1、肾窦病变的影像诊断 【解剖】从肾门进入为一扩大的腔隙，叫做肾窦，外周为肾实质。为肾动，静脉血管的分支、肾盂和肾大盏、肾小盏所占据，中间充填以脂肪组织。另外还有植物性神经系统的神经纤维，淋巴管和不同数量的.纤维组织。所以肾窦病变可以来自于其组成成分的任何组织，另外，肾窦还可以被肾实质病变及腹膜后病变所累及。肾窦的正常结构组成 肾窦的正常CT解剖 肾窦病变可以被分为肿瘤性病变和非肿瘤性病变，非肿瘤性病变包括肾窦脂肪过多症，肾窦囊肿，血管性病变。肿瘤性病变分为四类：a:tumors of the renal pelvis,肾盂肿瘤 b:primary tumors of mesenchymal or
2、igin,原发间叶组织肿瘤 c:tumors of the renal parenchyma that project into the renal sinus,肾实质肿瘤类及肾窦and d:retroperitoneal tumors that extend to the renal sinus.腹膜后肿瘤扩展到肾窦。诊断肾窦病变方法包括泌尿系造影术,ultrasonography(US),CT,MRI,和血管造影等。泌尿系造影术可用于评估肾脏收集系统的累及情况。超声检查可用于囊肿和实性肿块的区别。CT是评估肾脏和广泛的肾窦病变最敏感的，最有效地，最全面的影像方法。最近多排CT的发展提供了更
3、快的扫描时间，更薄的层厚获得更高的空间分辨率。多方位重建能够更精确的确定复杂的肾窦病变的范围。一般来说，冠状位是观察肾窦病变的最有用的。MRI能够显示复杂的肾窦病变的组织特异性，直接的多方位图像能够使轴位，失状位，冠状位具有同样的图像分辨率。并且能够用于肾衰患者和造影剂过敏的患者。【非肿瘤性病变】1-脂肪过多症正常肾窦内含有脂肪，并包裹其他的组织，正常肾窦脂肪含量随着年龄和肥胖程度逐渐的增加。肾窦脂肪的增加而发生不正常和引起肾组织的破坏和萎缩，以及内源性，外源性类固醇激素的增加相关联。肾窦脂肪过多症指脂肪显著增生而发生占位效应影响肾脏收集系统。肾窦脂肪过多症占位效应很少引起临床症状是因为单纯的
4、脂肪过多症不会引起肾盏梗阻。泌尿系造影能够显示肾窦的透亮区和拉伸的肾漏斗。超声能够显示肾窦的扩大。CT和MRI能够直接显示肾窦脂肪过多症的脂肪成分。76岁，男性，无症状。双侧肾窦脂肪过多症 Excretory urogram shows diffuse elongation and attenuation of the renal pelvis and infundibula of both kidneys.Axial contrast-enhanced CT scan shows proliferation of fat(arrows)in both renal sinuses,a find
5、ing suggestive of renal sinus lipomatosis.2-肾窦囊肿肾窦囊肿是一种常见疾病，据报道尸检发生率为1.28%-1.5%。肾盂周围囊肿，肾盂旁囊肿，肾盂旁淋巴囊肿和淋巴管扩张是用来描述发生在肾窦内的单发或多发囊肿得不同形式。有两种不同的形式，一种形式：多发的，小的，融合的囊肿，被称为肾盂周围囊肿和肾实质外的良性囊肿。他们被认为是淋巴源性的，很少引起临床症状，通常是双侧的。在泌尿系造影中肾盂周围囊肿和肾窦脂肪瘤样病很难鉴别。在超声和非增强CT和肾盂积水很难区别，但是肾盂周围囊肿不是相互连通的，并且不会延伸至输尿管。在肾盂期泌尿系造影和增强CT中两者区别是很明
6、显的。水样密度的肾窦囊肿势增强的肾脏收集系统受压移位。长期随访直径没有变化，没有症状的肾盂周围囊肿不需要密切的功能和形态监测。53岁，男性，无症状。肾窦囊肿 Axial contrast-enhanced CT scan obtained during the nephrographic phase shows low-attenuation cystic lesions(arrows)in the left renal sinus;this finding could be misinterpreted as hydronephrosis.Axial contrast-enhanced CT
7、 scan obtained during the excretory phase shows the cysts(arrows)in the renal sinus,an appearance different from that of hydronephrosis.The enhanced calices are stretched and attenuated but not obstructed by the cysts.另外一种形式：肾窦内单发的，较大的囊肿。非常像来自于邻近地肾实质。被称为肾盂旁囊肿。通常单发或者少数的，偶尔较大的肾盂旁囊肿因为压迫血管系统和收集系统出现症状如高血
8、压，血尿，局限性肾盂积水。54岁，男性，无症状。肾窦囊肿 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-attenuation cyst(arrows)protruding into the renal sinus.It has the sa
9、me appearance as the more common renal cortical cyst(arrowhead).但是两种形式的任何一种都不是临床和病理研究的重点，故缺乏病理-放射学相关资料。肾窦囊肿被推荐用来描述任何在肾窦内发现的液性密度的囊肿。3-血管病变血管病变，例如肾动脉瘤，动静脉吻合，肾静脉曲张。这些血管性质能够很容易的被彩色多普勒超声，增强CT,MRI,和血管造影发现。47岁，男性，重度血尿，肾动脉瘤Coronal reformatted CT scan obtained during the corticomedullary phase shows a small
10、saccular aneurysm(arrow)in the right renal sinus.肾动脉瘤最常见的原因是动脉粥样硬化。动脉粥样硬化的肾动脉超过50%发生环形钙化。在做体外冲击波碎石术之前，区别钙化的肾动脉瘤和肾结石是非常重要的。对比增强CT和血管造影肾动脉瘤根据瘤体内血栓的多少可发生不同程度的强化，彩色多普勒超声能够发现具有流体特性的肿块。67岁，男性，有高血压，肾动脉瘤内部分形成血栓，边缘钙化。Axial unenhanced CT scan shows a large,lobulated,masslike lesion with soft-tissue attenuatio
