윤여동오 1: 다암한신동내병변의영상진단 c D Fig. 1. Renal sinus lipomatosis.. IVU reveals elongation and attenuation of the pelvis and infundibula{arrows), especially i

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1 대한방시선의학호 지 1997; 37 : 다양한신동내병변의영상진단 1 윤여동 변재영 지원희 황태곤 2 김승협 3 김명진 4 박석희 신경섭 신동 (rena l sinus) 은신장의집합계를포함하고그주위를둘러싼구조물로서신장의내측에접해있다. 신동내에는집합계, 지방, 임파선, 동맥및정맥, 그리고신경이지나가며, 따라서다양한병변들이발생할수있다. 이러한다양한병변들은유사한영상소견으로나타날수있어신동내질환에대한충분한지식과이해가없이는진단상오류를범할수있다. 이엄상화보에서는다양한신동내병변들과이들의진단에유용한적절한영상진단법을보여주고자하였다.CT는신동의세부적인해부학적구조를잘나타내어병변의범위를평가하는데가장유용한영상진단법이었다. 그리고대부분의경우에있어서여러영상진단법의적절한조함으로정확한진단을내릴수있었다. 신동내에는다 % 댁f 병변들이발생할수있고이들병변들에 대한개별적인기술은많이있어왔지만, 하나의해부학적구조 물 (anatomical 의 entity) 로서의신동내병변에대한기술은거 없었다. 또한다 % 댄신동내병변들에대한충분한지식과 이해가없이는정확한진단을할수가없다. 이에저자들은다 양한신동내병변들을알아보고, 이들병변의진단에유용한영 상진단법과감별진단을하는데에적절한영상진단법들에대해 알아보고자하였다. 신동의해부와발달 신동은신장의집합계 (co ll ecti ng system) 를포함하고그주 위를둘러싼구조물로서, 외측으로는신수질 (renal medulla) 과 피질주 (cortica l column) 로경계지워지고, 내측으로는신문 (renal hilus) 과접해있다. 내부구조물로는임파관, 신경및혈 관들이있고이들을섬유지방조직이툴러싸고있다. 집합계를 신동내구조물에서제외시키는경우도있지만저자플은포함시 켜조사하였다. 신생아기의신피질 (rena l cortex) 과수질은신 장부피의약 90 % 를차지하고, 성인이되면약 82% 로감소하 게되는데이는신동내지방조직의발달로인한신동부피의증 가에기인한다 (1). 다발성지방종 다발성지방종 (rena l l 가롤릭대학교의과대학방사선과학교실 2 가툴릭대학교의과대학비뇨기과학교실 서울대학교의과대학방사선과학교실 4 연세대학교의과대학방사선과학교실 sinus lipomatosis) 이란신동내에지 이논문은 1997 학년도가툴릭중앙의료원학술연구보조비로이루어졌 o. 이논문은 1997 년 2 월 19 일접수하여 년 7 월 1 일에채택되었음 방조직이과다하게축적되는것을말한다. 정상젊은성인에서는앓은층의지방조직이신장내의집합계와신동내의다른구조물들을둘러싸고있으나, 연령이증가함에따라이지방층은서서히증가하게된다. 과다한지방축적으로인해경정맥요로조영술상신우선배의기형 (pyelocalyceal deformi t y ) 을일으켜신우두 (infundibula) 의연장 ( e longation) 을동반한방사투과성신동 (radio lu cent sinus) 을초래하게된다 (1, 2). 연령의증가, 비만등이주로원인이되지만, 이외에신장의감염, 경색, 동맥경화성질환에의한허혈 ( i schemia) 등도원인이된다. 드물게는스테로이드치료, 쿠썽씨병과골반내다발성지방종 (pelvic lipomatosis) 때도볼수있다 (1). 한편, parapelvic cyst의경우에도경정맥요로조영숭상방사선투과성신동 (radio lu cent renal sinus) 을보이는데, 이들의감별진단에초음파검사가유용하다. 즉, 다발성지방종 (Fig. 1) 에서는신장의중심에코복합체 (central echo co mplex) 가커지고에코가증가하는반면에 parapelvic cyst의경우에는무에코의낭성병변으로나타나게된다 (Fig. 2). 지방조직의 CT소견은매우특이적이고, 신동내지방의감약계수는 -15HU이하이다 (Fig. 1C). 후복막강지방에비해감약계수가약간높은데이는아마도신동내지방의섬유성분과주변신실질과의부피평균화 (volume a ver agi ng) 효과때문으로사료된다. 또한자기공명영상은낭종과지방을구별하는데매우유용한검사법이다. 액체성분의낭종은 T1 강조영상에서낮은신호강도, T2 강조영상에서는높은신호강도로나타나고, 지방은 Tl 강조영상에서높은신호강도 (Fig. 1D), T2 강조영상에서는중등도신호강도를보인다 (1 ). 신동낭종 (s;nus cyst) 신동내에발생하는낭종은 2가지의특징적인양상으로나타

