周 鶯董素貞殷敏智馬 婧鐘玉敏
兒童常見(jiàn)腹膜、網(wǎng)膜和腸系膜實(shí)體腫瘤的CT診斷
周 鶯1董素貞1殷敏智2馬 婧2鐘玉敏1
目的:分析兒童常見(jiàn)腹膜、網(wǎng)膜和腸系膜實(shí)體腫瘤的CT表現(xiàn),以提高對(duì)該部位實(shí)體腫瘤的認(rèn)識(shí)。方法:回顧性分析2006年6月至2015年8月經(jīng)CT診斷的兒童腹膜、網(wǎng)膜和腸系膜實(shí)體腫瘤共36例,包括炎性肌纖維母細(xì)胞瘤(IMT)5例,Castleman?。–D)6例,淋巴管畸形(LM)9例, Burkitt淋巴瘤11例,橫紋肌肉瘤(RS)5例。分析這5種實(shí)體腫瘤的臨床資料和影像學(xué)表現(xiàn),總結(jié)影像學(xué)特征。結(jié)果:①5例IMT,1例位于胰腺尾部后方,4例位于腹腔內(nèi)腹膜、網(wǎng)膜和腸系膜根部。增強(qiáng)后5例腫塊的實(shí)質(zhì)性部分均呈逐漸強(qiáng)化。②6例CD,3例位于腹腔內(nèi)腸系膜間隙,1例位于小網(wǎng)膜囊,2例位于脊柱前方、后腹膜大血管周圍。5例為單發(fā),1例為多發(fā)。增強(qiáng)后6例均為均勻強(qiáng)化,其中2例增強(qiáng)后邊緣有條狀明顯強(qiáng)化。③9例LM,3例位于左下腹與盆腔入口處,2例位于右下腹,4例占據(jù)大部分腹腔及盆腔,增強(qiáng)后腫塊中央分隔有強(qiáng)化。④Burkitt淋巴瘤11例,6例為腹、盆腔彌漫性腫塊,侵犯腸壁及系膜,1例表現(xiàn)為右腹部及盆腔2個(gè)腫塊,1例表現(xiàn)為肝門及下腹部2個(gè)腫塊,3例表現(xiàn)為腹腔內(nèi)單一腫塊。增強(qiáng)后均呈輕度明顯不均勻強(qiáng)化。⑤5例RS,3例為腹腔至盆腔的巨大腫塊,2例為盆腔內(nèi)腫塊。增強(qiáng)后均呈明顯不均勻強(qiáng)化。結(jié)論:兒童腹膜、網(wǎng)膜和腸系膜來(lái)源的實(shí)體腫瘤相對(duì)成人少見(jiàn),年長(zhǎng)兒童與幼兒發(fā)生的腫瘤種類又有明顯不同。CT能較好地提示該部位腫瘤的影像學(xué)特征。了解這幾種常見(jiàn)腫瘤的影像學(xué)表現(xiàn),能為診斷和鑒別診斷提供方便,同時(shí)對(duì)病人的治療提供更好的建議。
腹膜;網(wǎng)膜;腸系膜;兒童;實(shí)體腫瘤;體層攝影術(shù),X線計(jì)算機(jī)
兒童實(shí)質(zhì)性器官起源的腹、盆腔腫瘤十分常見(jiàn),但實(shí)質(zhì)臟器以外的組織如腹膜、網(wǎng)膜、腸系膜起源的腫瘤卻比較少見(jiàn)。了解這些部位起源的腫瘤對(duì)選擇合適的臨床治療手段十分重要。這組腫瘤主要包括炎性肌纖維母細(xì)胞瘤(IMT)、Castleman?。–D)、腸系膜硬纖維瘤、淋巴管畸形(LM)、Burkitt淋巴瘤、橫紋肌肉瘤(RS)、促結(jié)締組織增生性小圓細(xì)胞腫瘤等[1]。本研究回顧性分析2006年6月至2015年8月我院經(jīng)CT診斷的腹膜、網(wǎng)膜和腸系膜起源實(shí)體腫瘤共36例,分析其影像學(xué)表現(xiàn),以提高對(duì)本病認(rèn)識(shí)。
1.臨床資料
搜集我院自2006年6月至2015年8月經(jīng)CT檢查診斷的兒童腹膜、網(wǎng)膜和腸系膜實(shí)體腫瘤共36例,所有病例均經(jīng)病理證實(shí)。包括:IMT5例,CD6例,LM9例,Burkitt淋巴瘤11例,RS5例。分析這5種腫瘤的臨床資料和影像表現(xiàn),總結(jié)影像特征。
36例中,男21例,女15例。IMT5例,男2例,女3例;CD 6例,男、女各3例;LM 9例,男4例,女5例;Burkitt淋巴瘤11例,男8例,女3例;RS 5例,男4例,女1例。36例病例,年齡55天~18歲,平均年齡5.5歲。年齡最小55天,為L(zhǎng)M病例,最大的18歲,為CD病例。
