作者：stari
来源：1影1世界
胰腺囊性病变影像分类诊断
10cm，整个肿瘤不与胰腺管相通。囊壁结节明显和有钙化者，多为恶性，且常位于胰头。","marks":[]}]}],"state":{}},{"type":"block","id":"7bW8-1678423188682","name":"paragraph","data":{},"nodes":[{"type":"text","id":"0q20-1678423188681","leaves":[{"text":"CT表现，多房水样低密度，囊壁厚薄不规则和壁结节，或者偶可见高密度的钙化影，由于粘液产生，有时肿瘤在CT平扫图上可呈高密度或MRI T1W为高信号。","marks":[]}]}],"state":{}},{"type":"block","id":"6jRn-1678423277620","name":"paragraph","data":{},"nodes":[{"type":"text","id":"TEpH-1678423277618","leaves":[{"text":"影像学上判断MCN为恶性，较为困难。出现一些恶性征象，","marks":[]},{"text":"可提示恶性：","marks":[{"type":"color","value":"#FF0001"},{"type":"bold"}]}]}],"state":{}},{"type":"block","id":"go3Q-1678423313326","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"rsIj-1678423313325","leaves":[{"text":"1、周围脏器侵犯","marks":[]}]}],"state":{}},{"type":"block","id":"Dvda-1678423323234","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"ckj1-1678423323233","leaves":[{"text":"2、肝脏出现转移灶，同样为高密度囊性，呈环状强化。","marks":[]}]}],"state":{}},{"type":"block","id":"8XbS-1678423362347","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"5Y9k-1678423362346","leaves":[{"text":"3、外形呈分叶状轮廓。","marks":[]}]}],"state":{}},{"type":"block","id":"t5YN-1678423412044","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"VHBx-1678423412042","leaves":[{"text":"4、分隔较厚且不规则，出现壁结节，强化明显。","marks":[]}]}],"state":{}},{"type":"block","id":"diWZ-1678440131256","name":"image","data":{"version":1,"url":"https://note.youdao.com/yws/res/87636/WEBRESOURCE0d51d6012af2f015203c2f13e6b6d77b","width":1515,"height":567},"nodes":[],"state":{}},{"type":"block","id":"KEmI-1678426104982","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"EoX5-1678426104981","leaves":[{"text":"多个大囊聚集，囊壁略厚，并可见壁结节，中度强化。诊断：交界性黏液性囊腺瘤。","marks":[{"type":"italic"},{"type":"color","value":"#0089FB"}]}]}],"state":{}},{"type":"block","id":"pKHc-1678422881343","name":"paragraph","data":{},"nodes":[{"type":"text","id":"fx7Y-1678422881342","leaves":[{"text":"","marks":[{"type":"bold"},{"type":"backgroundColor","value":"#FFFF02"},{"type":"color","value":"#FF0001"}]}]}],"state":{}},{"type":"block","id":"jDUM-1678440209837","name":"paragraph","data":{},"nodes":[{"type":"text","id":"290p-1678440209836","leaves":[{"text":"导管内乳头状粘液性肿瘤（IPMN）：","marks":[{"type":"bold"},{"type":"backgroundColor","value":"#FFFF02"},{"type":"color","value":"#FF0001"}]}]}],"state":{}},{"type":"block","id":"0naf-1678422881481","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"CSbA-1678422881480","leaves":[{"text":"罕见的胰腺导管内肿瘤。","marks":[]}]}],"state":{}},{"type":"block","id":"AtDX-1678423508635","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"L5PA-1678423508634","leaves":[{"text":"临床特点：男性多发，由于过多的黏液阻碍胰液的分泌，患者常出现类似慢性胰腺炎或复发性急性胰腺炎的症状。