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1、囊性畸胎瘤,2010年7月7日,简介,畸胎瘤是原始胚细胞肿瘤，起源于潜在多功能的原始胚细胞卵巢，睾丸，纵膈，腹膜后和骶尾区常见,Fig.1C.21-year-old woman with suspected heart or liver disease.Photograph of gross specimen shows macroscopic appearance of excised mass.,简介,Fig.1D.21-year-old woman with suspected heart or liver disease.Photograph of gross specimen sho
2、ws appearance of inner wall of cyst after fluid removal.Note skin and hair structures.,成分,实性组织密度区域(介于水和钙化的密度之间)在畸胎瘤内常见凝胶状的、蛋白质液体或结缔组织。水样密度区域并混有毛发和皮屑是浆液或者脂肪坏死或者出血也可能存在,平片,囊性畸胎瘤特异平片表现包括牙齿或骨和脂肪大约40%的卵巢囊性畸胎瘤可以由典型的平片表现而被证实。曲线的壁或囊肿钙化,平片,Case 5.A,Plain film.Lucent right upper quadrant mass with globular ca
3、lcification,平片,Case 1.A.Plain film.Large soft-tissue mass with peripherall calcific plug.,超声,大部分畸胎瘤是囊性的，实性的，或复杂成分肿块。可见高度反射和声影。有时可见脂肪-液体平面行平片及超声检查之后，诊断畸胎瘤也不是那么容易，巨大卵巢囊性畸胎瘤有时候会漏诊。,超声,病例1和2的超声图像可见畸胎瘤内脂肪-液体平面在一个病变中同时存在两种液体，而这两种液体回声差异不大这两种液体间可见液平上面的液体可在另一区域可有因重力产生的声影区,超声,病例1中的超声图像清楚显示大量的无回声脂肪漂浮在混杂回声区域上方混
4、杂信号包括脂肪、毛发和皮屑在这个病例中，CT比超声特异因为超声的液液平面对皮样畸胎瘤不是特异的,Fig.1.-Case 1.A.Plain film.Large soft-tissue mass with peripherall calcific plug.B.Transverse sonogram.Bilobed mass.Medial fluid-debris level shifted with changes in position.Lateral component appears cystic.C.Realtime image in region of calcification.
5、Shadowing.,D and E.CT scans.Well marginated bilobed mass with plug of calcification at junction of lobes.Part of capsule is seen where there is sufficient fat for contrast(arrowheads).,CT表现,特征性表现是含有脂肪的肿块伴有附属成分更常见（脂肪、毛发、皮质和液体混杂）和钙化（牙和或发育停止的骨）周围可见固体突起(Rokitansky结节,皮样栓).皮样栓常常是圆形肿物从壁突向囊内(fig.1 D,1 E）隔穿过
6、囊腔(fig.3B),CT表现,D and E,CT scans.Well marginated bilobed mass with plug of calcification at junction of lobes.Part of capsule is seen where is sufficient fat for contrast(arrowheads).,皮样栓常常是圆形肿物从壁突向囊内,CT表现,隔穿过囊腔(fig.3B),FIG.3B.CT scan.Septated fatty mass with calcification(tooth)and solid tissue mas
7、s in septum.,CT表现-钙化,提示性的表现包括脂肪肿块伴有线性钙化和水样密度肿块含有固体组织内容物和球形钙化。无钙化或脂肪，CT帮助不大。牙齿或发育不全骨的发现可借助平片尽管钙化的表现可能模糊或者不典型以至于怀疑其存在。CT通过证实典型的骨的结构或者高于牙釉质骨的骨的数量，可以区分。,良性表现,CT可以清楚地了解肿块和周围结构的关系以及评价囊壁的状态。CT在可以排除侵润，但是往往不能确定肿物是否与周围组织粘附。无脂肪层可以是正常的，也可能是由于与周围组织粘附或者侵犯。粘附临近器官的皮样畸胎瘤可能仍然是良性的。如果周围有大量脂肪，在CT上表现为薄壁或囊性病变，提示即使恶变发生，囊壁也
8、是完整的。锐利的边缘也提示囊壁完整。显微镜下的囊壁侵犯不排除,病例,Fig.2.-Case 2.C.CT scan.Anterior displacement of rectum by near-water density mass.Thicking of left side wall(arrow).,Fig.3.-Case 3.A,Lateral chest film.Large posterior mass.B,CT scan.Septated fatty mass with calcification(tooth)and solid tissue mass in septum.C,Low
9、er cut.Dependent near-water density component.Other scans showed mass to arise in retrocrural space.,病例,Fig.5.-Case 5.A,Plain film.Lucent right upper quadrant mass with globular calcification.B,Parasagittal sonogram.Complex,shadowing mass inseparable from kidney.,病例,Fig.5.-Case 5.C,CT scan.Predomina
10、ntly fatty mass with calcific plug attached to connective tissue loculation/septation(arrowheads).D,Lower cut.Kidney margins are intact.,病例,Fig.1A.21-year-old woman with suspected heart or liver disease.Abdominal CT scan obtained at level of lower dorsal column shows large cystic mass with fatfluid
11、level and cluster of small,round fatty vesicles at top.Mass displaces small and large bowel to right side.,病例,Fig.1B.21-year-old woman with suspected heart or liver disease.Abdominal CT scan obtained at level of midlumbar column shows mass displacing left kidney to prevertebral position and round fa
12、tty image with target shape floating at top.,选择,理论上来讲CT 的诊断较超声及平片特异,CT在确诊囊性畸胎瘤上，应当是首选因为相连组织声阻抗的差异可以产生回声而与是否是脂肪组织无关，因此脂肪可以是发生回声的或者无回声的，CT在检查骨及牙齿片段、显示肿块与周围组织边界方面优于超声。但是往往先行超声检查，由于大部分肿瘤发生在卵巢，并且常常是年轻女性因发现盆腔肿物就诊在平片及超声无法确诊时才行CT检查。,预后,临床上最关心的是良性皮样畸胎瘤的恶变可能性恶变的几率为0.25%-0.8%恶变往往发生在皮样栓大于40岁的患者恶变的可能性更大如果囊壁未被穿透，
13、预后佳，反之侧预后不良,处置,不管良性还是恶性，所有腹膜后囊性畸胎瘤都应该完全切除因为即便是组织学是良性的病变，如持续生长，也会有生命危险术前精确的诊断非常重要由于腹膜后囊性畸胎瘤容易与手术引起的肉瘤相混淆，因为后者无需手术准确显示周围组织结构对手术非常重要,处置,为了防止将来的并发症，卵巢囊性畸胎瘤常常需要切除，例如扭转(1 6%),感染(1%-2%),破裂(1%-2%),和恶变.孕妇的并发症发生率上升到24%，并且与肿块大小有关。妇产科医生建议体积较小的卵巢囊性畸胎瘤的年轻患者保守治疗，并且无症状的患者手术率较低。在这些病例中良性囊性畸胎瘤的准确诊断和恶变排除是最重要的。,Thanks for your attention,
