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卵巢囊腺瘤MR表现及其病理特点

更新时间:2021-07-29 10:03点击:

  摘    要:目的 探讨卵巢囊腺瘤磁共振(MR)改变及病理特点。方法 回顾性分析58例卵巢囊腺瘤患者共有63个肿瘤病灶,其中53位单侧发病, 5例为双侧发病。所有患者均进行了MR平扫及增强扫描检查,并对肿瘤进行病理分析。结果 肿瘤最大径线3.2~23.2 cm,平均最大径线6.3 cm;100.0%(63/63)肿瘤边界清楚。76.2%(48/63)呈圆形或椭圆形, 23.8%(15/63)呈不规则形;55.6%(35/63)为单房, 44.4%(28/63)为多房, 20.6%(13/63)为囊内套囊;36.5%(23/63)出现壁结节。30.2%(19/63)为浆液性囊腺瘤, 28.6%(18/63)为黏液性囊腺瘤, 12.7%(8/63)为交界性浆液性囊腺瘤, 28.6%(18/63)为交界性黏液性囊腺瘤。63个病灶在T1WI图像上44个病灶呈低信号, 13个病灶呈高信号, 2个病灶呈等信号,4个病灶呈混杂信号;49个病灶信号均匀, 14个病灶信号不均匀。T2WI图像上56个病灶呈高信号,7个病灶呈混杂信号;48个病灶信号均匀, 15个病灶信号不均匀。63个肿瘤病灶进行了增强扫描,63个囊壁中度强化, 63个囊内容物无强化, 10个壁结节轻度强化, 13个壁结节中度强化, 28个肿瘤病灶分隔强化。病理特点:浆液性囊腺瘤为囊性肿物,多为单房,囊液多呈清晰草黄色、浆液性,无细胞异型或核分裂;黏液性囊腺瘤切面呈多房囊壁附着与柱状上皮,细胞核出现增大,囊液内含有增生小血管,并伴随小乳头状突起,无核分裂。交界性浆液性囊腺瘤表现为乳头状芽状增生,切面呈囊实性,且实性部位带有细密乳头,囊性部分为淡黄色液体,无间质浸润,细胞层次、细胞增生活跃度增加。交界性黏液性囊腺瘤切面呈多房,由大小不等腺体、水草状乳头突起、囊腔等构成,上皮细胞呈现轻度至重度的不典型增生,且黏液分泌亢进或出现减少,无间质浸润。结论 浆液性及黏液性卵巢囊腺瘤MR表现囊性肿块,浆液性囊腺瘤多为单房,黏液性囊腺瘤多表现为多房。交界性浆液性及黏液性卵巢囊腺瘤MR表现为囊实性肿块,交界性浆液性囊腺瘤多为单房并壁结节,交界性黏液性囊腺瘤多表现为多房并壁结节, T2WI上多为混杂信号,典型者出现囊内套囊。MR可以清晰显示囊腺瘤的图像特征,充分显示肿瘤大小、形态、成分改变,可反映肿瘤病理特征,对囊腺瘤定位、定性诊断率及准确率均较高。
  
  关键词:磁共振成像 卵巢囊腺瘤 病理学 诊断
  
  MR findings and pathological features of ovarian cystadenoma
  
  WU Xiao-feng
  
  Department of Imaging, Zengcheng District People's Hospital,Guangzhou;
  