经常表现为渐进性腹块、腹痛，早期仅表现上腹部不适和消化不良等症状。IPMN预后较好。","marks":[]}]}],"state":{}},{"type":"block","id":"lhYb-1678423654204","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"cmDR-1678423654203","leaves":[{"text":"病理上，肿瘤在胰腺导管内生长，使胰腺导管局限性或弥漫性扩张。","marks":[]}]}],"state":{}},{"type":"block","id":"YDnQ-1678423825457","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"C0AX-1678423825456","leaves":[{"text":"根据肿瘤生长特点，可分三型：","marks":[{"type":"bold"}]}]}],"state":{}},{"type":"block","id":"s9xq-1678423760179","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"f8iP-1678423760177","leaves":[{"text":"1、黏液分泌型，扩张的胰管内充满凝结的黏液，而肿瘤细胞呈扁平或微小乳头状生长。","marks":[]}]}],"state":{}},{"type":"block","id":"R9YH-1678423778241","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"ka3E-1678423778240","leaves":[{"text":"2、乳头绒毛型，除扩张的胰管和导管内黏液外，导管内见多发乳头绒毛状生长的肿瘤。","marks":[]}]}],"state":{}},{"type":"block","id":"3eap-1678424405970","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"cmqh-1678424405969","leaves":[{"text":"3、重度异型增生型，和浸润性癌类似，预后较差。","marks":[]}]}],"state":{}},{"type":"block","id":"9HUn-1678423834956","name":"paragraph","data":{"style":{"indent":0}},"nodes":[{"type":"text","id":"WYjW-1678423834955","leaves":[{"text":"根据与胰管的交通，可分三型：","marks":[{"type":"bold"}]}]}],"state":{}},{"type":"block","id":"z68B-1678423852449","name":"paragraph","data":{"style":{"indent":0,"textIndent":0}},"nodes":[{"type":"text","id":"Rlos-1678423852447","leaves":[{"text":"1、主胰管型（MD-IPMN）：较少见，约占15%，胰头、体和尾部均可发生。主胰管型可发展成恶性，但预后良好，包括两个亚型：","marks":[]}]}],"state":{}},{"type":"block","id":"eCPe-1678442025271","name":"paragraph","data":{"style":{"indent":28,"textIndent":0}},"nodes":[{"type":"text","id":"7pZu-1678442025270","leaves":[{"text":"节段型","marks":[]}]}],"state":{}},{"type":"block","id":"0G0W-1678442028243","name":"paragraph","data":{"style":{"indent":28,"textIndent":0}},"nodes":[{"type":"text","id":"SZ9R-1678442028242","leaves":[{"text":"弥漫型","marks":[]}]}],"state":{}},{"type":"block","id":"b0e4-1678423869041","name":"paragraph","data":{"style":{"indent":0,"textIndent":0}},"nodes":[{"type":"text","id":"pwcb-1678423869039","leaves":[{"text":"2、分支胰管型（BD-IPMN）：约占50%，胰头部多发，为良性肿瘤，生长缓慢。","marks":[]}]}],"state":{}},{"type":"block","id":"oxCK-1678424146088","name":"paragraph","data":{"style":{"indent":0,"textI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#0089FB"}]}]}],"state":{}},{"type":"block","id":"7pOF-1678425434637","name":"paragraph","data":{},"nodes":[{"type":"text","id":"q4o5-1678425434636","leaves":[{"text":"实性假乳头状瘤（SPN）：","marks":[{"type":"bold"},{"type":"color","value":"#FF0001"},{"type":"backgroundColor","value":"#FFFF02"}]}]}],"state":{}},{"type":"block","id":"TxJW-1678425452074","name":"paragraph","data":{},"nodes":[{"type":"text","id":"jazt-1678425452072","leaves":[{"text":"年轻女性多发，又叫女儿瘤（Duaghter tumor），胰尾多见，囊实性混合肿瘤，为交界性肿瘤，随发病年龄增加，恶性程度增加。