高分辨率肺部ct诊断（中）

Case 34, in an asymptomatic 34-year-old man with an abnormal chest radiograph suggesting lymph node enlargement 胸片提示淋巴结肿大,纵隔窗：双侧肺门淋巴结增大,A few small lung nodules are also visible. The nodule distribution is:少数小结节可见，分布特点？ (a) perilymphatic淋巴管周围 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules 胸膜下结节are visible particularly in relation to the major fissures叶裂. The nodules are scattered and patchy in distribution, and predominate in the upper lobes结节在上叶. Some of the nodules are peribronchovascular支气管血管束结节.,胸膜下结节,支气管血管束结节,What is the most likely diagnosis?最可能的诊断 (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Sarcoidosis Correct. A perilymphatic pattern of nodules, with predominance in relation to the fissures and peribronchovascular regions is typical of sarcoidosis结节病以胸膜下、支气管血管束分布为主. Diagnosis: Sarcoidosis, mild轻度, with perilymphatic nodules 淋巴管周围结节,Case 35 in follow-up of an asymptomatic 43-year-old man with with a history of heart transplantation several years before 几年前心脏移植史,The nodule distribution is结节分布: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules 胸膜下结节are visible in relation to the major fissure斜裂. The nodules are scattered and patchy in distribution, and predominate in the upper lobes. Some of the nodules are peribronchovascular支气管血管束分布.,胸膜下结节,支气管血管束结节,The most likely diagnosis is:最可能的诊断 (a) opportunistic infection机遇性感染 (b) post-transplantation lymphocytic disorder移植后淋巴混乱 (c) sarcoidosis结节病,sarcoidosis Correct. This appearance is typical of sarcoidosis.,移植前胸部异常,Diagnosis: Progressive前进的 sarcoidosis, with perilymphatic nodules 淋巴管周围分布结节,Case 36 in an asymptomatic 29-year-old man with chest pain and infiltrates on chest radiograph 胸痛胸片可见渗出性病变,双侧肺门淋巴结增大,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules 胸膜下结节are visible in relation to the major fissures叶裂. The nodules are scattered and patchy in distribution分布是分散不均的.,胸膜下结节,What is the most likely diagnosis最可能的诊断? (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Sarcoidosis Correct. A perilympatic pattern of nodules is present, although this appearance is somewhat atypical淋巴管周围分布不太典型. A very patchy distribution of nodules is common in sarcoidosis结节病不均分是常见的, but the grouping of nodules seen in this case is unusual. When seen on chest radiograph, this appearance is sometimes called “alveolar sarcoid,”类似肺泡癌 although the nodules are discrete不连续 and interstitial.,Diagnosis:Sarcoidosis, with patchy lung involvement不均的肺内侵润.,Case 37 in an 45-year-old South African diamond miner with progressive dyspnea 南非钻石矿工进行性呼吸困难,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules 胸膜下分布are visible at the lung periphery. The nodules are scattered and patchy in distribution, and predominate posteriorly and in the upper lobes上叶后部占优势. The nodules show symmetrical involvement 对称受累(Figure 2, Figure 3) of both upper lobes双上叶.,胸膜下结节,What is the most likely diagnosis最可能的诊断? (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Silicosis Correct. The history suggests silicosis历史支持硅肺病. A perilympatic pattern of nodules淋巴管周围分布方式, with predominance 上叶后部胸膜下间质对称性分布为著in relation to the supleural interstitium, with a symmetrical, posterior, upper lobe predominance is consistent with this diagnosis.,Case 38 in a 63-year-old woman with breast cancer乳癌 and progressive shortness of breath进行性呼吸困难,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Large subpleural nodules 胸膜下结节are visible in the lung periphery肺外围. In addition, the nodules are patchy in distribution and predominate in relation to thickened interlobular septa小叶间隔结节分布不均.,胸膜下结节,增厚的小叶间隔,What is the most likely diagnosis最可能的诊断? (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Lymphangitic spread of carcinoma Correct. This appearance is typical of lymphangitic spread of carcinoma外观是典型的癌性淋巴管炎. In patients with lymphangitic spread of tumor, when nodules are visible, they are most often visible within the thickened peribronchovascular interstitium 结节在支气管血管束内、小叶间隔内更常见and interlobular septa. Septal thickening can result in the appearance of a “beaded串珠状“ septum.,Case 39 in a 53-year-old man with known thyroid cancer 甲状腺癌and progressive shortness of breath进行性喘憋,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules胸膜下结节 are visible in relation to the left major fissure and the lung periphery左叶裂、肺外围. In addition另外, the nodules are patchy in distribution and are also seen in relation to central vessels中心血管. Mediastinal lymph node enlargement 纵隔淋巴结增大is visible on soft tissue window scans.,胸膜下结节,中心血管,增大淋巴结,What is the most likely diagnosis最可能的诊断? (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Lymphangitic spread of carcinoma Correct. This appearance is nonspecific非特性, but consistent with lymphangitic spread of carcinoma. Although this appearance could also be seen in patients with sarcoidosis, the history suggests the appropriate diagnosis与结节病不好鉴别，结合病史考虑. Interlobular septal thickening, common with lymphangitic spread of carcinoma is not seen in this case.,Case 40 in a 43-year-old man with AIDS, cutaneous 皮肤Kaposi sarcoma肉瘤 (KS), and progressive shortness of breath进行性喘憋,支气管血管束间质,小叶中心,小叶间隔增厚,The nodule distribution is结节分布方式 (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,perilymphatic Correct. This patient shows a perilymphatic pattern with a peribronchovascular predominance分布以支气管血管束为优势. In a patient with AIDS, this distribution suggests lung involvement by KS.,Case 41 in a 44-year-old woman with AIDS, fever 。