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胰腺囊腺瘤與囊腺癌39例的CT影像學(xué)特征

2011-11-21 10:17杜麗娟詹茜邵成偉盧明智左長京呂桃珍陸建平
中華胰腺病雜志 2011年3期
關(guān)鍵詞:性囊胰管黏液

杜麗娟 詹茜 邵成偉 盧明智 左長京 呂桃珍 陸建平

·論著·

胰腺囊腺瘤與囊腺癌39例的CT影像學(xué)特征

杜麗娟 詹茜 邵成偉 盧明智 左長京 呂桃珍 陸建平

目的探討胰腺囊腺瘤與囊腺癌的CT影像學(xué)特征。方法回顧性分析經(jīng)過病理證實(shí)的21例漿液性囊腺瘤、12例黏液性囊腺瘤、6例黏液性囊腺癌的CT影像學(xué)資料,分析腫瘤部位、單(多)囊、最大囊直徑、囊壁特征、囊內(nèi)分隔、腫瘤邊界、腫瘤與胰管關(guān)系等影像學(xué)征象。結(jié)果21例漿液性囊腺瘤中17例位于胰頭頸部,5例位于胰體尾部,其中1例為多發(fā);均為多囊,平均最大囊直徑為1.8 cm;4例囊壁或分隔有鈣化,7例分隔可見軟組織成分;10例胰管輕度增寬。12例黏液性囊腺瘤中6例位于胰頭頸部,6例位于胰體尾部;4例為多囊,平均最大囊直徑為4.5 cm;1例分隔可見鈣化,6例囊壁可見軟組織成分;2例胰管擴(kuò)張,3例胰管輕度增寬。6例黏液性囊腺癌中5例位于胰體尾部,1例位于胰頭頸部;4例為多囊,平均最大囊直徑為5.1 cm;1例分隔可見鈣化,5例囊壁可見軟組織成分;1例胰管擴(kuò)張,1例胰管輕度增寬。所有病灶與胰管均不相通,增強(qiáng)后病灶軟組織成分及分隔均有不同程度強(qiáng)化。結(jié)論胰腺囊腺瘤與囊腺癌的CT表現(xiàn)具有一定的特征性,但對于少數(shù)不典型表現(xiàn)病例,診斷仍存在困難。

胰腺腫瘤; 囊腺瘤; 囊腺癌; 體層攝影術(shù),X線計(jì)算機(jī); 磁共振成像

胰腺囊性腫瘤較少見,約占胰腺腫瘤的10%,占惡性胰腺腫瘤的2%~4%[1],其中以漿液性囊腺瘤和黏液性囊腺瘤最為常見。近年來,影像學(xué)技術(shù)的發(fā)展與應(yīng)用,使得該病的檢出率不斷提高[2]。本研究回顧性分析已經(jīng)獲得病理診斷的39例胰腺囊腺瘤及囊腺癌患者的CT影像資料,以期進(jìn)一步探討與總結(jié)它們的CT特征。

材料與方法

一、一般材料

收集2005年至2010年我院收治的經(jīng)病理證實(shí)的39例胰腺囊性腫瘤患者的CT影像資料,其中男13例、女26例,年齡28~85歲。主要臨床表現(xiàn)為中上腹隱痛、腰背部脹痛(18例)或無明顯癥狀體檢發(fā)現(xiàn)胰腺占位(21例)。最后確診漿液性囊腺瘤21例,黏液性囊腺瘤12例,黏液性囊腺癌患者6例。

二、CT檢查方法

采用64排螺旋 CT(西門子)掃描儀進(jìn)行掃描,平掃后行增強(qiáng)掃描。增強(qiáng)掃描采用CT專用高壓注射器團(tuán)注射對比劑碘海醇80~100 ml,注射流率為3~4 ml/s,分別于注藥開始后延遲20~25、40~50、85~100 s掃描獲得動(dòng)脈期、胰腺期和肝臟期圖像。重建層厚為3 mm。由影像科主任醫(yī)師讀片。最大囊直徑取長徑與短徑的平均值。胰管直徑≤3 mm為輕度增寬,>3 mm為擴(kuò)張[3]。

