Parotiidnäärme tuumorid. Liisi Talv

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1 Parotiidnäärme tuumorid Liisi Talv

2 I patsient Aasta tagasi tekkis väike tuumor vasakul põsel, mis asümptomaatiliselt pidevalt suuremaks kasvas KT alusel sai diagnoosihüpoteesiks pandud pleomorfne adenoom

3 II patsient Kaks aastat tagasi tekkis vasakul kõrva eesmises piirkonnas väike sõlm, mis aeglaselt suurenes ja mõnikord põhjustas kerget lokaalset surumistunnet. KT alusel sai diagnoosihüpoteesiks pandud pleomorfne adenoom

4 III patsient Väike, tihke moodustis paremal gl. parotise piirkonnas, olnud umbes pool aastat KT alusel sai diagnoosihüpoteesiks pandud diferentsiaaldiagnostiliselt kas pleomorfne adenoom või näärmesisene lümfisõlm?

5 IV patsient Varasemalt tekkinud pool aastat tagasi vasakpoolselt kõrva ees turse, mis taandunud. Nüüd nädal tagasi tekkinud taas turse koos naha punetusega. KT alusel sai diagnoosihüpoteesiks pandud diferentsiaaldiagnostiliselt: pleomorfne adenoom?, abstsess? (samas moodustise keskosa tihedus kontrasteerumisel mõnevõrra tõuseb), lagunev lümfisõlm?? muu??

6 V patsient Nädal tagasi haigestus, oli palavik ca 37,6 neli päeva, nohu, rögaeritusega köha. Nüüd avastas vasakul alalõualuunurga juures kõrva ees tihkema ümara moodustise, mis kergelt valutab. KT alusel sai diagnoosihüpoteesiks pandud infitseerunud esimese lõpuspilu tsüst? Pleomorfne adenoom? muu??

7 Parotiidnääre

8 Parotiidnäärme beniigsed kasvajad

9 Pleomorfne adenoom Kõige sagedasem parotiidnäärme kasvaja Koosneb erineva histoloogiaga epiteliaalsetest ja mesenhümaalsetest kudedest Sagedamini ndatel eluaastetel, veidi rohkem naistel Sagedamini pindmises sagaras Aeglase kasvuga, kümnete aastate jooksul väike osa tuumoreid maligniseerub

10 Pleomorfne adenoom Tavaliselt selgepiirilised lobulaarsete (vahel ümarate või ovaalsete) kontuuridega Struktuur on ühtlane või ebaühtlane (suurematel sageli nekrootilisi alasid) või harvem multinodulaarne Sisaldavad üsna sageli väikseid lubistusi Sageli UH-s hüpoehhogeensed posterioorse kajavõimendusega; vaskularisatsioon on tavaliselt vähene MRT-s tavaliselt T1 hüpo- ja T2 hüperintensiivsed; sageli T2 hüpointensiivne fibroosne kapsel MRT uuringul kontrasteerumine on tavaliselt intensiivne; KT-l võrreldes 30 sek faasiga intensiivsem 120 sek faasis

11 Kontrasteerumine: 30 sek, 120 sek ja ca 12 min

12 Plemorfne adenoom

13 Pleomorfne adenoom

14 Pleomorfne adenoom

15 Warthin i tuumor (papillary cystadenoma lymphomatosum) Sageduselt teine parotiidnäärme tuumor Sisaldab rohkelt lümfotsüüte ja germinaaltsentreid (lümfisõlmetaoline strooma) Seotud suitsetamisega, seoses sellega varem oli rohkem meestel, nüüd ka naistel Esineb sagedamini ndatel eluaastatel Bilateraalne ca % juhtudest Eelistatud asukoht on parotiidnäärme saba regioon

