UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

小肾脏占位性病变的诊断方法、鉴别诊断与治疗

Authors
Susanna I Lee, MD, PhD
Shauna Duigenan, MD, FRCPC
Section Editors
Jerome P Richie, MD, FACS
Michael B Atkins, MD
Deputy Editor
Don S Dizon, MD, FACP
Translators
张骞, 副主任医师，副教授

引言

鉴于无相关指征所进行的影像学检查[如超声(ultrasound, US)、计算机断层扫描(computed tomography, CT)和磁共振成像(magnetic resonance imaging, MRI)]使用增多，小肾脏占位性病变的检出率上升[1]。大多数肾脏病变可表现为良性单纯性囊肿，不需要进一步诊断性检查。然而，有对比度增强的完全实性或囊实混合性肾脏病变很可能是恶性的，这种情况需要进一步评估和治疗[2]。

本文将总结小肾脏占位性病变的初步评估、鉴别诊断、诊断方法和治疗。肾细胞癌和肾囊肿的评估将单独讨论。 (参见“肾细胞癌的临床表现、评估和分期”和“成人单纯性和复杂性肾囊肿”)

定义

最大径小于4cm并且腹部影像学检查显示对比度增强的肾脏病变符合小肾脏占位性病变的诊断标准[3]。这些病变(影像 1)根据影像学表现可分为[4](影像 2)实性或复杂囊性(Bosniak分级Ⅲ级或Ⅳ级)。 (参见“成人单纯性和复杂性肾囊肿”)

自然病程

小肾脏占位性病变因为有肾细胞癌(renal cell carcinoma, RCC)的风险，目前备受关注；肿块越大，这种风险越高(表 1)。超过3/4的小肾脏占位性病变是恶性[4]，在恶性肿瘤中，肿块越大病理分级越高[5]。然而，在小于2cm的肿块中几乎有70%是恶性的[6]。

目前尚无实性或复杂囊性肾脏肿块的临床特点或影像学特点可精确预测哪些病变会增大；而且也没有精确的特征用于预测组织学诊断、恶性肿瘤的风险或预后[7-11]。生长速率也不能可靠地预测肿块的生物学行为[7]。阐述了该观点的代表性研究结果如下：

                  