結(jié) 果

一、漿液性囊腺瘤的CT征象

21例漿液性囊腺瘤中,17例位于胰頭頸部,5例位于胰體尾部,其中1例為多發(fā)。病灶為圓形或類圓形。21例均為多囊,內(nèi)見分隔(圖1a),邊緣清晰。最大囊直徑0.5~7.0 cm,平均為1.8 cm。4例見病灶鈣化,其中1例囊壁鈣化,3例分隔鈣化,為斑點(diǎn)狀或斑片狀而非放射狀。7例囊壁見軟組織成分,其中1例軟組織成分多于囊性成分。增強(qiáng)后病灶軟組織成分及分隔均有強(qiáng)化(圖1b),其中1例軟組織成分較多,且明顯強(qiáng)化,被誤診為胰島細(xì)胞瘤。10例患者胰管輕度增寬,11例胰管未顯示。病灶與胰管均無溝通。

圖1 漿液性囊腺瘤的CT征象

二、黏液性囊腺瘤的CT征象

12例黏液性囊腺瘤中,6例位于胰頭頸部,6例位于胰體尾部。病灶為圓形、類圓形或不規(guī)則形。4例為多囊,內(nèi)見分隔(圖2);8例為單囊,其中1例囊內(nèi)見稍高密度液平。3例病灶與周圍組織境界欠清,邊緣模糊。最大囊直徑0.8~9.0 cm,平均為4.5 cm。1例分隔見鈣化。6例囊壁見軟組織成分。增強(qiáng)后囊壁、分隔及病灶軟組織有不同程度強(qiáng)化。2例胰管擴(kuò)張,3例胰管輕度增寬,7例胰管未顯示。病灶與胰管均未溝通。

三、黏液性囊腺癌的CT征象

6例黏液性囊腺癌中,1例位于胰頭頸部,5例位于胰體尾部。病灶為圓形、類圓形或不規(guī)則形。4例為多囊,內(nèi)見分隔;2例為單囊。病灶邊緣模糊,與周圍組織分界欠清。最大囊直徑2.3~10.5 cm,平均為5.1 cm。1例分隔可見鈣化。5例囊壁可見軟組織,突向囊腔(圖3)。增強(qiáng)后囊壁、分隔及病灶軟組織成分均有不同程度強(qiáng)化。1例胰管擴(kuò)張,1例胰管輕度增寬,4例胰管未顯示。另外,5例有肝轉(zhuǎn)移灶。

圖2黏液性囊腺瘤的CT征象圖3黏液性囊腺癌的CT征象

討 論

Compagno等[4]于1978年將胰腺囊腺瘤分為漿液性囊腺瘤和黏液性囊腺瘤。前者起源于胰腺腺泡的中心細(xì)胞,故腫塊常由多個(gè)小囊構(gòu)成,囊內(nèi)壁為富含糖原的扁平或立方上皮細(xì)胞,囊內(nèi)液體多清亮,大體切面腫塊呈分葉狀。后者起源于胰腺外周的導(dǎo)管上皮,腫塊一般較大,可單囊或多囊,囊壁常有較完整的包膜,內(nèi)襯具有分泌黏液功能的高柱狀上皮,局部可見乳頭狀突起,囊腔內(nèi)含有黏液。囊腺癌囊壁上皮常不規(guī)整,囊內(nèi)可見腫物。漿液性囊腺瘤好發(fā)于胰頭頸部,黏液性囊腺瘤(癌)好發(fā)于胰體尾部[5]。本組CT結(jié)果與之大致相符。

CT征象方面,漿液性囊腺瘤表現(xiàn)為邊界清楚的圓形或類圓形囊實(shí)性腫塊,邊緣可呈分葉狀,內(nèi)呈多囊型,可見分隔,以單囊直徑≤2 cm的小囊最為多見[1]。黏液性囊腺瘤(癌)亦表現(xiàn)為邊界較清的圓形或類圓形囊實(shí)性腫塊,邊緣可分葉,腫塊內(nèi)分隔不如漿液性囊腺瘤多見,囊壁較厚。本組資料顯示,漿液性囊腺瘤均為多囊型,81%的囊最大直徑≤2 cm,67%為單囊,平均最大囊直徑為4.5 cm;而33%的黏液性囊腺癌為單囊,平均最大直徑為5.1 cm。黏液性囊腺瘤(癌)單囊直徑明顯大于漿液性囊腺瘤,與Curry等[6]的報(bào)道結(jié)果一致。

