超声造影检查在肾脏非典型占位性病变诊断中的价值

Value of contrast-enhanced ultrasound in diagnosis of atypical renal space occupying lesions

目的:探讨超声造影检查对肾脏非典型占位性病变的诊断价值。方法:回顾性分析2015年5月至2019年6月北京大学第一医院收治的44例肾脏非典型占位性病变患者的常规超声和超声造影检查资料。男26例,女18例。年龄(55.9±13.7)岁。44例共47个占位,均行常规超声检查观察肿物的位置、大小、回声、边界、彩色血流情况,做出常规超声诊断。行超声造影检查观察肿物增强时相、增强水平、增强模式、是否有环状增强,做出超声造影诊断。将超声检查诊断与最终病理或临床诊断进行比较。绘制受试者工作特征(ROC)曲线,比较常规超声和超声造影检查对肾脏非典型占位性病变的诊断效能。结果:本研究47个病灶中,诊断为恶性15个,良性32个。19个病灶经手术病理诊断,分别为肾细胞癌13个、肾淋巴瘤2个、肾囊肿3个、炎性肉芽肿1个;28个经增强CT或MRI检查诊断为良性肿瘤或假性肿瘤,且定期随访≥1年无变化,分别为血管平滑肌脂肪瘤5个、囊肿15个、肾连接部皮质缺损3个、肾柱肥大2个、未萎缩肾实质1个、驼峰肾1个、瘢痕1个。常规超声检查病灶最大径(2.5±1.3)cm。肾细胞癌常规超声检查以低回声多见(8/13);超声造影检查以快进快出为主(9/13),多为不均匀低增强(6/13),9个发现假包膜,6个发现坏死。2个肾淋巴瘤常规超声检查均为低回声;超声造影检查均为快进快出,等增强1个,低增强1个。5个肾血管平滑肌脂肪瘤常规超声检查为高回声;超声造影检查以慢进慢出为主(4/5),低增强2个,高增强2个,等增强1个。肾囊肿常规超声检查以无回声多见(16/18);超声造影检查,单纯性肾囊肿无增强,复杂性肾囊肿囊壁或分隔薄且均匀强化,呈慢进慢出、等增强或低增强。炎性肉芽肿常规超声检查呈囊实性;超声造影检查实性部分与肾实质同步强化,呈低增强。肾柱肥大、驼峰肾和局限性未萎缩肾实质常规超声检查为低回声;超声造影检查为与肾实质同进同出的均匀等增强,无明显包块轮廓出现。肾连接部皮质缺损和瘢痕常规超声检查为高回声,超声造影检查自始至终无增强。常规超声检查将1个炎性肉芽肿、1个未萎缩肾实质、2个复杂肾囊肿误诊为恶性,2个高回声肾细胞癌误诊为良性;超声造影检查仅将1个炎性肉芽肿误诊为恶性。常规超声检查对良恶性病变诊断的敏感性为86.7%,特异性为87.5%,准确性为87.2%,ROC曲线下面积0.871。超声造影检查对良恶性病变诊断的敏感性为100.0%,特异性为96.9%,准确性97.9%,ROC曲线下面积为0.984。常规超声与超声造影检查的ROC曲线下面积比较差异有统计学意义(P=0.03)。结论:超声造影检查对肾脏非典型占位性病变的诊断效能优于常规超声检查,对于常规超声检查诊断困难的肾肿瘤,以及酷似肾占位病变的良性病变和解剖异常的诊断和鉴别诊断具有优势。

Objective To evaluate the diagnostic value of contrast-enhanced ultrasound(CEUS)in renal atypical space occupying lesions.Methods The images of conventional ultrasound and CEUS in 44 patients with 47 renal atypical space occupying lesions from May 2015 to June 2019 were retrospectively analyzed,including 26 males and 18 females.The mean age of patients was(55.9±13.7)years old,ranged from 27 to 79 years old.The mean size of the lesions in conventional ultrasound was(2.5±1.3)cm,ranged from 1.0 to 6.0 cm.The location,size,echo,boundary and color flew signals of renal lesions were observed by conventional ultrasound.The degree and the pattern of enhancement,presence or absence of a clear capsule sign were analyzed by CEUS.The ultrasound diagnosis results were compared with the pathological or clinical diagnosis.Results Of the 47 lesions,15 were malignant and 32 were benign.19 lesions were diagnosed by operation pathology,including 13 renal cell carcinomas,2 renal lymphomas,3 renal cysts and 1 inflammatory granuloma;the other 28 benign tumors or pseudotumors were diagnosed by enhanced CT or MRI,and were followed up for more than 1 year,including 5 angiomyolipomas,15 cysts,3 renal junction cortex defects,2 renal column hypertrophies,1 local non-atrophic renal parenchyma,1 hump kidney and 1 scar.Most of the renal cell carcinomas were hypoechoic(8/13),"fast wash-in and fast wash-out"(9/13),heterogeneous hypoenhancement(6/13),9 with pseudocapsule and 6 with necrosis.2 renal lymphomas were hypoechoic,"fast wash-in and fast wash-out",1 isoenhancement and 1 hypoenhancement.The angiomyolipomas were hyperechoic,"slow wash-in and slow wash-out"(4/5),2 hypoenhancement,2 hyperenhancement and 1 isoenhancement.Most renal cysts were anechoic(16/18).There was no enhancement in simple renal cysts.The wall or septum of complex renal cysts was thin and homogeneous enhanced,showing"slow wash-in and slow wash-out"with isoenhancement or hypoenhancement.Inflammatory granuloma was cystic-solid.The solid part was hypoenhancement.Renal column hypertrophy,hump kidney and local non-atrophic renal parenchyma were hypoechoic,showing the same enhancement pattern as renal parenchyma by CEUS.The junctional parenchyma defect and renal scar were hyperechoic,showing no enhancement.The sensitivity,specificity,accuracy and the area under the ROC curve of conventional ultrasound and CEUS in the diagnosis of benign and malignant lesions were 86.7%,87.5%,87.2%,0.871 and 100.0%,96.9%,97.9%,0.984.There were significant differences in the diagnosis of renal atypical space occupying lesions between two methods(P=0.03).Conclusions CEUS was better than conventional ultrasound in the diagnosis of renal atypical space occupying lesions.CEUS had advantages in the differential diagnosis of benign and malignant tumors,benign lesions and anatomical variants mimicking a renal tumor.