Testis lenfoması ve bilateral testis tutulumu BT bulguları

Özet

Testiküler lenfoma, ileri yaş erkeklerde sıklıkla görülen nadir bir ekstranodal hastalıktır; primer veya sekonder olarak testisi tutabilir. BT, testis parankimini karakterize etmekten çok retroperitoneal ve diğer lenf nodlarını, dalak-karaciğer tutulumunu ve başka ekstranodal odakları evrelemeye yarar; lokal testis incelemesinde ultrason ön plandadır. Bilateral testis tutulumu lenfomayı düşündürür (vakaların yaklaşık %38'inde), ancak testis parankiminin karakterizasyonu için kontrastlı BT yerine skrotal ultrason tercih edilir. Testis ve merkezi sinir sistemi dahil ekstranodal yayılımın fark edilmemesi hastalığın sistemik kapsamını eksik gösterebilir.

Faz ve pencere

Portal tanısal: Kontrastlı abdomen-pelvis BT'de retroperitoneal lenfadenopati, böbrek hiluslarını saran kitleler, splenik veya hepatik odaklar ve diğer ekstranodal yumuşak doku tutulumları aranır; skrotal BT primer testis karakterizasyonu için uygun değildir.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30), Yumuşak doku (G 400 / M 40), Mediasten (G 350 / M 50).

BT bulguları

Paraaortik, parakaval ve pelvik zincirlerde birden fazla istasyona yayılan lenf nodu büyümeleri lenfomanın sistemik dağılımını gösterebilir.
Birleşik retroperitoneal yumuşak doku renal hilus damarlarını sarabilir; damarların açıklığının korunması ve belirgin hidronefroz olmaması infiltratif lenfoma görünümüne eşlik edebilir.
Dalak büyümesi veya fokal splenik lezyonlar lenfatik sistemik hastalığı destekler.
Karaciğerde lenfoma genellikle düşük yoğunluklu focal kitleler veya yaygın infiltrasyon olarak görünür; kontrastlı BT'de bu odaklar hipofenitre zemininde düşük atenüasyon gösterir.
Lenfoma dalak, karaciğer, gastrointestinal sistem, böbrek, adrenal bezler ve peritoneal kavite gibi birçok ekstranodal bölgeyi tutabilir.
Testis büyümesi ve bilateral tutulum klinik/ultrason bulgusu olarak önemli olsa da rutin abdomen BT testis parankim değerlendirmesinin yerini tutmaz.
Mediastinal ve supraklaviküler lenf nodları lenfomanın abdominal dışı nodal tutulumuna örnek olabilir.

Normalde

Normal lenf nodları yaklaşık 1 cm boyutundadır; retroperitoneal bölgede bu ölçütü aşan büyüme veya yumuşak doku infiltrasyonu patolojik kabul edilir. Şüpheli nodal dokunun damarları çevreleyip lümeni açık bırakıp bırakmadığına, kaç nodal istasyonun etkilendiğine ve dalak-karaciğer parankiminin homojenliğine bakın.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0119; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Testis germ hücreli tümörleri radyolojik olarak kitle veya parankimal heterojenite ile prezent edebilir; kesin ayırıcı tanı için orşiektomi ve histopatoloji şarttır.
Lenfoma, metastatik solid organ tümörlerini taklit eden genişletilmiş toraksik-abdominal tutulumlar oluşturabilir; ayırıcı tanıda histopatolojik doğrulama esastır.
Retroperitoneal fibrozis: damarları ve üreterleri çevreleyen plak benzeri doku oluşturur; çok istasyonlu nodal kitle ve splenik odak örüntüsü tipik değildir.
Nekrotizan lenfadenopati (tüberküloz, mikobakteriyel enfeksiyon veya kedi tırmığı hastalığı gibi granülomatöz süreçler), lenfomaya benzer nekrotik düğümler oluşturabilir; kesin tanı için doku örneği şarttır.

Tuzaklar

BT'de testislerin normal görünmesi lenfomatöz tutulumu dışlamaz; lokal değerlendirmede bilateral karşılaştırmalı skrotal ultrason önceliklidir.
Lenfoma böbrek hilüsündeki büyük damarları çevirse de lümenler genellikle açıktır; bu bulgu tek başına damar invazyonu ya da trombozu anlamına gelmez.
Bilateral testis kitlesi lenfomayı düşündürse de malakoplaki, IgG4 ilişkili hastalık veya plazmositom gibi nadir inflamatuar/neoplastik süreçler de benzer görünüm verebilir; kesin tanı için ultrason ve doku örneklemesi şarttır.

Kendini dene

Primer testis lenfomasının (PTL) en yaygın radyolojik evreleme yöntemi ve testis lezyonunun karakterizasyonunda tercih edilen modalite hangisidir?
Cevabı göster
Multidetektör BT (evreleme) ve skrotal ultrason (primer lezyon). Kaynaklara göre PTL'nin sistemik evrelenmesinde multidetektör BT (MDCT) birincil yöntemdir; primer testis lezyonunun çalışmasında ise doppler ultrason önceliklidir.
Kontrastlı BT'de çok istasyonlu retroperitoneal lenfadenopati renal damarları sararken lümen açıklığını koruyor; dalakta ise düşük atenüasyonlu fokal lezyonlar izleniyor. En olası tanı nedir? En olası süreç?
Cevabı göster
Lenfoma. Çok istasyonlu nodal yumuşak doku, damarları sararken açıklığı koruması ve splenik lezyonlar lenfomayı destekler. Lenfomada peripelvik tutulum renal hilus yapılarını çevreleyebilir; damarlar sıklıkla açık kalır ve hidronefroz minimal olabilir.

Kaynaklar

Bu sayfadaki 33 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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