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-08-23.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA 1999; 281:1628.
  2. Millet I, Doyon FC, Hoa D, et al. Characterization of small solid renal lesions: can benign and malignant tumors be differentiated with CT? AJR Am J Roentgenol 2011; 197:887.
  3. Volpe A, Panzarella T, Rendon RA, et al. The natural history of incidentally detected small renal masses. Cancer 2004; 100:738.
  4. Bosniak MA. The current radiological approach to renal cysts. Radiology 1986; 158:1.
  5. Schlomer B, Figenshau RS, Yan Y, et al. Pathological features of renal neoplasms classified by size and symptomatology. J Urol 2006; 176:1317.
  6. Akdogan B, Gudeloglu A, Inci K, et al. Prevalence and predictors of benign lesions in renal masses smaller than 7 cm presumed to be renal cell carcinoma. Clin Genitourin Cancer 2012; 10:121.
  7. Chawla SN, Crispen PL, Hanlon AL, et al. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol 2006; 175:425.
  8. Kunkle DA, Crispen PL, Chen DY, et al. Enhancing renal masses with zero net growth during active surveillance. J Urol 2007; 177:849.
  9. Pahernik S, Ziegler S, Roos F, et al. Small renal tumors: correlation of clinical and pathological features with tumor size. J Urol 2007; 178:414.
  10. Klatte T, Patard JJ, de Martino M, et al. Tumor size does not predict risk of metastatic disease or prognosis of small renal cell carcinomas. J Urol 2008; 179:1719.
  11. Steffens S, Junker K, Roos FC, et al. Small renal cell carcinomas--how dangerous are they really? Results of a large multicenter study. Eur J Cancer 2014; 50:739.
  12. Beer AJ, Dobritz M, Zantl N, et al. Comparison of 16-MDCT and MRI for characterization of kidney lesions. AJR Am J Roentgenol 2006; 186:1639.
  13. Vargas HA, Chaim J, Lefkowitz RA, et al. Renal cortical tumors: use of multiphasic contrast-enhanced MR imaging to differentiate benign and malignant histologic subtypes. Radiology 2012; 264:779.
  14. Birnbaum BA, Hindman N, Lee J, Babb JS. Renal cyst pseudoenhancement: influence of multidetector CT reconstruction algorithm and scanner type in phantom model. Radiology 2007; 244:767.
  15. Newatia A, Khatri G, Friedman B, Hines J. Subtraction imaging: applications for nonvascular abdominal MRI. AJR Am J Roentgenol 2007; 188:1018.
  16. Siegel CL, McFarland EG, Brink JA, et al. CT of cystic renal masses: analysis of diagnostic performance and interobserver variation. AJR Am J Roentgenol 1997; 169:813.
  17. Yamashita Y, Ueno S, Makita O, et al. Hyperechoic renal tumors: anechoic rim and intratumoral cysts in US differentiation of renal cell carcinoma from angiomyolipoma. Radiology 1993; 188:179.
  18. Barwari K, de la Rosette JJ, Laguna MP. The penetration of renal mass biopsy in daily practice: a survey among urologists. J Endourol 2012; 26:737.
  19. Shannon BA, Cohen RJ, de Bruto H, Davies RJ. The value of preoperative needle core biopsy for diagnosing benign lesions among small, incidentally detected renal masses. J Urol 2008; 180:1257.
  20. Lebret T, Poulain JE, Molinie V, et al. Percutaneous core biopsy for renal masses: indications, accuracy and results. J Urol 2007; 178:1184.
  21. Maturen KE, Nghiem HV, Caoili EM, et al. Renal mass core biopsy: accuracy and impact on clinical management. AJR Am J Roentgenol 2007; 188:563.
  22. Wang R, Wolf JS Jr, Wood DP Jr, et al. Accuracy of percutaneous core biopsy in management of small renal masses. Urology 2009; 73:586.
  23. Menogue SR, O'Brien BA, Brown AL, Cohen RJ. Percutaneous core biopsy of small renal mass lesions: a diagnostic tool to better stratify patients for surgical intervention. BJU Int 2013; 111:E146.
  24. Volpe A, Kachura JR, Geddie WR, et al. Techniques, safety and accuracy of sampling of renal tumors by fine needle aspiration and core biopsy. J Urol 2007; 178:379.
  25. Rybicki FJ, Shu KM, Cibas ES, et al. Percutaneous biopsy of renal masses: sensitivity and negative predictive value stratified by clinical setting and size of masses. AJR Am J Roentgenol 2003; 180:1281.
  26. Thompson RH, Hill JR, Babayev Y, et al. Metastatic renal cell carcinoma risk according to tumor size. J Urol 2009; 182:41.
  27. Thompson RH, Kurta JM, Kaag M, et al. Tumor size is associated with malignant potential in renal cell carcinoma cases. J Urol 2009; 181:2033.
  28. Lieber MM. Renal oncocytoma: prognosis and treatment. Eur Urol 1990; 18 Suppl 2:17.
  29. Kim JK, Park SY, Shon JH, Cho KS. Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at biphasic helical CT. Radiology 2004; 230:677.
  30. Hafron J, Fogarty JD, Hoenig DM, et al. Imaging characteristics of minimal fat renal angiomyolipoma with histologic correlations. Urology 2005; 66:1155.
  31. van Baal JG, Smits NJ, Keeman JN, et al. The evolution of renal angiomyolipomas in patients with tuberous sclerosis. J Urol 1994; 152:35.
  32. Jones EC, Pins M, Dickersin GR, Young RH. Metanephric adenoma of the kidney. A clinicopathological, immunohistochemical, flow cytometric, cytogenetic, and electron microscopic study of seven cases. Am J Surg Pathol 1995; 19:615.
  33. Davis CJ Jr, Barton JH, Sesterhenn IA, Mostofi FK. Metanephric adenoma. Clinicopathological study of fifty patients. Am J Surg Pathol 1995; 19:1101.
  34. Hartman DJ, Maclennan GT. Renal metanephric adenoma. J Urol 2007; 178:1058.
  35. Patel U, Ramachandran N, Halls J, et al. Synchronous renal masses in patients with a nonrenal malignancy: incidence of metastasis to the kidney versus primary renal neoplasia and differentiating features on CT. AJR Am J Roentgenol 2011; 197:W680.
  36. Gervais DA, McGovern FJ, Arellano RS, et al. Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR Am J Roentgenol 2005; 185:64.
  37. Zagoria RJ, Traver MA, Werle DM, et al. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. AJR Am J Roentgenol 2007; 189:429.
  38. Breen DJ, Rutherford EE, Stedman B, et al. Management of renal tumors by image-guided radiofrequency ablation: experience in 105 tumors. Cardiovasc Intervent Radiol 2007; 30:936.
  39. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 2010; 7:754.
  40. Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012; 118:997.