  Abstract:Objective To investigate the magnetic resonance(MR) changes and pathological features of ovarian cystadenoma. Methods A total of 63 lesions in 58 patients with ovarian cystadenoma were analyzed retrospectively. Among them, 53 cases were unilateral and 5 cases were bilateral. All patients underwent MR plain scan and enhanced scan, and pathological analysis of the tumor was performed. Results The maximum diameter of the tumor was 3.2-23.2 cm, and the average maximum diameter was 6.3 cm; 100.0%(63/63) of the tumor had a clear border. 76.2%(48/63) were round or oval, 23.8%(15/63) were irregular; 55.6%(35/63) were single rooms, 44.4%(28/63) were multiple rooms, and 20.6%(13/63) were intracapsular cuffs; 36.5%(23/63) had wall nodules. 30.2%(19/63) were serous cystadenomas, 28.6%(18/63) were mucinous cystadenomas, 12.7%(8/63) were borderline serous cystadenomas, and 28.6%(18/63) were borderline mucinous cystadenomas. On the T1 WI image, 63 lesions showed low signal intensity in 44 lesions, 13 lesions showed high signal, 2 lesions showed isointensity, 4 lesions showed mixed signal; 49 lesions had uniform signal, and 14 lesions had uneven signal. On the T2 WI image, 56 lesions showed high signal, 7 lesions showed mixed signal; 48 lesions had uniform signal, and 15 lesions had uneven signal. 63 tumor lesions underwent enhanced scan, 63 cyst walls were moderately enhanced, 63 cyst contents were not enhanced, 10 mural nodules were slightly enhanced, 13 mural nodules were moderately enhanced, and 28 tumor lesions were separated and enhanced. Pathological characteristics: serous cystadenoma was a cystic mass, mostly single-chambered, and the cyst fluid was mostly clear grass-yellow, serous, without cell atypia or mitosis; the cross-section of the mucinous cystadenoma showed multilocular cyst wall attached to the columnar epithelium, the nucleus appeared enlarged, the cyst fluid contained proliferating small blood vessels, accompanied by small papillary protrusions, without nuclear division. Borderline serous cystadenoma was characterized by papillary bud like hyperplasia. The section was cystic and solid, and the solid part had fine nipples. The cystic part was light yellow liquid, no interstitial infiltration, cell hierarchy and cell proliferation activity increased. The cross-section of borderline mucinous cystadenoma was multilocular, consisting of glands of varying sizes, aquatic papillae, cysts, etc. The epithelial cells showed mild to severe dysplasia, and mucus secretion was hyperactive or decreased, with interstitial infiltration. Conclusion Serous and mucous cystadenomas of ovary show cystic mass by MR. Serous cystadenomas are mostly unilocular, while mucous cystadenomas are mostly multilocular. The borderline serous and mucinous ovarian cystadenomas present solid cystic masses on MR. Serous cystadenomas mostly present unilocular and mural nodules, while borderline mucous cystadenomas mostly present multilocular and mural nodules. Most of the mixed signals on T2 WI are found, typically with intracapsular cuffs. MR can clearly show the image features of cystadenoma, fully show the changes of tumor size, morphology and composition, and can reflect the pathological characteristics of the tumor. It has high accuracy in the localization and qualitative diagnosis of cystadenoma.
  
  Keyword:Magnetic resonance imaging; Ovarian cystadenoma; Pathology; Diagnosis;
  
  卵巢囊腺瘤为卵巢最常见肿瘤,约占卵巢良性肿瘤的30%[1]。MR上表现囊性或囊实性肿块,极易与附件区病变相混淆,如盆腔脓肿、单纯性囊肿、子宫内膜异位症、卵巢癌等,为此本研究分析卵巢囊腺瘤的MR表现及病理特点,以提高对该肿瘤的诊断水平,更好的为临床服务。
  
  1 资料与方法
  
  1.1 一般资料
  
  选择2013年2月19日~2020年11月27日本院收治的58例病理诊断为卵巢囊腺瘤患者的临床资料。患者年龄20~77岁,平均年龄43.5岁;双侧发生肿瘤5例;其中19个为卵巢浆液性囊腺瘤,18个为卵巢黏液性囊腺瘤,8个为卵巢交界性浆液性囊腺瘤,18个为卵巢交界性黏液性囊腺瘤;所有患者接受MR平扫及增强检查前均未曾手术治疗。
  
  1.2 方法
  
  所有患者使用通用电气公司(GE)1.5 T超导型磁共振成像系统Signa Hdi进行平扫加增强扫描,扫描采取相控阵体表线圈,使用呼吸补偿技术;患者取仰卧位,放置正线圈,进行常规SE、横断面T1、T2扫描、冠状位、矢状位、横断位等,扫描参数视场角(FOV):300 mm×300 mm,矩阵:256×256,层间距1 mm,横轴位T2WI加权成像脂肪抑制序列重复时间(TR)3000~3500 ms,回波时间(TE)80~100 ms,回波链长度19;T1WI压脂增强扫描轴位采用三维容积超快速多期动态扫描(LAVA)增强扫描:TR 4.5 ms,TE 2.1 ms,对比剂钆特酸葡胺注射液(江苏恒瑞医药股份有限公司,国药准字H20153167),0.2 ml/kg,注射速度2.5 ml/s。
  