囊壁、分隔的鈣化可為本病的診斷及鑒別診斷提供參考。漿液性囊腺瘤較黏液性囊腺瘤(癌)更易發(fā)生變性、鈣化;其中漿液性囊腺瘤病灶中心的放射狀鈣化較具特征性[7]。本組19%的漿液性囊腺瘤、8%的黏液性囊腺瘤、17%的黏液性囊腺癌有鈣化,鈣化形態(tài)均為斑點(diǎn)狀或斑片狀而非典型的放射狀,可能與病灶鈣化程度速度不一致有關(guān)。與Curry等[6]的報(bào)道結(jié)果不完全一致。

病灶中軟組織成分及其強(qiáng)化狀況對于疾病的診斷具一定參考價(jià)值。Procacci等[8]認(rèn)為,病灶軟組織成分的增多,病變惡性的可能性也隨之增大。本組33%的漿液性囊腺瘤的囊壁及分隔可見軟組織,其中1例軟組織成分多于囊性成分,增強(qiáng)后軟組織明顯強(qiáng)化,該例被誤診為胰島細(xì)胞瘤。本組50%黏液性囊腺瘤囊壁可見軟組織成分,83%黏液性囊腺癌囊壁可見軟組織,增強(qiáng)后軟組織成分均有不同程度強(qiáng)化,與文獻(xiàn)報(bào)道大致相符。

漿液性囊腺瘤、黏液性囊腺瘤(癌)的囊腔與胰管均未見相通。部分病例胰管擴(kuò)張或增寬可能與腫塊壓迫造成遠(yuǎn)端胰管胰液引流不暢所致。

黏液性囊腺瘤需要與胰腺囊腫、胰腺實(shí)性假乳頭狀瘤(SPTP)相鑒別。黏液性囊腺瘤好發(fā)于中年女性,單囊或多囊,囊壁、分隔均可見軟組織成分,增強(qiáng)后不同程度強(qiáng)化;潴留性囊腫位于阻塞胰管遠(yuǎn)端,張力高,無分隔;假性囊腫常伴有重癥急性胰腺炎或慢性胰腺炎表現(xiàn),或有外傷病史,多位于胰腺外,可有分隔;SPTP好發(fā)于年輕女性,病灶軟組織成分較多,可表現(xiàn)為實(shí)性腫塊或囊實(shí)性腫塊,腫塊包膜完整,邊緣清晰,囊性成分內(nèi)可見出血改變。

囊腺癌主要與胰腺癌、惡性導(dǎo)管內(nèi)乳頭狀黏液性腫瘤(IPMN)鑒別。IPMN好發(fā)于男性,病灶通常與主胰管相通,表現(xiàn)為胰管的擴(kuò)張,囊內(nèi)可見乳頭狀突起。囊腺癌表現(xiàn)為邊緣不清的囊性腫塊,可見分隔,囊壁及分隔可見軟組織密度結(jié)節(jié)影,胰管擴(kuò)張不明顯,對鄰近組織的侵犯不明顯,有時(shí)可見遠(yuǎn)處轉(zhuǎn)移灶;胰腺癌表現(xiàn)為低密度實(shí)性病灶,增強(qiáng)后強(qiáng)化不明顯,腫塊內(nèi)囊變壞死較少見,常侵犯鄰近組織,腫塊較大時(shí)鑒別有一定困難。

[1] 郭啟勇.實(shí)用放射學(xué).北京:人民衛(wèi)生出版社,2007:882.

[2] Sahani DV,Kadavigere R,Saokar A,et al.Cystic pancreatic lesions:a simple imaging-based classification system for guiding management.Radiographics,2005,25:1471-1484.

[3] 周康榮.醫(yī)學(xué)影像診斷學(xué)∥腹部CT.上海:上海醫(yī)科大學(xué)出版社,1994:116.

