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胆囊癌

 zskyteacher 2018-05-07

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【双语病例】Gallbladder carcinoma 胆囊癌

双语学影像;病例选自《Mayo Clinic Body MRI Case Review》

History

54-year-old man with a chronic biliary disorder; MRI was performed for routinesurveillance

54岁男性,长期慢性胆道病变。MRI常规复查。

Fig 3.6.1:


Fig 3.6.2:

Fig 3.6.3:



Imaging Findings

Coronal SSFSE (Figure 3.6.1) and axial fat-saturated FSE (Figure 3.6.2) images demonstrate an irregular lesion in the gallbladder, abutting the superior wall. Coronal, delayed phase 3D SPGR images (Figure 3.6.3) show transmural extensionof the lesion. Note the dilated left hepatic lobe biliary duct and irregular generalized parenchymal enhancement in the liver, suggestive of fibrosis.

冠状位SSFSE(Figure 3.6.1)及横断位脂肪抑制FSE序列(Figure 3.6.2)示:胆囊内可见一不规则病变,紧邻胆囊前壁。

增强扫描延迟期冠状位重建图像(Figure 3.6.3)示病灶跨胆囊壁生长。另可见肝左叶胆管扩张,肝实质弥漫性不规则强化、提示纤维化。

Diagnosis

Gallbladder carcinoma

胆囊癌

Comment

The lesion in this case is much smaller than in Case 3.5 and the diagnosis is a little more difficult. However, the coronal delayed phase images show transmural extension of the mass, which shouldn’t be seen for a benign gallbladder polyp. This finding was confirmed at surgery, and no direct invasion of the liver was identified. The patient unfortunately developed metastatic disease within 2 years of surgery and subsequently expired. This outcome emphasizes the poor prognosis of even low-stage lesions (stage II in this case).

本例病灶比Case3.5(点击页尾阅读原文可查看历史消息)的病灶小了很多,诊断存在一定的困难。但是,增强扫描延迟期冠状位重建图像可以清晰地显示肿块跨胆囊壁生长,随后手术证实了这一表现,而良性的胆囊息肉不会出现该征象。本例肝实质没有明确受侵的表现。

不幸的是,该患者术后2年发现了转移病灶,后死亡。这一结果页强调了早期胆囊癌预后也可能很差(本例胆囊癌分期为II期)。


The main differential diagnosis in this case (especially if it had no mural invasion) would be a gallbladder polyp or adenoma. Most benign polyps are small and round and have uniform low signal intensity on T2-weighted images and minimal enhancement. They are often difficult to distinguish from gall stones except that you might see them in nondependent locations. A rule of thumb from US that should apply equally well to MRI is that the level of suspicion becomes higher for lesions greater than 1 cm in diameter, with surgical consultation often recommended. An example of a gallbladder adenoma (benign at surgery but definitely a worrisome imaging appearance) and a coexisting polyp are shown in Figures 3.6.4, 3.6.5, and 3.6.6.

本病例需要鉴别诊断的主要是胆囊息肉和腺瘤,特别是如果没有胆囊壁受侵时更需谨慎鉴别。大部分良性息肉体积较小,呈圆形,T2WI呈均匀低信号,增强扫描轻度强化。有时难以与胆囊结石相鉴别,除非有时可见结石与胆囊壁不连续。

超声检查的经验同样适用于MRI:如果病灶的直径大于1cm,则提示可能需要外科手术。

本文后半部分给大家展示一例胆囊腺瘤伴息肉的病理,手术证实为良性,但影像上不能排除恶性可能。


Diagnosis of gallbladder carcinoma can be trickier in the setting of focal or diffuse gallbladder wall thickening without hepatic invasion, in which case adenomyomatosis, as well as chronic inflammatory conditions such as xanthogranulomatous cholecystitis,should also be considered. In general, gallbladder carcinoma tends to show greater wall thickening and a more heterogeneous appearance, although this description is relatively nonspecific.Recently, some authors have suggested that diffusion-weighted imaging may help to discriminate these lesions;gallbladder carcinoma tends to have more restricted diffusion and a lower apparent diffusion coefficient than inflammatory conditions. This conclusion is based on very little data,however, and it seems likely that apparent diffusion coefficient criteria for gallbladder carcinoma will be about as useful as those for other biliary and hepatic masses (ie, not at all).

胆囊壁弥漫性或局限性增厚、且临近肝实质无明显异常时,诊断胆囊癌需谨慎,胆囊腺肌瘤病、慢性炎性病变(如黄色肉芽肿性胆囊炎)也可以有类似表现。一般来说,胆囊癌的患者胆囊壁更厚、更不均匀,但这一表现没有明显的特异性。

近期,部分研究认为DWI可能有助于鉴别诊断。与炎性病变先比,胆囊癌病灶弥散更加受限,ADC图呈低信号。这一研究的样本数较少,但是ADC值定量测量应用于胆囊癌的诊断,可能与在其他胆道或肝脏肿瘤中的作用类似。

Fig 3.6.4:


Fig 3.6.5:


Fig 3.6.6:


Axial fat-suppressed FSE T2-weighted images (Figure 3.6.4) from an examinationperformed after incidental detection of a gallbladderlesion on abdominal CT in a 75-year-old man show an irregular lesion (adenoma) along the anterior surface of the gallbladder, as well as a much smaller, round, hypointense lesion (polyp)posteriorly. Corresponding in-phase 2D SPGR images (Figure 3.6.5) demonstrate that the small polyp has a relatively high T1-signal intensity and the larger adenoma has an intermediate signal. Arterial phase postgadolinium 3D SPGR images (Figure 3.6.6) show moderate enhancement of the adenoma, with associated mild thickening and enhancement of the adjacent gallbladder wall. The gallbladder polyp has minimal enhancement, which is difficult to appreciate because of its high signal intensity before contrast administration.

75岁男性,腹部CT偶然发现胆囊前壁不规则形病灶(腺瘤)后行MRI检查,另胆囊后壁可见一个更小、圆形、T2WI低信号病灶。对应IP 2D SPGR图像(Figure 3.6.5)示胆囊后壁小息肉呈T1WI高信号,腺瘤呈中等信号。3D SPGR增强扫描动脉期(Figure 3.6.6)示腺瘤呈中等强化,临近胆囊壁轻度增厚并强化;胆囊息肉由于平扫T1WI高信号,增强轻度强化但无法明确评价。


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