正常测量胰腺超声图(胰腺的超声测量图片)
本文中图片均来自于影像大讲堂(北京大兴站)中,中国人民解放军总医院叶惠义教授讲课。在此特别感谢叶教授!
作者|杜华阳
来源|华夏影像诊断中心
长期以来,因胰腺占位发病率低、临床病例不常见。对其潜在的恶性行为认识存在不足,以至于临床上出现很多不恰当的治疗。一部分患者因盲目等待、观察而贻误病情错失最佳手术治疗时机;另一部分患者因仓促手术导致切除不彻底而出现肿瘤复发甚至转移。因此正确认识胰腺病变的影像学表现,对于指导临床治疗,选择适当的治疗方案和时机,有着重要的意义。
MRI对胰腺病变诊断有重要作用,有CT、CT强化达不到的效果。但是,胰腺病变种类很多,如何很全面的掌握胰腺病变?本文做了一个胰腺病变的思维导图,并在后面附上典型的病例,希望对大家所帮助。
从胰腺病变的特征,胰腺病变有囊性病变、囊实性病变、实性病变三方面,每一个病变下都包含一些常见、不常见、易混的疾病。分别如下:
囊性病变:
1.囊肿/假性囊肿
2.弥漫囊性病变(VHL 等)
3.浆液性/黏液性囊腺瘤
4.IPMN
5.良恶性肿瘤显著坏死囊变
囊实性病变:
1.SPN( 曾经 SPT )
2.IPMN
3.良恶性肿瘤坏死囊变
实性病变:
1.恶性肿瘤(少血供可以,多血供也可以);胰腺癌;神经内分泌肿瘤;SPN和转移瘤等。
2.良性肿瘤或肿瘤样病变(IgG4 相关性疾病,异位脾等,一定要注意异位脾,很容易误诊、错诊)。
为了让大家有一个清晰的整体思路,将上面所有的内容列成一个整体框架图:
点击图片可放大保存
![](https://p3-sign.toutiaoimg.com/pgc-image/7d795e261d0941c8b35daff167b8c300~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=%2BWsw3xAoHK1IFd0PMiR2GDZKseQ%3D)
胰腺囊性病变分单发、多发两方面,分别给大家举例:
囊性病灶:单发
![](https://p3-sign.toutiaoimg.com/pgc-image/706a8274e658427f980236c89301fc52~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=WlbF67%2BEB%2BOTGSxGYoNAd8C0C5s%3D)
T2WI
![](https://p3-sign.toutiaoimg.com/pgc-image/cfd3814b3b684b819bdbdb2ec4e1398b~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=eCzI%2Fq9%2B%2B%2FkRPLdvFNfT9F9zoe8%3D)
DWI
![](https://p3-sign.toutiaoimg.com/pgc-image/0443f90e1bb24b739eff64d19360ac15~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=hmVP8BCSs9bzibLbaFWC82YKMZY%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/17275476c94e42afa15a2a8d4dfb8a84~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=lUzo5R5bzTMI%2B7V1ZLysoVBWeWc%3D)
动脉期
![](https://p3-sign.toutiaoimg.com/pgc-image/6b494f36b65e401d97dd94ff00506704~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=036Wi0MREiF9SKaRVQqm2Te%2B2pA%3D)
实质期
![](https://p3-sign.toutiaoimg.com/pgc-image/b3f60495d3a24320a77855be0afe26ac~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=8XXSob8OrGpfebgwyvxoJKqZ2ao%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/f11636fb130740dba6aeb416eb6110ec~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=c36kR0nU8Os%2FfOe9dgm%2B0DgNmtk%3D)
动脉期
![](https://p3-sign.toutiaoimg.com/pgc-image/f11636fb130740dba6aeb416eb6110ec~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=c36kR0nU8Os%2FfOe9dgm%2B0DgNmtk%3D)
延迟期
女性46岁,胰尾部单房状囊性病变,考虑:良性,黏液性囊腺瘤可能性大。病理证实是:黏液性囊腺瘤。
囊性病灶:多发
![](https://p3-sign.toutiaoimg.com/pgc-image/b284c4be6cdb441b987aa4856d85511a~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=6XzkgYVnuv6AXSY26p%2Bndgkkb7A%3D)
T2WI
![](https://p3-sign.toutiaoimg.com/pgc-image/b74fd5d2523a4f1eaef7b994677d94e4~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=aCCqfWf%2BRmVPtEHZpJxajAr7X5I%3D)
DWI
![](https://p3-sign.toutiaoimg.com/pgc-image/58e35fc65d7e4fea884436a6338f2238~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=XXEgvjICnI5b2V7IFiSiGAXn5BE%3D)
预扫描
![](https://p3-sign.toutiaoimg.com/pgc-image/0e36ff9513904657a3b91aaf883edd89~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=f1rM5%2BSMaCHofz0WxeM5FZ6%2FvRg%3D)
动脉期
![](https://p3-sign.toutiaoimg.com/pgc-image/ae440c2a18b449b996bebfb7393502e3~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=OzOTORhFfUgjCyrghbeX3OJqX3I%3D)
实质期