[4] Compagno J,Oertel JE.Microcystica denomas of the pancreas(glycogen-richcystadenomas):a clinicopathologic study of 34 cases.Am J Clin Pathol,1978,69:289-298.

[5] 袁東,余衛(wèi),任小波. 胰腺囊腺瘤的多層螺旋CT表現(xiàn)特征及診斷準(zhǔn)確性.中國醫(yī)學(xué)科學(xué)院學(xué)報(bào),2007,29:232-237.

[6] Curry CA,Eng J,Horton KM,et al.CT of primary cystic pancreaticneoplasms:can CT be used for patient triage and treatment?AJR,2000,175:99-103.

[7] Kim YH,Saini S,Sahani D,et al.Imaging diagnosis of cystic pancreatic lesions:pseudocyst versus nonpseudocyst.Radiographics,2005,25:671-685.

[8] Procacci C,Carbognin G,Accordini S.CT features of malignant mucinous cystic tumors of the pancreas.Eur Radio,2001,11:1626-1630.

2011-03-08)

(本文編輯:呂芳萍)

RadiologicalfeaturesofCTofpancreaticcystadenomasandcystadenocarcinomas:areportof39cases

DULi-juan,ZHANQian,SHAOCheng-wei,LUMing-zhi,ZUOChang-jing,LüTao-zhen,LUJian-ping

DepartmentofRadiology,GeneralHospitaloftheShanghaiPrisonAdministration,Shanghai200082,China

Correspondingauthor:SHAOCheng-wei,Email:cwshao@sina.com

ObjectiveTo investigate the CT radiological features of pancreatic cystadenomas and cystadenocarcinomas.MethodsThe CT scans from 39 patients with pathologically proven cystic pancreatic tumors (21 cases of serous cystadenomas, 12 cases of mucinous cystadenomas, and 6 cases of mucinous cystadenocarcinomas) were retrospectively analyzed. Tumor location, the number of cyst (polycystic or not), diameter of the largest cyst, features of the cyst wall, partition within cyst, border of tumor, and the relationship between tumors and pancreatic duct were recorded.ResultsIn 21 patients with serous cystadenomas, tumors were located at the pancreatic head and neck areas in 17 cases, at the pancreatic body and tail areas in 5 cases, and 1 case was multiple. All 21 cases were polycystic; the median diameter of the largest cyst was 1.77 cm; calcification was seen in cyst wall or partition in 4 cases and soft tissue was seen in 7 cases; mild pancreatic duct dilatation was found in 10 cases. In 12 patients with mucinous cystadenomas, tumors were located at the pancreatic head and neck areas in 6 cases, at the pancreatic body and tail areas in 6 cases; 4 cases were polycystic; the median diameter of the largest cyst was 4.88cm; calcification was seen in 1 case and soft tissue was seen in 6 cases; pancreatic duct dilatation was found in 2 cases and mild duct dilatation was found in 3 cases. In 6 patients with mucinous cystadenocarcinomas, tumors were located at the pancreatic body and tail areas in 5 cases, tumor was located at the pancreatic head and neck areas in 1 case; 4 cases were polycystic; the median diameter of the largest cyst was 5.09 cm; calcification was seen in 1 case and soft tissue was seen in 5 cases; duct dilatation was found in 1 case. In all cases, there was no pancreatic duct communication. After enhancement, the soft tissue and partition of lesion was enhanced to some extent.ConclusionsThere are CT radiological features of pancreatic cystadenomas and cystadenocarcinomas. However, there are still some atypical CT appearances that may challenge the diagnosis.

Pancreatic neoplasms; Cystadenomas; Cystadenocarcinomas; Tomography, X-ray computed; Magnetic resonance imaging

10.3760/cma.j.issn.1674-1935.2011.03.006

200082 上海,上海市監(jiān)獄管理局總醫(yī)院放射科(杜麗娟);第二軍醫(yī)大學(xué)長海醫(yī)院放射科(詹茜、邵成偉、呂桃珍、陸建平),放療科(盧明智),核醫(yī)學(xué)科(左長京)

共同第一作者:詹茜

邵成偉,Email:cwshao@sina.com

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