IMT5例,1例表現(xiàn)為發(fā)熱后B超發(fā)現(xiàn)占位,3例發(fā)現(xiàn)下腹膨隆,1例反復(fù)腹痛2月;CD6例,無(wú)意中發(fā)現(xiàn)腫塊2例,反復(fù)發(fā)熱2例,發(fā)熱伴腹痛1周1例,發(fā)熱伴雙下肢腫脹1例;LM9例,反復(fù)腹痛5例,因呼吸道感染行體檢發(fā)現(xiàn)3例,孕期超聲發(fā)現(xiàn)腹部囊腫1例; Burkitt淋巴瘤11例,無(wú)意中發(fā)現(xiàn)腹部膨隆3例,腹痛伴嘔吐3例,發(fā)現(xiàn)頸部腫塊2例,便血1例,下肢疼痛伴足部腫脹1例,面蒼伴牙齒、脊柱疼痛1例;RS5例,下腹隱痛1例,下腹膨隆2例,排尿困難1例,反復(fù)尿路感染1例。
2.影像檢查
36例病例,全部進(jìn)行CT低劑量增強(qiáng)掃描。使用GE Discovery 750HD 64排螺旋CT或GE Light speed 16排螺旋CT。GE Discovery 750HD 64排螺旋CT掃描參數(shù)為層厚8~10mm, 100kV,自動(dòng)mA;GE Light speed 16排螺旋CT掃描參數(shù)為層厚8~10mm, 80kV,50mA。機(jī)器均自動(dòng)重建層厚為1.25mm,并在工作站進(jìn)行腫瘤三維重建。掃描范圍包括整個(gè)腫瘤。對(duì)比劑為歐乃派克2ml/kg,不配合小兒選用水合氯醛0.5ml/kg體重口服或灌腸鎮(zhèn)靜。
5例IMT:1例位于胰腺尾部后方(圖1),大小為6.12cm×4.96cm×6.72cm,邊界清晰,平掃無(wú)明顯鈣化,密度稍欠均勻,增強(qiáng)后實(shí)質(zhì)性部分呈逐漸強(qiáng)化,周圍部分強(qiáng)化更明顯,胰腺尾部受壓明顯;4例位于腹腔內(nèi)腸系膜根部,體積最大的為15.0cm×7.8cm×14.0cm,最小的為7.34cm×5.65cm×9.79cm,腫塊邊界清晰,平掃腫瘤密度稍欠均勻,其中1例內(nèi)部有條狀鈣化,增強(qiáng)后腫瘤均表現(xiàn)為不均勻強(qiáng)化,其中實(shí)質(zhì)性部分呈逐漸強(qiáng)化。5例病灶與周圍組織分界均清晰,無(wú)明顯侵襲性,腹腔內(nèi)均無(wú)明顯腹水。
圖2 男性,10歲,中腹部Castleman病。A.CT平掃顯示腹腔內(nèi)軟組織密度腫塊,邊界清晰。B、C.增強(qiáng)顯示腫瘤呈均勻強(qiáng)化,邊緣有明顯的血管影。
圖3 女性,20個(gè)月,大網(wǎng)膜來(lái)源胚胎性橫紋肌肉瘤。A.CT平掃顯示下腹部至盆腔巨大軟組織密度腫塊,膀胱受壓明顯,平掃見(jiàn)鈣化灶,腹腔內(nèi)見(jiàn)少量腹水。B.橫斷面增強(qiáng)顯示腫瘤呈較明顯不均勻強(qiáng)化。C.冠狀面重建顯示腫瘤內(nèi)部見(jiàn)新生腫瘤血管,腸系膜血管受壓明顯。
6例CD:3例位于腹腔內(nèi)腸系膜間隙(圖2),1例位于小網(wǎng)膜囊,2例位于脊柱前方、后腹膜大血管周圍。5例為單發(fā),1例為多發(fā)。單發(fā)腫塊最大為3.56cm×4.87cm×5.13cm,多發(fā)腫塊最大約1.91cm×1.53cm×1.46cm,腫塊邊界清晰,邊緣光滑,平掃均無(wú)明顯鈣化。增強(qiáng)后6例為均勻輕度強(qiáng)化,2例增強(qiáng)后邊緣強(qiáng)化較明顯。6例病例腹腔內(nèi)均未見(jiàn)明顯腹水。
9例LM:3例位于左下腹與盆腔入口處,2例位于右下腹,4例占據(jù)大部分腹腔及盆腔,范圍為3.66cm ×3.70cm×3.03cm~21.01cm×4.93cm×12.60cm,腫塊邊緣清晰,平掃腫塊表現(xiàn)為囊性低密度影,無(wú)明顯鈣化,增強(qiáng)后腫塊中央分隔有強(qiáng)化,其余成分不強(qiáng)化。9例病例均無(wú)鈣化及腹水。
