移植肾早期常规活检的临床意义

36例移植肾功能正常的患者在肾移植术后 1、3个月分别常规性进行 6 5次移植肾活检 ,全部患者均服用环孢素、泼尼松、硫唑嘌呤及雷公藤多甙等免疫抑制剂治疗 ,移植肾组织病理按Banff分类法分类。结果发现 ,有 1 8 4 5 % (1 2 / 6 5 )出现亚临床的排斥反应或临界改变 ,分析病理异常组与正常组的临床特点 ,发现两组患者雷公藤多甙剂量有显著差异 ,其他免疫抑制剂剂量无差异 ;异常组经给予甲泼尼龙冲击治疗并调整免疫抑制剂剂量 ,移植肾 5年长期存活率与术后常规肾活检正常的患者无差异。研究表明 ,移植肾术后 1、3个月常规行移植肾活检能及早发现亚临床的排斥反应及临界改变 ,为临床采取措施、及时调整治疗方案提供帮助。     

粗针穿刺活检在纵隔T淋巴母细胞淋巴瘤与B1型胸腺瘤鉴别诊断中的价值

目的 分析纵隔T淋巴母细胞淋巴瘤(T-LBL)和B1型胸腺瘤病例的临床和病理学特点,提高粗针穿刺活检在这两种疾病鉴别诊断中的准确性.方法 收集连续诊断的34例T-LBL和10例B1型胸腺瘤患者作为研究对象,均接受纵隔粗针穿刺活检获取标本,并经手术标本病理诊断确认.收集两组患者的临床资料,对比其粗针穿刺活检标本的组织病理学和免疫表型的差异.结果 T-LBL患者以小于30岁为主(73％),男性发病明显多于女性,男女比3.3∶1.B1型胸腺瘤平均年龄43岁(40岁以上占50％),男女比2∶3.T-LBL患者均有胸闷、气短、咳嗽等临床症状;B1型胸腺瘤患者中3例出现胸闷气短症状,2例出现重症肌无力症状.影像学特征:两组患者均为前纵隔单发肿物,肿块＞10cm者在T-LBL患者中占88％,在B1型胸腺瘤患者中仅占50％.T-LBL患者全部可见肿瘤侵犯引起的胸腔或心包腔积液,而B1型胸腺瘤无此特征.病理学特征:T-LBL的瘤细胞在纤维组织中呈“列兵样”浸润性生长(65％),有骨骼肌组织侵犯(41％)和肿瘤性坏死(21％),而B1型胸腺瘤无此特征.所有B1型胸腺瘤均保留胸腺小叶结构,可见粗大纤维间隔,但仅3％的T-LBL保留胸腺小叶结构.免疫组化染色显示所有B1型胸腺瘤均可见完整的细胞角蛋白网,但T-LBL的细胞角蛋白网破坏.T-LBL和B1型胸腺瘤出现周围脂肪组织浸润的比例有差异,分别为59％和20％.结论 T-LBL与B1型胸腺瘤在患者性别、发病年龄、临床症状及影像学改变上有明显差异,以病理学特征的改变最具鉴别意义.密切联系临床表现与组织病理学改变有助于提高纵隔粗针穿刺活检在两种疾病鉴别诊断中的价值.     

手动活检结合声触诊组织成像量化技术在鉴别浅表淋巴结良恶性中的应用

目的：探讨手动活检结合声触诊组织成像量化（VTIQ）技术在浅表淋巴结诊断中的应用价值。方法：选取204例浅表淋巴结肿大患者为研究对象,随机分成观察组和对照组各102例。观察组应用VTIQ技术结合手动活检诊断,对照组应用常规超声结合手动活检诊断,以最终病理结果为金标准,比较2组取样穿刺时间、穿刺部位疼痛评分及诊断效果。结果：最终病理结果显示,观察组良性46例,恶性56例;对照组良性48例,恶性54例。观察组诊断灵敏度94.64%（53/56）,特异度95.65%（44/46）,阳性预测值96.36%（53/55）,阴性预测值93.62%（44/47）,准确率95.10%（97/102）。对照组诊断灵敏度85.19%（46/54）,特异度87.50%（42/48）,阳性预测值88.46%（46/52）,阴性预测值84.00%（42/50）,准确率86.27%（88/102）。观察组诊断准确率明显高于对照组（P<0.05）。观察组取样穿刺时间平均（44.38±9.82）s,穿刺部位疼痛评分（10.46±4.75）分;对照组取样穿刺时间（57.19±12.97）s,穿刺部位疼痛评分（21.47±6.18）分,观察组穿刺取样时间和穿刺部位疼痛评分均明显低于对照组（均P<0.05）。结论：手动活检结合VTIQ技术能明显提高浅表淋巴结的诊断准确率,对指导临床治疗具有重要的应用价值。     

