精囊原发性平滑肌瘤1例

2019-05-15 彭琳 田林 医学影像学杂志

患者男,46岁。“左下腹部隐痛不适4天”入院。患者4天前无明显诱因出现左下腹部隐痛不适。当地医院超声提示盆腔肿块。我院盆腔CT增强检查示(图1,2):盆腔左后方肿块,良性首先考虑,来源于精囊腺可能性大。门诊以“盆腔肿物待查”收入院。病程中患者无尿痛、肉眼血尿及脓尿。既往史:1996年“精囊炎”病史,精液偶见少许血丝,近3年症状消失。

患者男,46岁。“左下腹部隐痛不适4天”入院。患者4天前无明显诱因出现左下腹部隐痛不适。当地医院超声提示盆腔肿块。我院盆腔CT增强检查示(图1,2):盆腔左后方肿块,良性首先考虑,来源于精囊腺可能性大。门诊以“盆腔肿物待查”收入院。病程中患者无尿痛、肉眼血尿及脓尿。既往史:1996年“精囊炎”病史,精液偶见少许血丝,近3年症状消失。
 


图1 CT增强动脉期膀胱左后方类椭圆形肿块,边界清楚,密度均匀;图2 曲面重建显示左侧精囊腺与肿块有一细小蒂相连
 
体格检查:T36.5℃、P70次/min、R20次/min、Bp 124/86mmHg。实验室检查尿液正常,肿瘤标志物均正常。入院后气管内插管全麻静吸复合麻醉下行腹腔镜下盆腔肿物切除术。术中见膀胱左侧底部及左输尿管下段内侧见约一3.3 cm×4.6 cm软组织包块,与左侧精囊相连,相连部分呈蒂状,较细,精囊各壁未见明显异常,肿物与周围无明显粘连。术中将部分精囊及肿物完整切除送病理学检查。
 
病理巨检:管壁样物一条4 cm×1 cm,一端见一灰白包块5.0 cm×4.0 cm×2.0 cm,切面灰白质稍韧;病理诊断(图3):精囊平滑肌瘤。术后随访8月,未见复发。
 


图3 病理切片显示肿块为平滑肌瘤(HE×100)
 
讨论:
 
大多数精囊腺肿瘤为邻近组织肿瘤蔓延而来,精囊腺的原发良性肿瘤少见,其中来源于精囊上皮的精囊腺瘤和精囊囊肿较多,而来源于间质的平滑肌瘤极为罕见。国内仅可查阅极少量个案报道。精囊腺平滑肌瘤一般好发于中年男性,常为单侧,其CT表现国内未见相关报道。本例CT表现为膀胱左外偏后侧见一截面约3.3 cm×4.6 cm软组织肿块,密度均匀,边界清晰,膀胱左侧壁稍受压,肿块中心CT值约32HU,左侧精囊见一细小蒂与肿块相连。增强动脉肿块未见明显强化(CT值34HU),静脉期轻度强化(CT值48HU),延迟期持续轻度强化(CT值42HU)。CT表现上符合良性肿块表现,结合肿块与精囊相连故而考虑肿块来源于精囊,但由于精囊腺平滑肌瘤少见,诊断医师未能考虑该病。
 
精囊腺平滑肌瘤与精囊腺囊肿鉴别容易,精囊囊肿为精囊区单发或多发囊性低密度肿块,囊壁菲薄光滑;但与其它良性肿瘤(如精囊腺瘤)鉴别尚缺乏经验。此外,精囊腺良性肿瘤尚要与原发性精囊癌和邻近组织恶性肿瘤侵犯相鉴别。膀胱癌及前列腺癌是最常累及精囊腺的恶性肿瘤。累及精囊时膀胱精囊三角变钝或消失,但绝大多数精囊形态正常。原发性精囊癌的影像表现为实性或囊实性肿块,精囊腺不规则膨大,与周围脂肪界限模糊,精囊角消失;CT增强上肿块多表现为较明显不均匀强化;临床表现上多数精囊癌患者合并血精,当患者合并血精并出现恶性肿瘤表现应考虑精囊癌的可能。本例为良性平滑肌瘤,既往因精囊炎出现血精,但近3月来血精症状消失。因此,在血精的鉴别上应注意精囊炎的可能。
 
原始出处:

彭琳,田林.精囊原发性平滑肌瘤1例[J].医学影像学杂志,2018,28(03):417+421.

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