肝脏孤立性髓外浆细胞瘤的影像学特征
Imaging features of solitary extramedullary plasmacytoma of liver
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摘要:
目的:总结肝脏孤立性髓外浆细胞瘤(SEP)的超声、CT及钆塞酸二钠动态增强MRI(GdEOBDTPA MRI)影像学检查特征，探讨其诊断及鉴别诊断要点。
方法:回顾性分析2015年5月7日第三军医大学西南医院收治的1例肝脏SEP患者的临床资料，患者行超声造影、CT平扫及增强扫描、钆塞酸二钠动态增强MRI检查。完善术前相关检查后行手术治疗，术后行病理学检查和免疫组织化学染色检测。术后患者门诊行彩色多普勒超声检查，随访时间截至2015年11月12日。影像学检查记录肿瘤的部位、大小、形态、回声、密度或信号、强化特征、继发表现。记录手术治疗情况、病理学检查、免疫组织化学染色检测结果，术后恢复情况，随访期间肿瘤复发情况。
结果:超声造影检查示右半肝S7段探及范围约24 mm×19 mm的低回声包块，边界清晰，内部可见点状血流信号；动脉相迅速增强。腹部CT检查：平扫期右半肝团块状稍低密度影，CT值为34～64 HU，边界清楚，邻近肝脏包膜无明显外凸。CT增强检查动脉期示包块明显均匀强化，其内可见肝右动脉后上段分支走行；门静脉期包块持续强化，强化程度稍低于正常肝实质，CT值为77～102 HU；平衡期包块强化程度减低，CT值为41～98 HU。动脉期最大密度投影图像示包块内可见增粗血管影走行；门静脉期最大密度投影图像示包块与肝右静脉、下腔静脉毗邻，邻近肝右静脉受压移位改变。GdEOBDTPA MRI检查：右半肝稍长T1、稍长T2信号影，边界清楚，信号均匀，其内未见明显脂质成分及出血、钙化。动脉期明显强化；门静脉期持续均匀强化，强化程度高于正常肝实质；平衡期强化减低；肝胆期呈低信号，包块与下腔静脉、肝右静脉毗邻，肝右静脉呈受压移位表现，肝脏未见明显肝硬化结节表现。完善检查后，患者行腹腔镜右半肝占位性病变切除术，术中见肝右叶灰白色病灶，色黄，质地坚硬，边界清晰，有包膜，与肝右静脉、下腔静脉前壁邻近。病理学检查：肿瘤细胞较小，核呈圆形、卵圆形，偏位，可见核分裂象，瘤细胞弥漫成束状分布。免疫组织化学染色检测：血管内皮标记CD34、多发性骨髓瘤基因MUM1、波形蛋白、浆细胞标记物38和138、λ轻链蛋白表达均为阳性，细胞增殖活性标记Ki-67阳性细胞指数为10%。术后血常规和血生化检测：患者无贫血、高钙血症、肾功能异常，血清或尿液中无单克隆免疫球蛋白。术后患者行骨髓穿刺、免疫球蛋白测定、全身骨扫描结果均正常。综合术后检查最终诊断为右半肝SEP。患者术后9 d恢复良好出院。术后1个月彩色多普勒超声检查结果示右半肝术后改变，术后 6个月未见明显复发征象。
结论:肝脏SEP多发生于右半肝，其影像学主要表现为边界清楚，回声、密度或信号均匀，邻近包膜无明显外凸，周围血管无明显受侵犯，呈受压移位改变，强化方式为快进快出。Abstract:Objective:To summarize the imaging features of ultrasound, computed tomography (CT) and gadoliniumethoxybenzyldiethylenetriamine pentoacetic acid (GdEOBDTPA) enhanced magnetic resonance imaging (MRI) of solitary extramedullary plasmacytoma (SEP) of liver, and investigate the key points of identification and diagnosis.
Methods:The clinical data of 1 patient with SEP of the liver who was admitted to the Southwest Hospital of the Third Military Medical University at 7 May, 2015 were retrospectively analyzed. The patient received contrastenhanced ultrasound (CEUS), plain and enhanced scan of CT and GdEOBDTPA enhanced MRI. The patient underwent treatment after preoperative examinations. Pathological examination and immunohistochemical staining were done after operation. The patient was followed up by outpatient examination of color Doppler ultrasonography till 12 November, 2015. The location, size, shape, echo, density or signal, enhancement pattern, secondary performance were recorded by imageological examinations. Surgical treatment, results of pathological examination, immunohistochemical staining, postoperative recovery and recurrence of tumor were recorded.Results:CEUS examination demonstrated a hypoechoic hepatic lesion at S7 segment of the right liver measuring 24 mm×19 mm with clear boundary and dotted blood flow signal in the mass. In the arterial phase, the lesion was enhanced rapidly. Abdominal CT scan showed that the mass at the right liver lobe had slightly low density with clear boundary, the CT value of 34-64 HU, and liver capsule having no significant outer convex. On enhanced CT, the lesion presented a homogeneous enhancement and shape of posterior upper tributaries of right hepatic artery in the arterial phase, the lesion presented continuous enhancement which was slightly lower than that of liver parenchyma in the portal venous phase with the CT value of 77-102 HU, the lesion presented decreased enhancement with the CT value of 41-98 HU in the equilibrium phase. The maximum density projected image showed that the shape of an enlarged vascular image was found inside the lesion in the arterial phase and the lesion was adjacent to inferior vena cava and right hepatic vein which was compressed and displaced in the portal venous phase. On GdEOBDTPA enhanced MRI, the right liver lobe showed a homogeneous T1weighted and T2weighted signal with clear boundary and without lipid component, hemorrhage or calcification. The lesion presented obvious enhancement in the arterial phase, homogeneous continuous enhancement which was slightly lower than that of liver parenchyma in the portal venous phase, decreased enhancement in the equilibrium phase. The lesion showed mild signal, adjacent to inferior vena cava and right hepatic vein which was compressed and displaced in the hepatobiliary phase. There was no obvious cirrhotic nodule in the liver. The patient received laparoscopic spaceoccupying lesion resection at the right liver lobe after finishing inspection. The grayish white lesion in hardness was seen, with clear boundary and capsule, adjacent to anterior wall of inferior vena cava and right hepatic vein in the operation. The results of pathological examination showed that the small tumor cells were scattered in bundle, nuclear were round or oval shape and eccentric with mitosis seen. The results of immunohistochemical staining showed that endothelium cell marker CD34, human multiple myeloma gene MUM1, vimentin, plasmacyte markers 38 and 138, expression of λ light chain protein were positive, the positive cell rate of proliferation activity marker Ki-67 was 10%. The results of blood routine test and blood biochemistry showed that the patient had no anemia, hypercalcemia, abnormal renal function or monoclonal immunoglobulin in the serum or urine. The results of postoperative bone marrow aspiration, immunoglobulin determination and whole body bone scan showed normal. Postoperative examinations confirmed the SEP of right liver. The patient recovered well and was discharged at postoperative day 9. Postoperative change at right liver lobe was detected by color Doppler ultrasonography at 1 month after operation. The patient was followed up for 6 months without tumor recurrence.
Conclusion:SEP of liver mainly locates at the right lobe of liver, and the imaging features include clear boundary, homogeneous echo, density or signal，adjacent capsule showing no significantly outer convex, surrounding vein demonstrating no violation and shifted by compression，enhancement pattern as fastin and fastout. -
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