16 Warthin i tuumor Heterogeense struktuuriga, sageli tsüstjate aladega Tavaliselt selgepiiriline ja ovaalne UH-ga tavaliselt hüpoehhogeenne mitmete anehhogeensete tsüstjate aladega Sageli hüpervaskulariseeritud MRT-l T2 signaal sageli heterogeenne, T1 signaal tavaliselt madal või vahepealne; kolesteroolikomponente sisaldavad tsüstjad alad on hüperintensiivsed MRT uuringul kontrasteerumine on tavaliselt väheintensiivne; KT-l intensiivsem 30 sek faasis kui 120 sek faasis Tehneetsium 99m pertehnetaat stsintgraafial hot spot (ka onkotsütoom, teised tuumorid tavaliselt mitte)

17 Warthin i tuumor

18 Warthin i tuumor

19 Harvad parotiidnäärme beniigsed kasvajad Onkotsütoom Basaalrakuline adenoom Müoepitelioom Lipoom Hemangioom Schwannoom

20 Onkotsütoom Koosneb mitokondririkastest onkotsüütidest; sageli kahepoolne/mitmekoldeline UH-ga hüpoehhogeensed hästi piirdunud KT-l hästi piirdunud varase homo- või heterogeense ( arm ja tsüstjad alad) kontrasteerumisega (üsna kiire wash-out ) Teistest tuumoritest eristavaks tunnuseks vahel esinev tsentraalne mittekontrasteeruv käävjas arm ja suuremate tuumorite deformeeritav iseloom!!! Enamasti T1 hüpointesiivne hästi piiritletud tuumor; T2 fatsat ja T1 post-kontrast sageli isointensiivne võrreldes parotiidnäärmega Koguvad Tc99m pertehnetaati!

21 Basaalrakuline adenoom Koosneb monomorfsest basalioidsete epiteliaalsete rakkude populatsioonist; ei ole kondromüksoidset stroomat nagu pleomorfsel adenoomil Selgepiiriline (sile või lobulaarne) hetero- või homogeense struktuuriga KT-l kontrasteerumismuster sarnane Warthini tuumorile ja onkotsütoomile MRT-l sageli vahepealne signaal T1 kujutistel, T2 kujutistel vahepealne või hüperintensiivne; tsüstjad osad T2 ja sageli ka T1 hüperintensiivsed (sageli sisaldavad verdumisi) Tavaliselt esineb T2 hüpointensiivne kapsel

22 Müoepitelioom Koosneb müoepiteliaalsetest rakkudest; ei ole kondromüksoidset stroomat Tavaliselt superfitsiaalses sagaras kapsliga külgnevalt Selgepiiriline (sile või lobulaarne) pigem heterogeense struktuuriga (kontrasteeruvad noodulid, mittekontrasteeruvad lineaarsed, pilutaolised või tsüstilised alad) MRT: T1 hüpo/isointensiivne, T2 üldiselt hüperintensiivne hüpointensiivse kapsliga; Intensiivne kontrasteerumine aeglase wash-out -ga

23 UH-s tavaliselt ovaalne hüpoehhogeenne selgepiiriline seest hüperehhogeensete lineaarsete struktuuridega KT-l rasvatihedus MRT-l rasvasignaal Lipoom

24 Hemangioom UH uuringul homogeenne või heterogeenne kergelt lobuleeritud mass ehhogeensete septidega ja väga kõrge vaskulaarsusega KT-l ja MRT-l intensiivne kontrasteerumine

25 Schwannoom VII kn-st (tavaliselt foramen stylomastoideum i lähedal) või mõnest perifeersest närviharust; diagnoosimise hetkel tavaliselt närvihalvatust ei ole UH uuringul hüpoehhogeenne selgepiiriline T1 isointensiivne lihasega, T2 hüperintensiivne, üsna sageli heterogeenne (seest hüpointensiivsem kui perifeerselt või tsüstilise degeneratsiooniga) Intensiivne kontrasteerumine

26 Lisaks veel eristada... Abstsess/ Infitseerunud tsüst/ Infitseerunud lümfisõlm- põletikutunnused! Tsüstjad moodustised: 1. lõpuspilutsüst, süljenäärme tsüst, dermoidtsüst, epidermoidtsüst, lümfangioom Üksiku granuloomina esinev granulomatoosne põletik- nt TBC, aktinomükoos

