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膀胱孤立性纤维性肿瘤1例报告
——影像与病理分析

2017-05-13武日江张辉王效春谭艳秦江波王乐张磊

磁共振成像 2017年2期
关键词:肿物肿块膀胱

武日江,张辉,王效春,谭艳,秦江波,王乐,张磊

WU Ri-jiang1, ZHANG Hui2*, WANG Xiao-chun2, TAN Yan2, QIN Jiang-bo2, WANG Le2, ZAHNG Lei2

膀胱孤立性纤维性肿瘤1例报告
——影像与病理分析

武日江1,张辉2*,王效春2,谭艳2,秦江波2,王乐2,张磊2

WU Ri-jiang1, ZHANG Hui2*, WANG Xiao-chun2, TAN Yan2, QIN Jiang-bo2, WANG Le2, ZAHNG Lei2

孤立性纤维瘤;磁共振成像;扩散加权成像;病理学

患者,女,85岁,主因尿痛、排尿不畅、左下腹疼痛2月余入院,无尿频、尿急、血尿等不适,尿量较少。专科检查:耻骨联合上膀胱区隆起,触及质硬包块,活动度欠佳。

盆腔CT及MRI检查,CT平扫示膀胱内巨大混杂密度软组织肿块影,等低密度相间分布,边界清,大小约9 cm×13 cm×12 cm (左右径×前后径×上下径),增强扫描病灶呈地图样不均匀强化、持续强化(图1~3)。MRI平扫示膀胱巨大软组织肿块影,T1WI呈稍低信号,T2WI呈混杂信号,扩散加权成像(diffusion weighted imaging,DWI)为不均匀稍高信号影(图4~8),动态增强扫描动脉期不均匀强化,静脉期及延迟期呈持续性强化、延迟强化(图9~12)。患者于2016年3月18日行膀胱部分切除术,术中见膀胱巨大肿物,基底位于膀胱三角区,突入腔内,表面光滑,电刀将黏膜做横行切口,在黏膜下钝性分离肿物,将肿物完整分离后切除肿物,并送病理。

病理检查:标本肉眼所见:肿物大小约10 cm×13 cm×11 cm,纵行剖开见肿物内部由核心及外层组成,核心为鱼肉样,外层大小约4 cm,粉红色。镜检:低倍镜下肿瘤境界清楚,由交替分布的细胞丰富区和细胞稀疏区及血管外皮瘤样区域构成,瘤细胞呈条束状。高倍镜下肿瘤细胞呈梭形,胞质少、红染,核染色质均匀,核仁不明显,未见核分裂象(图13)。免疫组化:CD31(-)、CD34(+)(图14)、CD56(+)、CgA (-)、CK20(-)、CK7(-)、HMB45(-)、melan-A (-)、S-100(-)、SMA (-)、Syn (-)。

病理诊断:(膀胱)孤立性纤维性肿瘤(低度恶性)。

讨论 SFT由Klemperer和Rabin首次提出[1],早期认为SFT起源于间皮或间皮下间叶细胞。随后学者采用免疫组化技术及电镜对其进行研究,认为SFT起源于CD34阳性的树突状间叶细胞,具有向纤维母细胞、肌纤维母细胞、血管外皮细胞等分化的特征[2]。可发生于身体多处,原发于膀胱的SFT非常罕见。

膀胱SFT临床表现为血尿、尿路刺激症、盆腔压迫症状,手术切除是治疗该肿瘤的主要方案[3]。肉眼观SFT呈界限清楚的孤立性实性肿块,呈灰白至棕褐色,少数可见出血、囊变等,镜下最重要的特点是:富细胞区与细胞稀少区交替排列,有致密瘢痕样胶原沉积以及血管外皮瘤样区[4]。通常CD34是比较特异和敏感的免疫标记物[5-6]。

影像学表现:CT平扫多为混杂密度软组织肿块影,肿瘤体积较大,SFT一般无钙化,增强扫描动脉期,肿块呈地图样不均匀强化,静脉及延迟期病变强化范围扩大、密度逐渐趋向均匀,呈“快进慢出”型强化[7]。本病例CT 表现与之相仿。

图1 ~12 患者,女,85岁。图1 CT平扫示膀胱巨大混杂密度软组织肿块,边界清;图2~3 CT增强扫描病灶呈地图样不均匀强化、持续强化;图4~8 MRI平扫示膀胱巨大软组织肿块影,T1WI呈稍低信号,T2WI呈混杂信号,DWI呈不均匀稍高信号影;图9~12 MRI动态增强扫描动脉期不均匀强化,静脉期及延迟期呈持续性强化、延迟强化Fig. 1—12 Patient, female, 85 years old. Fig.1 Plain CT images showed that a huge soft tissue mass in the bladder, and its boundary was clear; Fig.2—3 Enhanced CT images showed that the tumor was presented as map-like inhomogeneous enhancement and delayed enhancement; Fig.4—8 On T1 weighted images, there was heterogeneous mild hypointense. On T2 weighted images, there was heterogeneous mixed signal. On diffusion weighted images, there was a little high signal; Fig.9—12 Dynamic enhanced scan demonstrated inhomogeneous enhancement on artery phase and progressive enhancement on portal and delayed phase.