윤여동오 1: 다암한신동내병변의영상진단 c D Fig. 1. Renal sinus lipomatosis.. IVU reveals elongation and attenuation of the pelvis and infundibula{arrows), especially in the left kidney.

2 윤여동오 1: 다암한신동내병변의영상진단 c D Fig. 1. Renal sinus lipomatosis.. IVU reveals elongation and attenuation of the pelvis and infundibula{arrows), especially in the left kidney.. Ultrasonogram, longitudinal projection. S1ImC There. Contrast is increased enhanced prominence CT. of the central The renal sinus contains a large volume of fat (arrows) that surrounds the blood vessel D. Tl weighted coronal MR image shows increased volume of the sinus fat as enlarged central high signal intensity (arrows) in the both kidneys. Fig. 2. Parapelvic cyst in the right kidney.. xial ultrasonogram of the kidney reveals a well-defined, round anechoic lesion (arrow) with posterior enhancement in the renal sinus.. Contrast enhanced CT shows a mass of water density (arrow) in the renal sinus of the right kidney

대한방시선의학회지 1997 ; 37: 509-514 Fig. 3. Left renal artery aneurysm.. Contrast enhanced CT shows an ovoid dilated vascular structure (arrow) with thrombus (arrowheads) in the left renal sinus.

3 대한방시선의학회지 1997 ; 37: Fig. 3. Left renal artery aneurysm.. Contrast enhanced CT shows an ovoid dilated vascular structure (arrow) with thrombus (arrowheads) in the left renal sinus. Note the thrombus within the lumen seen as a semilunar low density.. Renal angiography demonstrates a large ovoid aneurysm (arrow) of the left renal artery.. ~ / Fig. 4. Venous hemangioma in the left renal sinus seen as a subtle high density lesion (arrow) on precontrast CT scan () and a low density lesion (arrow) on contrast enhanced CT scan{). The diagnosis was confirmed by surgery. 나는데하나는신동자체에서발생하는작고여러개의불규칙한 모양의낭종을보이는경우이고 (p e rip e lv ic cyst), 다른하나는 주위 실질로부터기원하는한개의커다란낭종 (parapelvic cyst) 으로나타난다 (1). 이둘의구분이애매하여혼동되어쓰 이며, 이풀을모두신동냥종 (sinu s cyst ) 으로부르기도한다. 초음파검사상, 신동내낭종이수신증 ( h y dronephro sis ) 으로 오인되는경우가있는데 ( 3 ), 이때에 C T가신동내의해부학적 조성을잘나타내어진단에도움을주는경우가많다 (Fig. 2). 초음파상커다란낭종이확장된신우와감별이어려울경 우조영제투입후에 CT 를시행하여집합계를잘묘사함으로 써낭종과수신증을쉽게감별할수있다. 기타비종앙성병변다발성지방종과신동내낭종이신동내에서가장흔한병변이지만, 선동내에서또는주위실질로부터기원하는다른비종양성병변들도발생할수있다. 혈관성병변들로는동맥류 (Fig. 3), 정맥류, 혈관종 (F ig.4) 되Fig. S. cute pyelonephritis in the left kidney. Contrast enhanced CT shows an ill-defined low density lesion (arrows) about contrast-filled calyx{c), suggestive of neoplastic process. On histopathological examination, a conglomerate of inflammatory cells was found in the left renal sinus. On follow-up CT, there was marked regression in ill-defmed low density lesion of the left renal sinus