  1.3图像与诊断分析
  
  由两名以上高年资的影像科医师单独对MR图像进行分析,如存在不同意见时协商后确定。(1)肿瘤生长情况:分析肿瘤的边界(是否清楚)、形态(分为圆形、椭圆形及不规则形3种)、肿瘤的内部(单房或多房、囊内套囊)、肿瘤内实性成分(是否出现壁结节)。(2) MR表现:包括平扫、增强表现。肿瘤平扫信号与肌肉相比分为低信号、等信号或高信号三级。增强扫描后肿瘤信号与肌肉相近为轻度强化,高于肌肉但低于血管为中度强化,与血管相近为高度强化。
  
  1.4 病理组织学检查
  
  63个肿瘤均行手术切除,制备病理切片后行苏木精-伊红染色法(HE染色),然后在光学显微镜下观察。
  
  2 结果
  
  2.1 MR图像上卵巢囊腺瘤的生长特点
  
  肿瘤最大径线3.2~23.2 cm,平均最大径线6.3 cm;100.0%(63/63)肿瘤边界清楚。76.2%(48/63)呈圆形或椭圆形,23.8%(15/63)呈不规则形;55.6%(35/63)为单房,44.4%(28/63)为多房,20.6%(13/63)为囊内套囊;36.5%(23/63)出现壁结节。见表1。
  
  表1 MR图像上卵巢囊腺瘤的生长特点(个,n=63)
  
  2.2 卵巢囊腺瘤的MR表现
  
  T1WI图像上44个病灶呈低信号,13个病灶呈高信号,2个病灶呈等信号,4个病灶呈混杂信号;49个病灶信号均匀,14个病灶信号不均匀。T2WI图像上56个病灶呈高信号,7个病灶呈混杂信号;48个病灶信号均匀,15个病灶信号不均匀。63个肿瘤病灶进行了增强扫描,63个囊壁中度强化,63个囊内容物无强化,10个壁结节轻度强化,13个壁结节中度强化,28个肿瘤病灶分隔强化。见表2。
  
  表2 卵巢囊腺瘤的MR表现(个,n=63)
  
  2.3 卵巢囊腺瘤病理学改变
  
  浆液性囊腺瘤为囊性肿物,呈单房囊性,囊液多呈清晰草黄色、浆液性,偶见混浊或伴有血性,囊壁存在纤维组织增生,细胞质透明,乳头状生长较多,无细胞异型或核分裂;黏液性囊腺瘤,切面呈多房囊壁附着与柱状上皮,细胞核出现增大,囊液内含有增生小血管,无乳头状突起,未见核分裂。交界性浆液性囊腺瘤单侧多见,表现为乳头状芽状增生,切面呈囊实性,且实性部位带有细密乳头,囊性部分存在淡黄色液体,无间质浸润,细胞层次、细胞增生活跃度增加;交界性黏液性囊腺瘤显示为单侧或双侧发生,切面呈多房,由大小不等腺体、水草状乳头突起、囊腔等构成,上皮细胞呈现轻度至重度的不典型增生,且黏液分泌亢进或出现减少,无间质浸润。
  
  3 讨论
  
  卵巢囊腺瘤是上皮组织来源肿瘤,是被覆内壁的腺上皮细胞增殖,逐渐形成多个大小不一的房室,导致腺瘤管腔内存在分泌物潴留(浆液、黏液、胶质等),且呈现囊状扩张[2]。根据囊内容物不同,分成浆液性和黏液性;按生物学行为分为良性和交界性,交界性囊腺瘤有恶性倾向,但发展缓慢。文献报道浆液性囊腺瘤最多见,交界性囊腺瘤多见于绝经后女性[3],本组病例与上述文献有所不同,其中36个黏液性囊腺瘤,17个浆液性囊腺瘤,黏液性囊腺瘤较浆液性囊腺瘤多;<50岁交界性囊腺瘤17例,>50岁交界性囊腺瘤9例。
  