免疫组化在肺肿瘤穿刺活检诊断中的应用

目的探讨免疫组化标记在CT引导下肺肿瘤穿刺活检病理诊断中的应用及意义。方法收集海军总医院病理科近2年来的肺穿刺标本,对进行过免疫组化标记的广谱细胞角蛋白（CKPAN）、细胞角蛋白7（CK7）、p63蛋白（p6）、表面活性蛋白B（SP-B）、甲状腺转录因子-1（TTF-1）、CD56蛋白（CD56）、突触素（Syn）、嗜铬颗粒A（CgA）及白细胞共同抗原（LCA）的病例表达情况进行分析及对比。结果 111例进行了免疫组化标记的肿瘤性病变中,结合组织病理学形态,最终诊断支持肺原发性恶性肿瘤的共有99例（鳞癌20例、腺癌65例、小细胞癌12例、特殊类型2例）,3例为转移性肿瘤,良性肿瘤2例,确定为恶性肿瘤但无法分型的7例。结论肺鳞癌表达p63,腺癌多表达CK7和TTF-1,小细胞癌常表达CD56、Syn和TTF-1。免疫组化联合应用能够有效辅助常规病理检查下对肺穿刺肿瘤的诊断及鉴别诊断。     

CT定位经纤维支气管镜纵隔淋巴结针吸活检术的价值

目的 为明确纵隔淋巴结肿大的性质,进行CT定位经纤维支气管镜纵隔淋巴结针吸活检术（CT－guided transbronchial needle aspiration biopsy,CT-TBNA)的研究。方法 根据纵隔淋巴结分区定位标准,对原发性肺癌（54例）伴纵隔淋巴结肿大、恶性淋巴瘤（5例）、纵隔脓肿（3例）、炎性淋巴结肿大（11例）共73例158枚纵隔肿大 淋巴结行CT－TBNA穿刺活检。结果 CT扫描证实穿刺针在全部158枚淋巴结内,其中86％（136／158）的淋巴结抽吸物经病理检查获得了病理组织学和（或）细胞学诊断,未发生严重并发症。结论 CT－TBNA的标准是可靠的,穿刺操作安全有效,对确定纵隔淋巴结肿大性质和肿瘤分期有重要意义。     

弹簧活检枪在胸部肿块活检中的应用

目的 :探讨应用弹簧活检枪行胸部肿块CT引导下穿刺活检的临床价值。材料和方法 :使用 15～ 18G弹簧活检枪在CT引导下对 42例胸部肿块 (肺 3 4例、纵隔 8例 )行穿刺活检术 ,标本行组织学、细胞学检查 ,活检结果与手术及随访结果对照。结果 :活检枪活检总准确性为 90 .5 %。肺部肿块中恶性肿瘤 3 0例、良性病变 4例 ,肺癌假阴性 3例 ,无假阳性 ;纵隔肿块中恶性 8例 ,1例淋巴瘤穿刺物难以定性。并发症发生率 2 1.4% ,其中气胸 6例、针道区少量出血 3例 ,除 1例气胸行闭式引流外均无需处理。结论 :使用弹簧活检枪行CT引导下胸部肿块穿刺活检准确、安全 ,临床价值高。     

立体定位核芯针活检在乳腺疾病诊断中的应用研究

目的探讨乳腺微小病变行立体定位核芯针活检（SCNB）的临床应用价值。方法采用计算机辅助乳腺三维立体定位系统、弹射式活检枪和16G核芯针，对47例乳腺X线发现的可疑恶性病变直接行穿刺活检，记录每例的临床和X线表现（钙化、结节、结构紊乱等）、穿刺活检诊断、外科术后病理诊断或随访观察资料。比较SCNB与外科手术二者的病理诊断结果，统计其诊断符合率。对照分析SCNB准确性与病灶X线表现的关系，分析SCNB成败、误诊原因。结果欲行SCNB47例，成功完成44例，未能完成3例。31例患者随后行外科手术，SCNB诊断与术后病理符合27例，4例SCNB与术后病理不符。结论SCNB具有准确、快速、微创等优势，可减少手术活检数量，及早确诊乳腺疾病，具有良好的临床应用前景。     

