential diagnosis when C

33、T demonstrates poor enhancement of a renal mass located at the pelvicaliceal junction or in the inner medulla.,,,,28歲，女性，重度血尿，腎竇平滑肌瘤 Excretory urogram shows focal smooth mass effect on the pelvicalices of the right kid

34、ney (arrows).,,b) Axial contrast-enhanced CT scan obtained during the nephrographic phase shows a small mass (arrow) with soft-tissue attenuation obliterating the fat in the right renal sinus along the posterior margin o

35、f the renal pelvis.,,Coronal reformatted CT scan shows the round soft-tissue attenuation mass (arrow) in the right renal sinus and mild dilatation of the pelvicaliceal system.,,Photograph of the surgical specimen shows t

36、he well-defined round mass (arrows) in the renal sinus. Microscopic examination demonstrated a renal leiomyoma.,,65歲，女性，左側(cè)腰痛，并可觸及左側(cè)腹部包塊。平滑肌肉瘤 Axial contrast-enhanced CT scan shows a large mass (arrows) with heterogeneo

37、us attenuation expanding the left renal sinus. The renal parenchyma (P) is markedly compressed and displaced laterally.,,Coronal turbo spin-echo T2-weighted MR image (6,500/120) shows the location and extent of the tumor

38、 (arrows). P = renal parenchyma.,,Photograph of the surgical specimen shows the relatively well-defined tumor (arrows) (13 x 9 x 8 cm) in the renal sinus. The tumor has a solid and compact cut surface with central hemorr

39、hage and necrosis. It is confined to the sinus and does not invade the renal parenchyma (P) or pelvis. The adjacent renal parenchyma is compressed by the tumor.,,30歲，女性，血管外皮細(xì)胞瘤Axial contrast-enhanced CT scan shows a lar

40、ge, well-defined mass (M) with soft-tissue attenuation occupying the central portion of the left renal sinus and compressing the enhanced pelvicaliceal system.,,3-----腎實(shí)質(zhì)腫瘤累及腎竇腎實(shí)質(zhì)腫瘤大部分呈球形腫塊，膨脹性生長(zhǎng)。累及腎竇，壓迫或侵犯腎竇脂肪。具有代表性的是腎

41、細(xì)胞癌和良性的多房性囊性腎瘤。,,腎細(xì)胞癌，是最常見的腎實(shí)質(zhì)腫瘤，大部分腎細(xì)胞癌膨脹性生長(zhǎng)通常累及腎竇。導(dǎo)致局部腎盂積水和腎盞移位。累及腎竇的臨床意義在于和移行細(xì)胞癌的區(qū)別，以及腫瘤的分期對(duì)外科治療的影響。不像移行細(xì)胞癌，腎細(xì)胞癌有向腎靜脈延及的趨勢(shì)。腎部分切除術(shù)適用于< 3cm，未侵及腎竇脂肪，腎周脂肪和腎臟收集系統(tǒng)，尤其是在那些腎功能衰減，孤立腎，雙側(cè)腎臟惡性腫瘤的患者。侵及腎竇脂肪意味著腎部分切除術(shù)不能成功的，完全的 切除腫

42、瘤。三維 CT和MRI能夠顯示腎臟腫瘤的位置，和收集系統(tǒng)，靜脈系統(tǒng)的關(guān)系。,,51歲，男性，重度血尿，-----腎細(xì)胞癌侵及腎竇 Coronal reformatted contrast-enhanced CT scan obtained during the excretory phase shows tumor involvement of the renal sinus and the extent of the renal c

43、ell carcinoma (arrows). The pathologic stage was T3b N0.,,多房性囊性腎瘤，是良性的，多房狀，囊性的腫瘤，起源于腎實(shí)質(zhì)。好發(fā)于兩個(gè)年齡階段，少年男性，中年 女性。該腫瘤經(jīng)常突出于腎竇內(nèi)。影像上多房性囊性腎瘤為境界清楚地囊性腫塊，內(nèi)有厚的分隔。,,,,多房性囊性腎瘤 Excretory urogram shows marked splaying of the upper and

44、 lower caliceal systems (arrows) with mild dilatation of the upper pole calix.,,Axial MR image obtained with true fast imaging with steady-state precession (6.3/3.0, 70° flip angle) shows a high-signal-intensity cys

45、tic mass in the left kidney. Note the numerous fine septations without solid components.,,Coronal gadolinium-enhanced T1-weighted MR image (130/4.1) shows herniation of the cystic mass (arrow) into the renal sinus.,,4---

46、---腹膜后腫瘤累及腎竇任何腹膜后腫瘤都可以累及腎竇，典型的例子是淋巴瘤。累及腎竇是腹膜后淋巴瘤的常見表現(xiàn)。多發(fā)于非何杰金氏淋巴瘤。腎血管系統(tǒng)通常是保留存在的，相反，收集系統(tǒng)受累引起腎盂積水。,,56歲，男性，淋巴瘤累及腎實(shí)質(zhì)和腎竇Coronal reformatted CT scan obtained during the nephrographic phase shows a large, relatively homogene

47、ous retroperitoneal mass (arrows) extending to the renal sinus and mild hydronephrosis of the right kidney.,,腎竇淋巴結(jié)轉(zhuǎn)移也可歸于此類，在原發(fā)的生殖腺腫瘤，有豐富的脈管系統(tǒng)和淋巴管系統(tǒng)通向腎竇。,,轉(zhuǎn)移性腎竇淋巴結(jié)腫大Axial contrast-enhanced CT scan shows a soft-tissue att