11、n 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 thrombus(T).Direct right renal arteriogram shows the large,saccular,bilobed aneurysm.有三种形式的动静脉吻合：先天性动静脉畸形，获得性动静脉瘘，-肾活检或其他操作，外伤，恶性肿瘤
12、（多数为肾细胞癌），先天性动静脉瘘。获得性动静脉瘘最常见，占70%80%，肾活检是最常见原因。大部分动静脉瘘 临床症状阴性。但是他们可以出现以下任何一种症状：重度血尿，腹部杂音，高输出量心力衰竭，高血压，腹痛。48岁，女性，突发血尿和右侧腰部疼痛。Retrograde pyelogram shows nonopacification of the lower pole calices and irregular tortuous filling defects in and around the interpolar calices and pelvis(arrows).The pelvica
13、liceal 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 dilated right renal pelvis and the double-J catheter(arrowhead)in the renal pelvis.Coronal co
14、ntrast-enhanced T1-weighted MR image(repetition time msec/echo time msec=111/4.1)shows the tortuous vascular structures with signal void(arrows)along the dilated collecting system.Right renal arteriogram shows the entangled vessels of the arteriovenous communication(arrows),which is sometimes referr
15、ed to as a cirsoid aneurysm,in the lower polar area of the right kidney.4-炎性病变尽管原发于肾窦内炎性病变很少见，但是肾脏炎性病变累及肾窦和肾周并非罕见。有时炎性病变聚集于肾窦内形成假性肿瘤征象。18岁，急性白血病患者，发热，左侧腰部疼痛。肾脏曲霉菌病 Axial unenhanced CT scan shows a lobulated masslike lesion(arrows)with focal internal high attenuation,a finding suggestive of intralesi
16、on hemorrhage.Coronal reformatted contrast-enhanced CT scan obtained during the excretory phase shows the poorly enhancing,low-attenuation,masslike renal parenchymal lesion extending to the renal sinus(arrow).Analysis of the nephrectomy specimen demonstrated a hemorrhagic mass due to focal invasive
17、aspergillosis.Aspergillosis causes vascular occlusion and multiple renal infarcts.However,as in this case,differentiation from a tumor is not always easy.（图片见下页）【肿瘤性病变】1-肾盂肿瘤肾盂恶性肿瘤仅占尿路新生物的5%。移行细胞癌占约90%，剩余10%为鳞状上皮细胞癌。肿瘤起自肾盂中心，侵及肾窦脂肪和肾实质。尿路造影原发肾盂肿瘤因为肿瘤或出血出现充盈缺损，因为恶性破坏出现肾盏中断。超声显示肾窦内脂肪被肿瘤替代。CT和MRI，I和II期
18、的早期移行细胞癌显示肾窦内脂肪受压移位，相反，III和IV期侵袭性移行细胞癌侵犯肾窦内脂肪 和侵袭周围肾实质，引起肾轮廓的改变。65岁，男性，左侧腰痛和间歇性血尿一月，移行细胞癌 Axial contrast-enhanced CT scan obtained during the nephrographic phase shows an ill-defined low-attenuation mass(arrow)in the central portion of the left kidney.Coronal maximum intensity projection CT scan obt
19、ained during the excretory phase shows a large filling defect with an irregular margin(arrows)in the pelvicalices of the left kidney,thus clearly demonstrating the extent of the tumor.影像不能区别移行细胞癌和鳞状上皮细胞癌，鳞状上皮细胞癌与肾结石和尿道上皮细胞的慢性刺激有关。肾窦内肾结石的存在提示鳞状上皮细胞癌的可能。50岁，男性，有慢性肾结石病史和左侧腰痛-鳞状上皮细胞癌 Axial unenhanced CT
20、 scan shows a high-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 excretory phase shows an infiltrative mass(arrows)in the renal pelvis
21、 that extends to the renal parenchyma.Note the metastatic lymph nodes(arrowhead)in the paraaortic space.2-原发间叶组织肿瘤原发间叶组织肿瘤比较罕见，可以同样发生于肾窦，肾包膜和肾实质。良性肿瘤有血管瘤，纤维瘤，平滑肌瘤，血管肌脂瘤，神经源性肿瘤，和畸胎瘤。原发间叶组织的恶性肿瘤有平滑肌肉瘤，纤维肉瘤，脂肪肉瘤，血管外皮细胞瘤，和恶性纤维组织细胞瘤。平滑肌肉瘤是最常见的。33岁，男性，重度血尿，左侧腰痛，肾窦静脉血管瘤。Axial unenhanced CT scan shows a wel