CT导引穿刺活检对纵隔病变的诊断价值

目的 评估CT导引经皮细针穿刺活检对纵隔病变的诊断价值.方法 回顾性研究CT导引经皮穿刺纵隔病变104例.活检部位包括前纵隔73例、中纵隔29例和后纵隔2例.病灶大小2.31 cm×1.11 cm～14.5 cm×10.3 cm,病灶直径＜3.0 cm 16例,3.1～5.0 cm 39例,＞5 cm 49例,使用18～20 G穿刺针作穿刺抽吸活检.结果 穿刺活检成功率100%,穿刺活检诊断为恶性病变67例、良性27例、假阴性8例,假阳性2例.穿刺活检正确率、灵敏度和特异度分别为90%、92%和100%.病变大小和病变良恶性对活检正确率差异无统计学意义(P＞0.05).并发症为轻度气胸(6例)、咯血(2例)和纵隔气肿(1例).结论 CT导引经皮细针穿刺活检纵隔病变是安全可行的诊断方法.     

超声引导下淋巴结经皮穿刺活检对颈部肿大淋巴结的诊断价值

目的 :探讨超声引导下淋巴结经皮穿刺活检术(percutafleous needle core biopsy,PNCB)对颈部肿大淋巴结诊断的应用价值。方法:选择104例颈部淋巴结肿大的患者,对其行常规超声检查、PNCB病理诊断及手术切除淋巴结病理诊断。统计进针次数、成功率、PNCB取材效果,并评价结果。将手术切除标本病理学检查结果为金标准,分为恶性(阳性)与良性(阴性),采用ROC分析方法计算常规超声与PNCB病理诊断的敏感度、特异度、阳性预测值、阴性预测值及准确率。结果 :104例均进针3~6次,共穿刺415针,其中386针适合进行病理学检查,成功率93.01%。415针穿刺取材效果评价分4级结果为:优202针,良141针,一般43针,差29针;术后病理学诊断显示,颈部淋巴结结核31例,炎性增生淋巴结5例,恶性淋巴瘤16例,转移或浸润癌52例。PNCB病理诊断除1例将转移癌诊断为炎性增生淋巴结外,其余病理诊断与术后病理学诊断一致;常规超声诊断敏感度97.06%、特异度75.00%、阳性预测值88.00%、阴性预测值93.10%、准确率89.42%,PNCB的病理诊断的敏感度98.53%、特异度100%、阳性预测值100%、阴性预测值97.36%、准确率99.04%。结论 :PNCB诊断颈部肿大淋巴结安全、易操作,且标本满意率及病理诊断准确性高,值得临床推广。     

放射性核素肾动态显像在诊断肾移植术后早期并发症中的应用价值

目的 探讨放射性核素肾动态显像的半定量参数对肾移植术后早期并发症诊断与鉴别诊断的价值,并评价其对患者预后判断的意义.方法 回顾性分析79例肾移植术后行放射性核素肾动态显像的患者资料,分为4组:急性排斥反应(简称急排)组18例,加速性排斥反应(简称加排)组12例、急性肾小管坏死(ATN)组29例,肾功能正常(对照)组20例,分别计算灌注相腹主动脉放射性高峰时间(A峰时)、移植肾放射性高峰时间(K峰时)、移植肾放射性高峰计数与腹主动脉高峰计数比值(Kmax/Amax)及1 min计数比值(K1 min/A1 min),功能相移植肾20 min计数/3 min计数(K20min/K3 min)、K20 min/高峰计数(K20 min/Kpeak)、20 min时膀胱/移植肾放射性计数比值(B/K).分析并比较各参数尤其是Kmax/Amax和K1 min/A1 min诊断与鉴别诊断肾移植术后早期并发症的价值;对ATN组K1 min/A1 min进行分区,分析K1 min/A1 min大小与患者预后之间的关系.结果 各参数中,以K1 min/A1 min、B/K临床价值较大.急排、加排组K1 min/A1 min分别为2.54±1.59和2.04±0.94,较对照组(9.29±1.63)明显下降(P均＜0.01),ATN组K1 min/A1 min为5.74±2.35,与急排、加排组差异有统计学意义(P均＜0.01),急排与加排组间差异无统计学意义(P＞0.05).K1 min/A1 min诊断ATN的准确性为89.7%,高于Kmax/Amax(55.2%).K1 min/A1 min≥4及B/K＞1,为肾功能正常;K1 min/A1 min≥4及B/K＜1为ATN;K1 min/A1 min＜4及B/K＜1为出现排斥反应.K1 min/A1 min与ATN预后及并发症间存在一定联系.结论 K1 min/A1 min结合B/K比值有助于肾移植术后早期并发症的诊断与鉴别诊断,且K1 min/A1 min可用于移植肾病变预后的监测.     