图13 ~14 患者,女,85岁。图13 肿瘤富细胞丰富区与乏细胞区交替分布,瘤细胞呈条束状排列,胶原、间质血管丰富(HE ×200);图 14 免疫组 织化学检查示孤立性 纤维性肿瘤 (solitary fibrous tumor,SFT )细胞胞浆CD34+( ×200)Fig. 13—14 Patient, female, 85 years old. Fig.13 Hypercellular and hypocellular areas were alternated in the tumor. The tumor cells were spindleshaped and arranged in bundles or helicoid pattern with obvious interstitial blood vessel (HE ×200); Fig.14 By immunohistochemistry, the tumor cells were positive for CD34+ ( ×200).

MRI信号特点常可反映肿瘤的组织特征。SFT在T1WI上多呈等低信号,T2WI呈混杂信号[7]。有学者认为T2WI低信号区是由于病灶内富含胶原纤维基质、细胞结构稀疏所致,等高信号区是由富细胞区构成[8-9]。SFT增强扫描呈明显不均匀强化、持续强化、延迟强化,并且认为肿瘤的持续强化区对应于组织学上的富细胞区、富血管区,延迟强化区对应于胶原组织或细胞结构稀疏区[8,10]。本病例在T1WI上呈等低信号,在T2WI上呈混杂信号,DWI为不均匀稍高信号,动态增强扫描动脉期T2WI上等信号区中度强化,静脉期及延迟期持续性强化,T2WI上高信号及低信号区呈延迟强化,部分低信号区各期均未强化。镜下瘤体内见富细胞区、乏细胞区交替分布,较多间质血管及胶原纤维,由此可解释富细胞早期中度强化,持续性强化,乏细胞区、胶原纤维区及黏液样变性造成细胞外间隙扩大,对比剂在细胞外间隙内聚积,导致呈延迟强化的特点,与文献报道[8]相近。因此CT、MRI检查对于SFT具有一定的诊断价值。

综上所述,膀胱SFT影像定性诊断较困难,当CT检查发现孤立性混杂密度软组织肿块,增强扫描呈地图样不均匀样强化;MRI检查T2WI呈混杂信号,增强扫描动脉期不均匀强化,静脉期及延迟期呈持续性强化、延迟强化时,应考虑到SFT的可能。总之,膀胱SFT临床少见,其确诊仍有赖于病理组织学及免疫组织化学检查,但该肿瘤具有相对典型的影像学特征。

[References]

[1]Klemperer P, Rabin CB. Primary neoplasms of the pleura: a report of five cases. Am J Ind Med, 1992, 22(1): 1-31.

[2]Poyraz A, Kilic D, Hatipoglu A, et al. Pedunculated solitary fibrous tumours arising from the pleura. Monaldi archives for chest disease, 2016, 65(3): 165-168.

[3]Chen Y, Zhu S, Liu GX, et al. One case report of solitary fibrous tumor of bladder and literature review. Journal of Clinical Urology, 2014, 29(5): 405-407.陈崯, 祝帅, 刘光香, 等. 膀胱孤立性纤维瘤1例报告并文献复习. 临床泌尿外科杂志, 2014, 29(5): 405-407.

[4]Yue ZY, Dong YD, Hu YY, et al. One case report of solitary fibrous tumor of bladder. Chin J Diagn Pathol, 2016, 23(4): 314-315.岳振营, 董艳光, 胡营营, 等. 膀胱孤立性纤维性肿瘤1例. 诊断病理学杂志, 2016, 23(4): 314-315.

[5]Ruan HJ, Huang AH, Cheng S, et al. Clinicopathologic features of solitary fibrous tumor in urogenital system. Chin J Pathol, 2016, 45(4): 248-251.阮华娟, 黄爱华, 成晟, 等. 泌尿生殖系统孤立性纤维性肿瘤的临床病理学分析. 中华病理学杂志, 2016, 45(4): 248-251.

[6]Pata F, Orsini V, Lucisano AM, et al. Solitary fibrous tumor of the pelvis: an uncommon soft-tissue tumor. Ann Ital Chir, 2010, 81(6): 457-460.

[7]Liu H, Wang YT, Bai YH, et al. The CT, MRI features and pathological basis of solitary fibrous tumor of the pleural. J Clin Radiol, 2014, 33(6): 863-867.刘衡, 王永涛, 柏永华, 等. 胸膜外孤立性纤维瘤的CT、MRI表现及其病理基础. 临床放射学杂志, 2014, 33(6): 863-867.

[8]Chong S, Kim TS, Cho EY, et al. Benign localized fibrous tumour of the pleura: CT features with histopathological correlations. Clinical radiology, 2006, 61(10): 875-882.

[9]Ginat DT, Bokhari A, Bhatt S, et al. Imaging features of solitary fibrous tumors. American Journal of Roentgenology, 2011, 196(3): 487-495.

[10]Kakihara D, Yoshimitsu K, Eto M, et al. MRI of retroperitoneal solitary fibrous tumor in the suprarenal region. American Journal of Roentgenology, 2007, 188(6): 512-514.

Solitary fibrous tumor of bladder: a report of one case: imaging and patholog

Solitary fibrous tumors; Magnetic resonance imaging; Diffusion weighted imaging; Pathology

1.山西医科大学医学影像学系,太原 030001

2.山西医科大学第一医院影像科,太原 030001

1Department of Medical Imaging, Shanxi Medical University, Taiyuan 030001, China

2Department of Radiology, First Clinical Medical College, Shanxi Medical University, Taiyuan 030001, China

张辉,E-mail:zhanghui_mr@163.com

2016-09-23接受日期:2016-10-31

R445.2;R738.6

B

10.12015/issn.1674-8034.2017.02.013

*Correspondence to: Zhang H, E-mail: zhanghui_mr@163.com

Received 23 Sep 2016, Accepted 31 Oct 2016

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