22、l-defined high-attenuation lesion(arrows)adjacent to 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 examination,the lesion was composed of
23、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 CT demonstrates poor enhancement of a renal mass located at the pelvicaliceal junction or in the inner medulla.28岁，女性，重
24、度血尿，肾窦平滑肌瘤 Excretory urogram shows focal smooth mass effect on the pelvicalices of the right kidney(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 posterio
25、r margin of 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 the well-defined round mass(arrows)in the renal sinus.Microscopic examination
26、 demonstrated a renal leiomyoma.65岁，女性，左侧腰痛，并可触及左侧腹部包块。平滑肌肉瘤 Axial contrast-enhanced CT scan shows a large mass(arrows)with heterogeneous attenuation expanding the left renal sinus.The renal parenchyma(P)is markedly compressed and displaced laterally.Coronal turbo spin-echo T2-weighted MR image(6,50
27、0/120)shows the location and extent of the tumor(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 hemorrhage and necrosis.It is confined to the si
28、nus and does not invade the renal parenchyma(P)or pelvis.The adjacent renal parenchyma is compressed by the tumor.30岁，女性，血管外皮细胞瘤Axial contrast-enhanced CT scan shows a large,well-defined mass(M)with soft-tissue attenuation occupying the central portion of the left renal sinus and compressing the enh
29、anced pelvicaliceal system.3-肾实质肿瘤累及肾窦肾实质肿瘤大部分呈球形肿块，膨胀性生长。累及肾窦，压迫或侵犯肾窦脂肪。具有代表性的是肾细胞癌和良性的多房性囊性肾瘤。肾细胞癌，是最常见的肾实质肿瘤，大部分肾细胞癌膨胀性生长通常累及肾窦。导致局部肾盂积水和肾盏移位。累及肾窦的临床意义在于和移行细胞癌的区别，以及肿瘤的分期对外科治疗的影响。不像移行细胞癌，肾细胞癌有向肾静脉延及的趋势。肾部分切除术适用于 3cm，未侵及肾窦脂肪，肾周脂肪和肾脏收集系统，尤其是在那些肾功能衰减，孤立肾，双侧肾脏恶性肿瘤的患者。侵及肾窦脂肪意味着肾部分切除术不能成功的，完全的 切除肿瘤。三维
30、CT和MRI能够显示肾脏肿瘤的位置，和收集系统，静脉系统的关系。51岁，男性，重度血尿，-肾细胞癌侵及肾窦 Coronal reformatted contrast-enhanced CT scan obtained during the excretory phase shows tumor involvement of the renal sinus and the extent of the renal cell carcinoma(arrows).The pathologic stage was T3b N0.多房性囊性肾瘤，是良性的，多房状，囊性的肿瘤，起源于肾实质。好发于两个年龄阶
31、段，少年男性，中年 女性。该肿瘤经常突出于肾窦内。影像上多房性囊性肾瘤为境界清楚地囊性肿块，内有厚的分隔。多房性囊性肾瘤 Excretory urogram shows marked splaying of the upper and 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 h
32、igh-signal-intensity cystic 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-腹膜后肿瘤累及肾窦任何腹膜后肿瘤都可以累及肾窦，典型的例子是淋巴瘤。累及肾窦是腹膜后淋巴瘤的常见表现。多发于非何杰金氏淋巴瘤。肾血管系
33、统通常是保留存在的，相反，收集系统受累引起肾盂积水。56岁，男性，淋巴瘤累及肾实质和肾窦Coronal reformatted CT scan obtained during the nephrographic phase shows a large,relatively homogeneous retroperitoneal mass(arrows)extending to the renal sinus and mild hydronephrosis of the right kidney.肾窦淋巴结转移也可归于此类，在原发的生殖腺肿瘤，有丰富的脉管系统和淋巴管系统通向肾窦。转移性肾窦淋巴结肿大Axial contrast-enhanced CT scan shows a soft-tissue attenuation mass(arrows)in the right renal sinus with obstructive hydronephrosis.