11例Burkitt淋巴瘤:6例表現(xiàn)為腹腔及盆腔彌漫性腫塊,侵犯腸壁及系膜,1例表現(xiàn)為右腹部及盆腔共2個(gè)腫塊,1例表現(xiàn)為肝門及下腹部共2個(gè)腫塊,3例表現(xiàn)為腹腔內(nèi)單一腫塊,平掃腫塊密度不均勻,均無(wú)明顯鈣化,增強(qiáng)后腫塊均呈輕度明顯不均勻強(qiáng)化。腫塊最大為10.46cm×7.12cm×11.43cm。11例病例中伴有胸腔積液7例,2例為單側(cè),5例為雙側(cè);伴有腹水為7例;7例伴有腹腔內(nèi)多個(gè)臟器或組織浸潤(rùn),分別為腎臟5例,胰腺3例,胃壁2例,肝臟2例,腹壁2例,膽囊1例,髂腰肌1例。
5例RS:3例為腹腔至盆腔的巨大腫塊(圖3),2例為盆腔內(nèi)腫塊,與膀胱分界稍欠清晰,腫塊范圍為3.26cm×3.48cm×2.89cm~13.87cm×8.05cm×10.06cm。平掃CT顯示腫塊的密度極不均勻,其中1例有小片鈣化,增強(qiáng)后腫塊均呈明顯不均勻強(qiáng)化。1例病例伴有少量腹水。
腹膜由大、小網(wǎng)膜、系膜、韌帶等多種結(jié)構(gòu)組成,因富含脂肪組織、血管和神經(jīng),有利于新生物的發(fā)展。并通過(guò)腹膜從腹膜腔延伸至腹膜后間隙[2-3]。腹膜、網(wǎng)膜、腸系膜起源的腫瘤在兒童時(shí)期比較少見(jiàn),其組織學(xué)頻譜在年齡上也有很大的差異。常見(jiàn)的包括炎性肌纖維母細(xì)胞瘤(IMT),Castleman病(CD),淋巴管畸形(LM),Burkitt淋巴瘤,橫紋肌肉瘤(RS)。腸系膜硬纖維瘤和促結(jié)締組織增生性小圓細(xì)胞腫瘤等十分罕見(jiàn)。
IMT和CD雖然可以發(fā)生于任何年齡,但年長(zhǎng)兒童的發(fā)病率更高。IMT常見(jiàn)的發(fā)生部位有肺、腸系膜和網(wǎng)膜[4],屬于一種交界性腫瘤。可有局部復(fù)發(fā),特別在腸系膜及網(wǎng)膜,女性多見(jiàn)[5]。CD又稱血管濾泡性淋巴增生,是一種良性特發(fā)性淋巴組織增生性疾病,全球文獻(xiàn)報(bào)道的兒童CD僅為100例左右[6]。本組5例IMT,最小1例發(fā)病者為5月,年齡偏小,其余4例均大于5歲。6例CD,僅1例為2歲,其余年齡均大于9歲,最大為18歲,符合文獻(xiàn)報(bào)道。淋巴瘤、LM、RS相對(duì)發(fā)病年齡較小,Burkitt淋巴瘤是累及腸系膜、網(wǎng)膜的非霍奇金淋巴瘤中最常見(jiàn)的一種形式。RS是兒童最常見(jiàn)的軟組織腫瘤,可以發(fā)生或轉(zhuǎn)移至全身幾乎任何部位,頭、頸、泌尿生殖系統(tǒng)最常見(jiàn)。約10%的病例有后腹膜的受累,可以是轉(zhuǎn)移或者原發(fā)[7]。男性多見(jiàn)。本組11例Burkitt淋巴瘤,發(fā)病年齡從2~10歲,平均年齡5歲。 LM9例,平均年齡4歲。RS5例,平均發(fā)病年齡3.5歲,男性4例,僅1例女性。從發(fā)病年齡上這三類腫瘤的發(fā)病年齡要小于IMT和CD。
由于IMT、CD、LM病理特點(diǎn)為良性或者偏良性,因此腫瘤在CT表現(xiàn)上有良性腫瘤的一些特點(diǎn)。典型的腸系膜或網(wǎng)膜IMT在CT上表現(xiàn)為邊界清晰的球形或者分葉形腫塊,體積可以較大,但較少具有侵襲性,密度均勻或者不均勻,極少數(shù)有鈣化,增強(qiáng)后可見(jiàn)早期周邊的強(qiáng)化(血管組織),中央部分均勻或不均勻強(qiáng)化,不強(qiáng)化的區(qū)域往往代表腫瘤的中心壞死,因纖維成分的存在腫瘤可有延遲強(qiáng)化[8]。本組5例病例,腫瘤直徑最大達(dá)15cm,但與周圍組織分界清晰,無(wú)明顯侵襲性,呈周邊向中央的逐漸強(qiáng)化,強(qiáng)化不均勻,鈣化發(fā)生為1/5,與文獻(xiàn)報(bào)道相符。CD在CT掃描時(shí)通常表現(xiàn)為邊界清晰,邊緣光滑的腫塊,直徑5cm左右,10%~31%可以鈣化,增強(qiáng)后透明血管型一般均勻強(qiáng)化,強(qiáng)化程度低于或接近大血管,周邊可見(jiàn)較明顯的血管影,漿細(xì)胞型的強(qiáng)化程度變化差異性較大。本組6例,5例單發(fā),1例多發(fā),增強(qiáng)后6例為均勻強(qiáng)化,2例增強(qiáng)后邊緣強(qiáng)化較明顯,均無(wú)明顯鈣化和腹水。