手术治疗，预后良好。","marks":[]}]}],"state":{}},{"type":"block","id":"SOvJ-1678426761739","name":"paragraph","data":{},"nodes":[{"type":"text","id":"ezVK-1678426761738","leaves":[{"text":"肿块常较大，直径为5~8厘米，有较厚的纤维包膜，边界清楚，常突出于胰腺外，由三种基本成分构，及实性结构、假乳头状结构、及出血囊变，约30%可发生边缘或中心钙化。","marks":[]}]}],"state":{}},{"type":"block","id":"os78-1678440359283","name":"image","data":{"version":1,"url":"https://note.youdao.com/yws/res/87641/WEBRESOURCE8985525eef2e5e46c665b71b4c357dac","width":1450,"height":565},"nodes":[],"state":{}},{"type":"block","id":"i4Mr-1678426856770","name":"paragraph","data":{},"nodes":[{"type":"text","id":"vBTp-1678426856769","leaves":[{"text":"女，28岁，胰头区巨大囊实性肿块，平扫可见线样、星芒样钙化；增强动脉期，实性成分强化，囊性成分与实性成分相间分布；静脉期，实性成分明显强化，包膜完整，强化明显，与胰腺分界清楚。诊断：实性假乳头状瘤。","marks":[{"type":"color","value":"#0089FB"},{"type":"italic"}]}]}],"state":{}},{"type":"block","id":"2KEA-1678440360721","name":"paragraph","data":{},"nodes":[{"type":"text","id":"kevq-1678440360719","leaves":[{"text":"CT/MR表现：囊实性肿块，实性部分位于肿块周边，有轻中度强化；囊性部分位于中心，若有出血，密度略高，MRI可准确区分出血和囊变区。MRCP示胰管受压、移位，与病变不相通。","marks":[]}]}],"state":{}},{"type":"block","id":"c7ku-1678441096986","name":"paragraph","data":{},"nodes":[{"type":"text","id":"cO6P-1678441096985","leaves":[{"text":"浮云征：","marks":[{"type":"bold"},{"type":"color","value":"#FF0001"}]},{"text":"某些肿瘤，实性成分和囊性成分间杂存在，CT增强后肿瘤的实性成分明显强化，漂浮于无强化的囊性成分中，形似浮云。","marks":[]}]}],"state":{}},{"type":"block","id":"fCz1-1678441288400","name":"image","data":{"version":1,"url":"https://note.youdao.com/yws/res/87662/WEBRESOURCEe6b2caecba112eaa4fd87786e7de8fa6","width":1618,"height":589},"nodes":[],"state":{}},{"type":"block","id":"NB5P-1678441288404","name":"paragraph","data":{},"nodes":[{"type":"text","id":"Wxs4-1678441288403","leaves":[{"text":"女，32岁，胰头部实性假乳头状瘤，浮云征，CT增强后静脉期更明显。","marks":[{"type":"color","value":"#0089FB"},{"type":"italic"}]}]}],"state":{}},{"type":"block","id":"PbHa-1678425363965","name":"paragraph","data":{},"nodes":[{"type":"text","id":"5QQ5-1678425363964","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"PHzN-1678422882693","name":"paragraph","data":{},"nodes":[{"type":"text","id":"2I2A-1678422882692","leaves":[{"text":"其它的，胰腺内分泌肿瘤、胰腺肿瘤样囊性病变，各类很多，但总体占比较少，如胰腺炎假囊肿，有一定特征性，有慢性胰腺炎相应表现，诊断相对容易，此处不再讨论。","marks":[]}]}],"state":{}},{"type":"block","id":"jai9-1678422882794","name":"paragraph","data":{},"nodes":[{"type":"text","id":"TK87-1678422