Papillary renal cell carcinoma in allograft kidney

Papillary renal cell carcinoma is a subgroup of malignant renal epithelial neoplasms. Its occurrence in allograft transplanted kidney has not been debated in the literature. We report two pathologically proven cases and discuss the clinical hypothesis for such neoplasms and the aspect on MR images. The paramagnetic effect of the iron associated with an absence of signal coming from calcifications is a plausible explanation for this unusual hypointense appearance on T2-weighted sequence.     

能谱CT技术及MRI在少脂肪肾错构瘤与早期肾癌的鉴别诊断分析

目的探讨少脂肪肾错构瘤(RAML)与肾透明细胞癌(ccRCC)能谱CT技术及MRI检查的影像特征。方法对经手术病理证实的少脂肪RAML(17例)和ccRCC(28例)共45例患者的影像学资料进行回顾性比较分析。结果少脂肪RAML患者17例,CT平扫12例呈稍高密度,3例呈等密度,2例呈混杂低密度,5例T2WI均呈均匀低信号,T1呈等信号;17例均强化较均匀,14例呈持续强化,3例呈"快进快出"强化方式。ccRCC患者28例,CT平扫14例低密度,8例呈等密度,6例呈混杂低密度;6例T2WI均呈混杂稍高信号,3例有假包膜;25例呈不均匀强化,呈"快进快出"强化方式,3例呈持续强化。能谱CT技术分析:17例少脂肪RAML中,10例平扫脂(水)密度图病灶呈稍高密度,水(脂)密度图呈稍低密度,平扫70 Kev ROI图的能谱曲线呈直线型,与脂肪标准曲线有一定不同,直方图显示大部分CT值位于30~40 HU,但仍有一小部分CT值在0 HU以下,三期增强能谱曲线呈衰减型,皮质期及实质期其曲线形态一致。28例ccRCC患者均未见RAML类似征象。结论能谱CT技术分析对少脂肪RAML诊断具有一定的特征性,结合MRI检查,可明显提高对少脂肪RAML及ccRCC的鉴别诊断价值。     

肾血管平滑肌脂肪瘤的超声诊断与鉴别诊断

目的探讨肾血管平滑肌脂肪瘤的声像图特征及其鉴别诊断。方法应用二维超声，彩色多普勒血流显像（CDFI），频谱多普勒（PW）对经手术病理证实的21例肾血管平滑肌脂肪瘤进行研究。结果肾血管平滑肌脂肪瘤的典型声像图为高回声或混合性回声呈洋葱样，不典型声像图为低回声。CDFI示肿瘤内血流信号少，PW测及其动脉血流为低速高阻型。结论肾血管平滑肌脂肪瘤声像图表现与血管、平滑肌、脂肪含量有关。典型声像图较易诊断。不典型声像图需结合彩色多普勒及CT增强扫描进行综合分析，并与肾癌相鉴别。     

肾脏小肿瘤的MRI诊断与鉴别诊断

目的分析直径≤4cm的肾透明细胞癌34例、乏脂肪肾血管平滑肌脂肪瘤18例的MRI表现,以提高肾脏肿瘤的MRI诊断及鉴别诊断水平。方法回顾性分析经手术病理及长期随访证实的52例直径≤4cm的肾脏肿瘤性病变的MRI资料。观察并记录病灶形态、边界、各序列信号、IP值/OP值及ADC值,计算rADC值及STII值,并进行统计学分析。结果病灶中心位置、与肾皮质交角、T2WI信号强度等研究指标在两组病例中差异均具有统计学意义,而两组病灶的强化方式各异,且多有重合。结论 MRI对直径≤4cm的肾脏小肿瘤的鉴别诊断具有重要意义,仔细分析其信号特征有助于做出准确的术前诊断。     

Role of diffusion-weighted MRI in diagnosis of acute renal allograft dysfunction: a prospective preliminary study

Objective

The aim was to evaluate the effects of diagnostic performance of diffusion-weighted (DW) MRI in the assessment of acute impairment of transplanted kidneys.