![](https://p3-sign.toutiaoimg.com/pgc-image/c1876516368d47e1bd208823e20c20f8~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=chJzitkFMmhRWWEzYoCXFrWvoIo%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/7fbb7e1a39474a8ba3c08aaa846d303b~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=VZ%2FydrU4QUX7R9htaCK0%2B2cSKrU%3D)
延迟期
女性36岁,胰头颈部多房状囊性病变伴分隔,考虑: 良性,浆液性囊腺瘤可能性大。
病例证实:浆液性囊腺瘤。
从上面的囊性病变中,我们可以知道粘液性囊腺瘤和浆液性囊腺瘤的典型表现:
黏液性囊腺瘤:单房(多较大),T1WI 稍低等和稍高,DWI 稍高信号,未见异常强化;
浆液性囊腺瘤:多房(常较小),T1WI 稍低,DWI 低和等信号,未见异常强化,分隔轻度强化。
胰腺囊实性肿块
9 岁男孩,发现腹部肿块 9月余,MRI图像如下:
![](https://p3-sign.toutiaoimg.com/pgc-image/e756be4ad11a4f5d8da281797df16789~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=8bhIjb2MQoNrQux9PXBVSsmNYu8%3D)
T2WI囊实性肿块
![](https://p3-sign.toutiaoimg.com/pgc-image/505cabc817714266a42841932fe92b38~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=rSNusRCC8Mz%2F3AcfZCNYmPTXEmw%3D)
T2WI囊实性肿块
![](https://p3-sign.toutiaoimg.com/pgc-image/5963b93a65334885a6cab2594ed73692~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=49y%2BZwWC2dgczmcrYmTLTjcfXHY%3D)
这4副图像是同反相位图像:肿块内见局灶出血。
![](https://p3-sign.toutiaoimg.com/pgc-image/531ff453e0a34451a855a0599d2fedae~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=ZdPpqyvMdndklcoL%2BupQiGyitks%3D)
预扫描
![](https://p3-sign.toutiaoimg.com/pgc-image/d3d067782cfc4363bc1b0c5668cb19a9~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=e2G3JJ201XvbAvQ7nCk2bct1OJ4%3D)
动脉期
![](https://p3-sign.toutiaoimg.com/pgc-image/f17fcf189ad34c74907e6761b6a8a856~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=V%2BdbpycC122U%2F6dm4Z2LWqOSX5U%3D)
实质期
胰体尾部囊实性肿块有一定血供伴出血,考虑:良性或者低度恶性肿瘤,实性假乳头状瘤(SPN)可能性大,病理学证实 SPN。
囊实性胰腺肿块
80 岁男性,B 超查体发现胰管异常扩张
![](https://p3-sign.toutiaoimg.com/pgc-image/07a78d38f50e447387c78c525f04165f~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=Z40E%2B%2BZcrch5j53CN1pfQ76%2Fw6Q%3D)
T2WI 囊实性肿块
![](https://p3-sign.toutiaoimg.com/pgc-image/a8a7b0fb20b541209239c08168feda4c~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=DBMYEOz2Heu8naQcI8WEnY6yKiA%3D)
T2WI 囊实性肿块
![](https://p3-sign.toutiaoimg.com/pgc-image/ea5112a4cfa1491c93bdab5b96527d0c~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=PelNwTC9QTlHFBmZg3ETVAGTNkQ%3D)
反相位图像
![](https://p3-sign.toutiaoimg.com/pgc-image/672e8ff392ba4171a05ea28d9174d619~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=xjRUGJFvCtpqZoOVl5%2BzPbmCPng%3D)
反相位图像
![](https://p3-sign.toutiaoimg.com/pgc-image/e9350c8375f343acb1f5655271f4ad28~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=SEEjI38fYXFryhA69wbURuaI%2BWE%3D)
反相位图像
![](https://p3-sign.toutiaoimg.com/pgc-image/3c618d777e5b4a1a9f8137d52b0030a8~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=PYLR%2Bw9YJqPN6aVp4XCvvWZUvzc%3D)
反相位
反相位:肿块信号未见异常降低。
![](https://p3-sign.toutiaoimg.com/pgc-image/fa1345a66d824f6e8ac9a7ed8f28956f~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=3WW%2FjQQ25aXGf0ivTZ4a1LoZpt4%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/0fdcb566860f417f8d6d80845e0b6930~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=4nujWhnP8ayADvSBEYGs3x53srQ%3D)
预扫描肿块呈稍低信号
![](https://p3-sign.toutiaoimg.com/pgc-image/39dba21c79ab4af7a6bd56b4abb7b4fe~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=zNXqqRBWeHATI2VfUBlNoqdzgLU%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/323d5ff45f4b48ffbfce4b5b4457b0da~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=FMFJG%2FIu91zVjzWQ3SR5qq0Q%2BbA%3D)
动脉期实性部分轻度强化