882793","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"mAqa-1678422882897","name":"paragraph","data":{},"nodes":[{"type":"text","id":"BkX1-1678422882896","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"YCj8-1678422882996","name":"paragraph","data":{},"nodes":[{"type":"text","id":"LMHZ-1678422882995","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"hUEC-1678422883097","name":"paragraph","data":{},"nodes":[{"type":"text","id":"RkDP-1678422883095","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"TxiP-1678422883199","name":"paragraph","data":{},"nodes":[{"type":"text","id":"TzOu-1678422883198","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"2utu-1678422883299","name":"paragraph","data":{},"nodes":[{"type":"text","id":"NhYi-1678422883298","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"hYxe-1678422883400","name":"paragraph","data":{},"nodes":[{"type":"text","id":"RWX6-1678422883399","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"hUDX-1678422883501","name":"paragraph","data":{},"nodes":[{"type":"text","id":"d9q2-1678422883500","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"6LeJ-1678422883602","name":"paragraph","data":{},"nodes":[{"type":"text","id":"Alru-1678422883601","leaves":[{"text":"","marks":[]}]}],"state":{}},{"type":"block","id":"nFTK-1678422883703","name":"paragraph","data":{},"nodes":[{"type":"text","id":"fl0c-1678422883702","leaves":[{"text":"","marks":[]}]}],"state":{}}]">在胰腺所有肿瘤中，囊性肿瘤约占20%，胰腺囊性病变较多，良性、恶性都有，有些影像学特征互有重叠，给鉴别诊断带来困难。
胰腺内囊性病变种类
临床上最常见的胰腺囊性肿瘤主要包括浆液性囊腺瘤、黏液性囊性肿瘤和导管内乳头状黏液性肿瘤等，占整个胰腺囊性肿瘤的90%左右。
其它少见的，还有胰腺原发实质性肿瘤囊性变，胰腺转移性肿瘤囊性变，以及一些囊性的肿瘤样病变。
具体分类，思维导图总结如下：
图片
胰腺囊性肿瘤影像学特点
胰腺囊性肿瘤，大部分位于腹腔后壁的腹膜外，由于其生长位置很深，几乎没有临床症状，很难早期发现，大多是检查时偶然发现的。
临床症状的缺如，加上化验指标的非特异性，给这类肿瘤早期诊断带来很大困难。
其中，浆液性囊腺瘤是良性的；实性假乳头状瘤则是低到中度恶性肿瘤；而导管内黏液性乳头状瘤、黏液性囊腺瘤则表现为中到高度恶性的特征。
图片
不同肿瘤有不同的好发年龄，和好发性别，所以在临床上有一些特殊的称呼。
比如，浆液性囊腺瘤，好发于老年女性，大家习惯叫它“奶奶瘤”（SCN）；而黏液性囊腺瘤好发于中年女性，大家习惯叫它“妈妈瘤”（MCN）；实性假乳头状瘤，则是青年女性多发，所以也叫“女儿瘤”（SPN）。
看似复杂、繁多，其实主要是这四种，大约占到90%多。
图片
鉴别诊断：
然而，胰腺囊性肿瘤间鉴别，以及与胰腺囊性病变、胰腺肿瘤的囊性变的鉴别，存在难点，CT表现或征象有一定的重叠。Sahani 等依据CT特征，分为四型。
I型，
包括假性囊肿（最常见）、真性囊肿、大囊型浆液性囊腺瘤、极少部分黏液性囊腺瘤、分支型导管内乳头状黏液性肿瘤、Hippel-Lindau氏综合征等等，胰腺呈单发或多发囊样病变。
结合曾有胰腺炎病史，则提示为假性囊肿。
如多平面重建或MRCP显示胰腺主胰管与囊性病变相通，则为分支型导管内乳头状粘液性肿瘤机会显著提高。
II型，
只见于良性小囊型浆液性囊腺瘤，有典型CT征象。
III型，
大囊型浆液性囊腺瘤和黏液性囊腺瘤（癌）均可相似表现，难以鉴别。
IV型，
包括黏液性囊腺癌、实质性假乳头状肿瘤、非功能性胰腺神经内分泌肿瘤、腺泡细胞囊腺癌和主胰管型/混合型导管内乳头状黏液性肿瘤。
这一类，CT鉴别有难度，确诊依赖病理。
那么 ，这种情况下，偶然发现胰腺囊性病变，该怎么处理呢？下面我们总结了临床诊治流程图，希望对大家有所帮助。
图片
由此可以看出，胰腺内囊性病变，和发病年龄、发病部位有密切关系，并且，各自形态学上、病理特点上、生物学行为上各不相同，临床预后也各不相同，所以鉴别诊断应充分考虑这些因素。图片
上面这幅图，形象地展示了胰腺内各类囊性病变的形态学特点，和好发部位，有助于理解其影像诊断与鉴别诊断。-待续-
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