4 윤여동오 1: 다앙한신동내병변의영상진단 c D E F Fig. 6. Neoplastic lesions in the renal sinus.. Lymphoma. Contrast enhanced CT shows a homogeneous soft tissue mass (arrows) expanding the left renal sinus and encasing the renal vessels within the sinus. Fibromyxosarcoma. Contrast enhanced CT shows a huge heterogeneously enhancing mass in the right renal sinus, markedly compressing the right kidney (rk) and ad jacent bowel loops. (arrows: dilated renal collecting system) C. Leiomyosarcoma. Contrast enhanced CT shows a well enhancing mass (arrows) in the right renal sinus, compressing the collecting systems D. Neurofibromatosis. Contrast enhanced CT shows bulky heterogenously enhancing masses (arrows) in the right renal sinus and both erector spinae muscles. E. Hemangiopericytoma. Contrast enhanced CT shows a soft tissue mass (arrows) in the left renal 잉s lnus, coαorr 매 res잃 s잉 m멍 g the collecting systems (arrowheads). F. Wilms tumor. Contrast enhanced CT shows an ovoid soft tissue mass (arrows) in the right renal sinus, partially obliterating the collecting systems. On histopathology, the tumor was located in the renal medulla and tumor invasion into the collecting system was seen - u J

대한방사선의학회지 1997: 37: 509-514 등이종괴로나타날수있는데, 초음파검사상무에코의낭성병 변으로관찰되고, 도플러초음파와역동적 CT 스캔으로이들 병변의혈관상 (vascular nature) 을잘나타낼수있으며, 혈관 조영술로확진할수있다.

5 대한방사선의학회지 1997: 37: 등이종괴로나타날수있는데, 초음파검사상무에코의낭성병 변으로관찰되고, 도플러초음파와역동적 CT 스캔으로이들 병변의혈관상 (vascular nature) 을잘나타낼수있으며, 혈관 조영술로확진할수있다. 춰l 장의가성냥종이신옹내로침범한 경우기 - 보고되였는데, 조영제주사후변연부에조영증강되는 두꺼운벽을갖고내부에조직파편을포함한낭성병변의비교 적특칭적인 CT 소견으로진단을내릴수있었다 ( 1). Fishman 등은몇예의자발성신동내출혈을보고하였는데항응고제와 관련된자율성경과 (self-limi ting process) 를보이는병변이었 다. 즉, 항응고치료를받던환자에서경정맥요로조영술 (I VU) 상신동내에종괴효과를보이고 CT 상 40-60HU 의종 괴로서 2-3 주후에저절로없어지는특정적인양상을보였다 (4). 이외에도 hypertrophied column of ertin, 염증세포의 집합에의한가성종괴 (pseudotumor) 등의병변들이있다 (Fig.5). 종양성병변신동내구조물이나주변신실질로부터발생하여신동으로침범핸여러종류의양성및악성종양들이올수있다. 신동내구조물에서발생하는종양으로는혈관근지방종 ( angiomyolipoma), 기형종 ( teratoma), 투명세포육종 (clear cell sarcoma), 악성부신경절종 (malignant paraganglioma), 럼프종 (Fig. 6), 전이성선암, 섬유점액육종 (Fig. 6), 평활근육종 (Fig.6C), 신경섬유종증 (Fig. 6D), 혈관주위세포종 (Fig.6E), 다발성골수종등이있다. 주변신실질로부터발생하여신동으로침범하는종양으로는윌름 (Wilm) 씨종양 (Fig. 60, 신세포암 (Fig.7), 호산성과럽세포종 ( oncocytoma) 등이었다. 연부조직종괴와신집합계의변형은신동내종양의주된소견이다. 종양의크기가매우큰경우에는신장을외측으로전위시키는경우도었다. 종양이미만성의침윤성경과 (diffuse infiltrating process) Fig. 7. Right renal cell carcinoma with invasion of right renal vein and IVC. Contrast enhanced CT shows a subtle low density lesion (arrow) in mildly dilated right renal vein. The diagnosis of renal vein thrombosis could not made confidently by CT alone.. T2-weighted coronal MRI clearly demonstrates tumor thrombi (arrow) in the right renal vein and IVC. 8 Fig. 8. Transitional cell carcinoma in the left renal sinus.. IVU reveals irregular filling defect and attenuation of collecting system (arrow) in the left kidney.. Contrast enhanced CT shows a poorly enhancing mass (arrows) in the left renal sinus with obliteration of sinus fat