![](https://p3-sign.toutiaoimg.com/pgc-image/0b07b68f8084402ba2293c273a3bdf33~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=wIphfD26o%2FpM74HaDc4y0%2BDA6x4%3D)
实性部分轻度强化
![](https://p3-sign.toutiaoimg.com/pgc-image/c667045980714290bb78aeed768ff8ab~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=PqQsHypTgJ51nIUW9Qqfhjqt%2BCg%3D)
延迟期实性部分持续强化
胰体尾部囊实性肿块伴胰管异常扩张,考虑:低度恶性或者良性肿瘤,以 IPMN可能性大。
病理: 黏液性囊腺癌。
胰腺实性肿块
77 岁女性,上腹不适 5 月余,超声检查发现胰腺病变。CA 199 轻度升高。MRI图像:
![](https://p3-sign.toutiaoimg.com/pgc-image/870a0d8f96284ce692734c78fa2dff9e~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=Kx%2BCdGRdEpe7UPlHTKOq6L%2FSWBk%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/7334e8c380844680aa84edd295c3ea25~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=XRkdyQjyaexg487uZ0wfzczKgdw%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/e682e1a2228140a98a06fffa5187d3d7~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=P4pkCnxZdIkaDPnslNpggy2oOJs%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/261a8b9111b54c5ebba4c386464b0b50~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=dZ%2FaXTiCzrwsI9GAYsQzIWyHKKE%3D)
上面4张图像T2WI 腹腔干周围实性肿块
![](https://p3-sign.toutiaoimg.com/pgc-image/9c74149e2d524912920dd35334bf0705~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=Ohw%2FUDE0LXacRe96S7yzttVcvts%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/67e24549c70c4168b64a173a024272cf~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=CSPKo7PWwAPWCh39wn7L9q%2Fk4s4%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/5652ae38f1c64eaa915db612f9a421fd~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=3NbWN01cqSyIN7uOlrnHY7kAS70%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/475bc20f7b864dd3aefc6f292b67b143~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=OMDfJXWb9SG65rULTrOtbe6nWdA%3D)
上面4张图像是反相位图像:腹腔干周围肿块信号未见降低。
![](https://p3-sign.toutiaoimg.com/pgc-image/0d3ad99b0c9846649c184aeec307eff0~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=FhQ%2F2WDoc2Idqssa2eWQKKhJVCs%3D)
预扫描病灶呈稍低信号
![](https://p3-sign.toutiaoimg.com/pgc-image/0d3ad99b0c9846649c184aeec307eff0~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=FhQ%2F2WDoc2Idqssa2eWQKKhJVCs%3D)
动脉早期病变轻微轻度异常强化
![](https://p3-sign.toutiaoimg.com/pgc-image/3bcc897623f849b8be7352c9dace2ffd~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=PWngCYOh5keYSgQqE5wnKS0j%2F34%3D)
动脉晚期病变轻微轻度异常强化
![](https://p3-sign.toutiaoimg.com/pgc-image/a43c2256cf68498f9e5cd2f9cae3a444~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=rQ%2BKEth4nbMW%2FejY4Ir%2Bmhem1WU%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/b082dc3243744a7a91943acc14420717~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=5uy0prl8sbwQbtNWSdN6rjuQmW0%3D)
上面2张图像是实质期病灶持续轻至中度异常强化
![](https://p3-sign.toutiaoimg.com/pgc-image/da7e8c1a7cc54b16bfe01c91d98d0558~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=cdHUQiYzLRXvgFA7%2F2RRrl6dDQg%3D)
![](https://p3-sign.toutiaoimg.com/pgc-image/7a3fa3cea56f4734bf103c03ff78adf8~tplv-tt-large.jpeg?x-expires=1970273330&x-signature=v37KHkp0AngIp93zptK5I8rorgk%3D)
延迟期病灶持续轻至中度异常强化
影像学诊断:胰头后部少血供肿瘤包绕腹腔干和肠系膜上动脉,考虑:恶性肿瘤,以胰腺癌的可能性最大。
病理诊断:胰腺癌。
胰腺癌:两种主要表现形式:胰腺局灶/弥漫病变; 胰腺周围(腹腔干或/和肠系膜上动脉/上静脉)病变。
血供:少血供常见,多血供少见(上面的病例是少血供的影像学表现)。
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