Burkitt淋巴瘤、RS病理為惡性腫瘤,CT表現(xiàn)上表現(xiàn)為惡性腫瘤常有的一些特點(diǎn)。常包繞腸腔和腸系膜血管,侵犯腸壁,易引起腸套疊和腸梗阻,可伴有腹水。本組36例病例中,腫瘤均呈彌漫性侵襲性生長(zhǎng),11例中有7例伴有胸、腹水,同時(shí)有1個(gè)或多個(gè)臟器或組織的累及,占64%。RS可以表現(xiàn)為少量至中度腹水以及腹膜內(nèi)和腸系膜結(jié)節(jié)和腫塊。
影像技術(shù)的發(fā)展使得CT對(duì)本組疾病的術(shù)前診斷及鑒別診斷更加具有價(jià)值。在CT診斷時(shí),可以首先確定病灶的發(fā)生部位、腫瘤大小,觀察病灶有無(wú)鈣化,如IMT和CD,30%左右病例可以伴有鈣化。腫瘤強(qiáng)化是否均勻,是否伴有腹水,周圍臟器是否受侵犯,同時(shí)考慮病人的性別和年齡,如IMT女性多見(jiàn),RS男性多見(jiàn),IMT和CD通常發(fā)生于青少年,這樣對(duì)準(zhǔn)確診斷幫助較大。為手術(shù)和進(jìn)一步治療提供更多有效的信息。
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CT Diagnosis of Solid Tumors of the Peritoneum, Omentum, and Mesentery in Children
ZHOU Ying1, DONG Su-zhen1, YIN Min-zhi2, MA Jing2, ZHONG Yu-min1
Purpose:To analyze the incidence and CT manifestations of solid tumors of the peritoneum, omentum, and mesentery in children for further recognizing this disease.Methods:We retrospectively reviewed 36 cases, which were diagnosed as solid tumors of the peritoneum, omentum, and mesentery in our hospital between June 2006 and August 2015. These 36 cases included 5 infammatory myofbroblastic tumors, 6 Castleman diseases, 9 lymphatic malformations, 11 Burkitt lymphomas and 5 rhabdomyosarcomas. We summarized the imaging features of these 36 cases.Results:(1) Of 5 infammatory myofbroblastic tumors, 1 was behind the pancreatic tail, 4 was located at the root of mesentery, the solid parts of these 5 tumors were enhanced gradually. (2) Of 6 Castleman diseases, 3 were located at abdominal cavity, 1 was located at omental bursa, 2 were located around the retroperitoneal vessels; 5were single masses, 1 was with multiple masses. All 6 cases were with homogeneous enhancement, 2 of them were enhanced obviously