6 윤여동오 1: 다앙한신동내병변의영상진단 를보이는경우신장주위지방 (perirenal fat) 의소실, 요관과 신장윤곽의소실로나타나며, 폐쇄성요로병증 (obstructive uropathy) 을흔히유발한다 (5). 초음파와 CT 는신동내종양 을진단하는데특히유용하다. 고형절의병변은다 % 댄정도의 에코로나타나는데이틀중럼프종은비교적흔하게신동내임 파절을침벙하여초음파상균일한저에코의음영으로나타나 며, 조영제주입후의 CT 스캔상균일한조영증강을보이는종 괴로나타난다. 신집합계내의병변들 (Les;ons ;n the ;ntrarenal collect;ng system) 신장내집합계 (intrarenal collecting system) 에흔한병변 으로는결석, 혈괴, 이행성상피세포암등이있다. IVU 상충만 결손 (filli ng defect) 을보인경우, 정확한진단을위해초음파 와 CT 가유용한검사법이다. 이행성상피세포암의초음파소견 은중심에코복합체 (echogenic central complex) 내에종양의 범위에상응하는상대적으로저에코 (less echogenic) 의연부조 직종괴로나타난다. 반면에혈괴는매우고에코 (echogenic) 로 나타나며, 결석은강한후방음향음영 (strong acoustic shadowing) 을보이는고에코병변 (echogenic lesion) 으로나 타난다 (1). 이행성상피세포암의 CT 소견은조영제주사후다양한정도 의조영증강을보이는신동내종괴로나타난다 (Fig.8). 결석 의진단에있어서는 CT 가가장좋은진단법이다. 방사투과성 인요산결석 (uric acid stone) 의경우에도조영전스캔에서 400HU 이상의감약계수를보여쉽게진단할수있다 (1). 참고문헌 1. mis ES, Cronan JJ. The renal sinus: an imaging review and proposed nomenclature for sinus cysts. J Urology 1988; 139: Yeh HC, Mitty H, Wolf S. Ultrasonography of renal sinus lipomatosis. Radiology 1977; 124: Hidalgo H, Dunnick NR, Rosenberg ER, Ram Pc, Korobkin M. Parapelvic cyst: ppearance on CT and sonography. JR 1982; 138: Fishman MC, P 이 lack HM, rger PM, anner MP. Radiographic manifestations of spontaneous renal sinus hemorrhage. JR 1984; 142: Davidson J, Hartman DS. Renal sinus and periureteral abnormalities. Radiology of the kidney and urinary tract. 2nd ed. Philadelphia: Saunders, 1994: J Korean Radiol Soc 1997; 37 : Imaging Diagnosis in Various Renal Sinus Lesions 1 Yeo Dong Yoon, M.D., Jae Young yun, M.D., Won Hee Jee, M.D. Tae Gon Hwang, M.D. 2, Seung Hyup Kim, M.D. 3, Myeong Jin Kim, M.D. 4 Sok Hee Park, M.D., Kyung Sub Shinn, M.D. 1 Department of Radiology, Catholic University Medical College 2Department of Urology, Catholic University Medical College 3Department of Radiology, Seoul National University College of Medicine 4Department of Radiolog)ι Yonsei University Medical College The renal sinus extends from the perinephric space into the deep recess situated on the medial border of the kidney. Contained within the space are the pelvocalyceal system, fat and lymph nodes. rteries, veins, lymphatic channels and nerves of the autonomic nervous system traverse the sinus, and various pathological conditions may occur in this area. These various sinusal lesions may present a similar imaging appearance, and diagnostic errors may frequently occur, especially if diagnosis is attempted without first clearly understanding the several possibilities. This pictorial essay demonstrates various renal sinus lesions and emphasizes the proper combination of multimodal imaging. For evaluation of the extent of the lesious, CT is the preferred imaging modality, since this best depicts the anatomy of the renal sinus. Using a proper combination of multimodal imaging, specific diagnosis was in most cases possible. Index Words: Kidney, diseases Kidney neoplasms, diagnosis ddress reprint requests to: Yeo Dong Yoon, M.D., Department of Radiology, Catholic University Medical College, Kangnam St. Mary s HospitaL # 505 anpo-dong, Seocho-Gu, SeouL , Korea. Tel Fax

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