Methods

From January 2009 to January 2010, 49 patients with stable renal allograft function (Group 1) and 21 patients with acute graft impairment (Group 2) were included in the study. All patients were evaluated with coronal T₂ weighted (T₂W) and DW MRI of the kidney. Patients in Group 2 underwent graft biopsy to determine the underlying histopathological aetiology. Apparent diffusion coefficient (ADC) was calculated and the kidneys were studied for any areas of diffusion restriction. Two radiologists, who were blinded to the results of histopathology, independently interpreted the T₂W and DW images.

Results

The histopathological diagnosis ofGroup 2 (21 patients) was acute cellular rejection (ACR) in 10, acute tubular necrosis (ATN) in 7 and immunosuppressive toxicity in 4 patients. ADC values in Group 1 were significantly higher compared with Group 2 (p<0.001), patients with ACR (p<0.001), patients with ATN (p<0.001) and patients with drug toxicity (p<0.001). Using 2×10⁻³ mm² s⁻¹ as a cut-off, there was no overlap between the ADC values of patients with normal graft function and those with ATN. Both ACR and ATN had a low ADC value, but on the ADC map the kidney in cases of ATN appears heterogeneous with a characteristic mosaic pattern resembling the Tiger skin. There was no significant T₂W morphological difference between the two groups.

Conclusion

These results show how DW MRI is a promising new technique for the diagnosis of acute renal transplant dysfunction.Renal transplantation is the preferred method of renal replacement therapy in end-stage renal disease [1]. Acute deterioration in function, in a transplanted kidney, is a diagnostic and a therapeutic challenge. It could be due to infection, renal allograft rejection, urinary or vascular obstruction, ciclosporin or tacrolimus nephrotoxicity, dehydration or acute tubular necrosis, and each requires distinctly different management [2]. Accurate differentiation between previous causes relies on combination of clinical findings and histopathological examination of a biopsy from the transplanted kidney. However, a needle biopsy from a transplanted kidney may be associated with serious morbidity, such as haematuria requiring transfusion, obstruction of the graft by clots, hypovolaemic shock and intraperitoneal haemorrhage that may lead to graft nephrectomy [3]. Unfortunately, there is no non-invasive tool that can diagnose the aetiology of acute graft dysfunction. Ultrasonography, including colour Doppler imaging, is a non-invasive diagnostic method that provides flowmetric quantitative parameters for the haemodynamic assessment of the renal transplant. These values present certain sensitivity but are not specific of renal graft dysfunction because there is no reliable differentiation between acute rejection and other parenchymal pathology [4].Diffusion-weighted (DW) MRI is an established method used in the diagnosis of acute stroke [5]. Diffusion-weighted imaging (DWI) provides quantification of Brownian motion of water protons by calculating the apparent diffusion coefficient (ADC), and can be used for in vivo quantification of the combined effects of capillary perfusion and diffusion [6]. Since the main kidney functions are related to transportation of water (glomerular filtration, active and passive tubular reabsorption, and secretion), diffusion characteristics may provide a useful insight into the functional consequences of different renal diseases.DW MRI has been used to examine transplanted kidneys in both animal and human studies [7-9]. However, none of these studies examined the value of DW MRI in identification of the underlying aetiology of acute graft dysfunction. Therefore, the aim of our study was to assess the clinical value of DW MRI in the diagnosis of the underlying aetiology of acute renal allograft dysfunction. In the future, this will allow us to reduce the need for invasive ultrasound-guided biopsies. which have a high-risk of complication.     

Ultrasonography of the kidney following renal biopsy in children

The frequency of renal and perirenal hematomas following percutaneous renal biopsy using a cutting needle was studied by means of ultrasonography in 30 children and young adults aged 3-16 years. Hematomas occurred in 64.5 percent of the biopsies but caused significant clinical symptoms in one patient only.     

肾结核的影像表现与鉴别诊断

目的:探讨影像学对肾结核诊断和鉴别诊断的价值。方法:33例肾结核病例中,21例经手术病理证实,12例经临床诊断。结果:33例肾结核中,12例行静脉尿路造影,30例CT检查,8例MR检查。影像学表现为肾影轮廓的改变,肾实质内低密度,肾盂肾盏破坏及狭窄,病灶内点状或斑点状钙化,输尿管的累及、周围组织的侵犯。结论:影像学对肾结核诊断及鉴别诊断有很重要的作用。