  肿瘤在MR图像上表现为囊性或囊实性肿块,单侧多见,边界清楚,呈圆形、椭圆形或不规则形,呈单房或多房,交界性肿瘤中多出现壁结节。良性囊腺瘤MR上主要表现为囊性肿块,反映肿瘤存在分泌物潴留的特点,直径绝大多数>3 cm;浆液性囊腺瘤MR图像上多呈圆形,边界清晰,囊壁呈线状,T1WI多呈低信号,T2WI多呈高信号,增强扫描可见囊壁强化,病理上囊液多呈清晰草黄色、浆液性,偶见混浊或伴有血性。黏液性囊腺瘤MR图像上多呈圆形或椭圆形,呈多房,T1WI多呈低信号,T2WI多呈高信号,增强扫描肿瘤囊壁及分隔强化,囊液成分主要为黏液,T2WI上表现为明亮高信号,与皮下脂肪信号类似,部分可出现房与房之间信号不同[4]。交界性囊腺瘤MR图像上主要表现为囊实性肿块;交界性浆液性囊腺瘤多表现为单房常见,边界清晰,多呈圆形或椭圆形,大者可占据整个盆腔,并可向上增大压迫腹腔内肠道,绝大部分可见实性成分,MR图像上表现为壁结节,多<7 mm,T1WI呈等信号,T2WI呈稍高信号,增强扫描病灶轻度或中度强化。病理上囊液淡黄色液体,亦为浆液性,T1WI上多呈低信号,T2WI上呈高信号。见图1~4。左侧卵巢交界性浆液性囊腺瘤,横断位T1WI压脂序列显示左侧附件区椭圆形略高信号,囊壁见结节状突起(见图1)。增强扫描横断位肿块囊性部分无强化,囊内结节明显均匀强化(见图2)。T2WI呈明亮高信号,囊壁结节状突起呈略低信号(见图3)。DWI上肿块呈高信号(见图4)。交界性黏液性囊腺瘤多房常见,边界清晰,多呈椭圆形或不规则形,大者亦可延伸至腹腔,压迫肠道,实性成分病理上为囊壁带有细密乳头,上皮细胞增生较为活跃,在MR图像上也表现为壁结节,与交界性浆液性囊腺瘤表现类似。多房由多个囊组成,各囊大小不等,可出现囊内套囊征像[5],T1WI呈低或高信号,T2WI呈高或混杂信号,可能与各囊黏液蛋白浓度不同。
  
  图1 横断位T1WI图像
  
  图2 横断位增强扫描图像
  
  图3 T2WI图像
  
  图4 DWI图像
  
  在临床上卵巢囊腺瘤主要需与以下病变鉴别:(1)卵巢单纯性囊肿,一般囊肿直径约<3 cm,囊肿直径>3 cm卵巢囊肿较难与囊腺瘤鉴别[6]。(2)子宫内膜异位症,一般有痛经病史,囊壁较厚,液-液平面及含铁黄素沉积是其特征性表现[7]。(3)盆腔脓肿,病史有腹痛及白细胞升高,脓腔囊壁较厚,有分层征像,扩散加权成像(DWI)上呈高信号,增强扫描无强化[8]。(4)卵巢癌,与囊腺瘤比较,病灶内实性成分较多,局部边界不清,容易发生腹腔种植转移[9]。
  
  综上所述,卵巢囊腺瘤MR表现比较有特征性,直径多>3 cm,良性囊腺瘤表现为囊性肿块,交界性囊腺瘤表现为囊实性肿块,浆液性囊腺瘤多为单房,黏液性囊腺瘤多为多房。交界性浆液性及黏液性卵巢囊腺瘤MR表现为囊实性肿块,交界性浆液性囊腺瘤多为单房并壁结节,交界性黏液性囊腺瘤多表现为多房并壁结节,T2WI上多为混杂信号,典型者出现囊内套囊。MR可以清晰显示囊腺瘤的图像特征,充分显示肿瘤大小、形态、成分改变,可反映肿瘤病理特征,对囊腺瘤定位、定性诊断率及准确率均较高。
  
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  [8]贾瑞娟,杨侃荣,赵继泉,等.盆腔MRI平扫、钆喷酸葡胺增强扫描及扩散加权成像对盆腔脓肿患者的诊断价值:64例患者前瞻性研究.分子影像学杂志, 2020, 43(2):286-290.
  
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