27 Abstsess ja 1. lõpuspilutsüst

28 Parotiidnäärme maliigsed kasvajad Maliigsusele viitavad tunnused: Ebateravad ähmased piirjooned (sensitiivsus ca 0,59, spetsiifilisus ca 0,79) Ebaregulaarne kuju Närvide ja ümbritsevate struktuuride infiltratsioon (kõrge spetsiifilisus, aga madal tundlikkus) Metastaatiliste lümfisõlmede olemasolu Doppleriga kõrge süstoolne tippvoolu kiirus ja kõrge vaskulaarne RI T2 hüpointensiivsus (sensitiivsus ca 0,70 ja spetsiifilisus ca 0,73)

29 Parotiidnäärme maliigsed kasvajad Mukoepidermoidne kartsinoom Adenoidne tsüstiline kartsinoom Lamerakuline kartsinoom Atsinaarrakuline kartsinoom Adenokartsinoom Duktaalne kartsinoom Pleomorfsest adenoomist tekkinud kartsinoom Rasunäärme kasvajad Maliigne fibrohistiotsütoom Lümfoom (primaarne haaratus on harv; sageli seotus Sjögreni sündroomiga) Metastaas(id) (pea- ja kaelapiirkonna kasvajad, melanoom, rinna- ja kopsuvähk)

30 Mukoepidermoidne kartsinoom Adenoidne tsüstiline kartsinoom

31 Kui täpselt on radioloogiliselt võimalik parotiidnäärme kasvaja tüüpi määrata?

32 Beniigne vs maliigne UH: sensitiivsus 88%, spetsiifilisus 54%, täpsus 79% KT: sensitiivsus 91%, spetsiifilisus 57%, täpsus 78% MRT: sensitiivsus 98%, spetsiifilisus 52%, täpsus 84% Sensitiivsus: kui paljud radioloogiline meetod nimetas beniigseks nendest, mis olid histoloogia alusel beniigsed Spetsiifilisus: kui paljud radioloogiline meetod nimetas maliigseks nendest, mis olid histoloogia alusel maliigsed

33 Radioloogiliselt määratud histoloogilise tüübi täpsus: Beniigsete kasvajate korral: UH: 57% KT: 45% MRT: 54% Maliigsete kasvajate korral UH: 13% KT: 13% MRT: 30%

34 I patsient Pleomorfne adenoom

35 Pleomorfne adenoom II patsient

36 Pleomorfne adenoom III patsient

37 IV patsient Tsütoloogia: mädane põletik; põletikulise tsüsti sisu?

38 V patsient Adenotsüstiline kartsinoom G3

39 Kasutatud kirjandus US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls E. Bialek, P. Zaijkowski (Radiographics 2006) Salivary gland tumors: evaluation with two-phase helical CT D. S. Choi, D. G. Na (radiology 2000) MR imaging of parotid tumors: typical lesion characteristics in MR imaging improve discrimination betwween benign and malignant disease A. Christe, C. Waldherr (AJNR Am J Neuroradiol 32: , aug 2011) Neither MRI, CT nor US is superior to diagnose tumors in the salivary glands an extended case study C. Rudack, S. Jörg, S. Kloska (Head and face medicine 2007) Pictorial essay: Salivary gland imaging R. Rastogi, S. Bhargava CT Features of Parotid Gland Oncocytomas: A Study of 10 Cases and Literature Review T.J. Tana and T.Y. Tan Oncocytoma: The Vanishing Parotid Mass N.D. Patela, A. van Zante Basal Cell Adenoma in the Parotid Gland: CT and MR Findings M. Jang, D. Park Myoepithelioma of the Parotid Gland: CT Imaging Findings S. Wanga, H. Shia, L. Wang Magnetic resonance imaging of myoepithelioma in the salivary glands Ami Kuribayashi, A. Imaizumi Schwannoma in the parotid gland. Experience at our institute and review of the literature M. Guzzo, L. Ferrar Intraparotid Facial Nerve Schwannoma: A Report of Five Cases and an Analysis of MR Imaging Results K. Shimizu, H. Iwai

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