at the margin of the masses. (3) Of 9 lymphatic malformations, 3 were located at left lower quadrant, 2 were located at right lower quadrant, and 4 occupied most abdomen and pelvis. The masses were with no enhancement except the septum. (4) Of 11Burkitt lymphomas, 6 were presented as abdominal and pelvic large masses which affected bowel walls and mesentery, 2 were with 2 masses each (1 was with right abdominal mass and pelvic mass, and 1 was with hepatic portal mass and lower abdominal mass), 3 were presented as single masses. All cases were with enhancement. (5) Of 6 rhabdomyosarcomas, 3 were with abdominal and pelvic large masses, 2 were with bladder masses. All cases were with heterogeneous enhancement.Conclusion:Peritoneal solid tumors are far less common in children than that in adults. The histologic spectrums of the neoplasms in young children are differing from those in older patients. Knowledge of the spectrums of this disease allows the radiologist to provide an appropriate differential diagnosis and suggest proper patient freatment.
Peritoneum; Omentum; Mesentery; Children; Solid tumors; Tomography, X-ray computed
R445.3
A
1006-5741(2016)-06-0560-04
2016.01.07;修回時(shí)間:2016.04.24)
中國(guó)醫(yī)學(xué)計(jì)算機(jī)成像雜志,2016,22:560-563
1上海交通大學(xué)醫(yī)學(xué)院附屬上海兒童醫(yī)學(xué)中心放射科
2上海交通大學(xué)醫(yī)學(xué)院附屬上海兒童醫(yī)學(xué)中心病理科
通信地址:上海市浦東新區(qū)東方路1678號(hào),上海200127
董素貞(電子郵箱:dongsuzhen@126.com)
Chin Comput Med Imag,2016,22:560-563
1 Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University
2 Department of Pathology, Shanghai Children's Medical Center, Shanghai Jiaotong University
Address: 1678 Dongfang Rd., Pudong New District, Shanghai 200127, P.R.C.
Address Correspondence to DONG Su-zhen (E-mail: dongsuzhen@126. com)
中國(guó)醫(yī)學(xué)計(jì)算機(jī)成像雜志2016年6期