,The nodule distribution is结节分布方式 (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,perilymphatic Correct. This patient shows a perilymphatic pattern. Subpleural nodules 胸膜下结节are visible in relation to涉及 the major fissure叶裂. In addition另外, the nodules are seen in relation to thickened interlobular septa增厚的小叶间隔可见结节状.,胸膜下结节,增厚的小叶间隔呈结节状,What is the most likely diagnosis最可能的诊断? (a) Sarcoidosis结节病 (b) Silicosis硅肺病 (c) Lymphangitic spread of carcinoma癌性淋巴管炎,Lymphangitic spread of carcinoma Correct. This appearance is typical of lymphangitic spread of carcinoma是典型的癌性淋巴管炎. An unusual cause of this pattern in patients with AIDS is lymphocytic interstitial pneumonia淋巴间质性肺炎 (LIP).,Case 42, in a 33-year-old man with shortness of breath 呼吸短缺,Large大的, ill-defined 不清楚的lung nodules are visible, predominating in relation to the peribronchovascular interstitium支气管血管束间质. Nodules also involve the supleural region胸膜下, and lymph node enlargement 淋巴结增大is present.,支气管血管束间质,胸膜下结节,淋巴结增大,Diagnosis: Lymphoma淋巴瘤 arising 起于from Mucosa Associated Lymphoid Tissue (MALToma粘膜相关组织的淋巴瘤 ), with peribronchovascular nodules. The presence of peribronchovascular nodules is typical. 支气管血管束结节是典型表现。,Case 43 in an 43-year-old man with fever and cough 发热咳嗽,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern. Subpleural nodules are visible peripherally and in relation to the major fissures胸膜下结节可见. Overall全面的, the nodules appear diffuse结节表现弥漫的, and a predominance in relation to perilymphatic structures is not visible淋巴管周围是不可见的.,胸膜下结节,What is the most likely diagnosis最可能的诊断? (a) Miliary tuberculosis粟粒型肺结核 (b) Hematogenous metastases血行转移瘤,Miliary tuberculosis Correct. Based on history, infection is likely感染是很可能的.,Case 44 in an 57-year-old man being treated确诊治疗 for bladder cancer 膀胱癌,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern随机分布图案. Subpleural nodules are visible peripherally 外围胸膜下结节可见and in relation to the major fissures涉及叶裂. Overall全面的, the nodules appear diffuse结节呈弥漫性.,胸膜下结节,Small nodules appearing randomly distributed in relation to structures of the lung肺小结节随机分布常见于： and secondary lobule are often seen in patients with miliary tuberculosis粟粒型肺结核, miliary fungal infections粟粒状真菌感染, and hematogenous metastases血行多发转移瘤.,What is the most likely diagnosis最可能的诊断? (a) Miliary TB粟粒型肺结核 (b) Miliary fungal infection粟粒状真菌感染 (c) Hematogenous metastases多发转移瘤,Hematogenous metastases Correct. Based on history依病史, hematogenous metastases is most likely血行转移瘤是可能的. However, this patient is being treated for bladder cancer by having BCG, a (usually) non-pathogenic mycobacterium通常卡介苗治疗后无致病源, instilled into his bladder. This rarely results in hematogenous dissemination, identical in appearance and histology to miliary TB, but easier to treat.,Following appropriate antibiotic treatment随后适当的抗生素治疗, the nodules结节 have resolved有减少.,Diagnosis: Miliary粟粒状的 nontuberculous mycobacterium (BCG)肺结核, with random nodules随机分布结节。,Case 45 in an 53-year-old man with fever and cough 发热咳嗽,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern. Subpleural nodules are visible peripherally and in relation to the major fissures肺外围、叶裂胸膜下小结节. Overall, the nodules appear diffuse弥漫性,胸膜下结节,Miliary nodules related to fungal infection许多粟粒状结节与真菌感染有关系 cannot be distinguished from miliary TB不能与粟粒型肺结核区别.,Diagnosis: Miliary 粟粒状coccidioidomycosis球孢子菌病, with random nodules随机分布。,Case 46 in an 51-year-old asymptomatic woman with breast cancer who is post liver transplantation 乳癌肝转移,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern. Subpleural nodules are visible peripherally and in relation to the major fissure胸膜下（外围、叶裂）. Overall, the nodules appear diffuse, with a peripheral predominance弥漫分布，外围占优势. Considering the history of breast cancer乳癌史, metastases are likely多发转移. An ill-defined不清楚得 opacity in the right upper lobe reflects fluid from recent bronchoscopy with bronchoalveolar lavage支气管镜检.,胸膜下结节,血行转移瘤，在外围、肺底，结节比粟粒状的大。 Diagnosis: Hematogenous metastases from breast cancer血行多发转移瘤, with random nodules 随机分布。,Case 47 in an 57-year-old woman with a history of breast cancer 乳癌史,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern随机分布. Subpleural nodules are visible peripherally and in relation to the major fissure胸膜下结节（外围、叶裂）. Overall, the nodules appear diffuse弥漫性.,胸膜下结节,Diagnosis: Hematogenous metastases from breast cancer血行多发转移瘤, with random nodules随机分布.,Case 48 in an 63-year-old man with a history of thyroid cancer 甲状腺癌,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern随机分布. Subpleural nodules are visible peripherally and in relation to the major fissure胸膜下（外围、叶裂）. Overall, the nodules appear diffuse弥漫性, with a peripheral predominance外围占优势.,胸膜下结节,In this patient该病例, interlobular septal thickening both smooth and nodular小叶间隔光滑、结节状增厚, is also visible可见, suggesting a perilymphatic pattern支持淋巴管周围分布.,Diagnosis: Metastatic thyroid carcinoma甲状腺癌, with random and perilymphatic nodules随机、淋巴管周围分布.,Case 49 in an 43-year-old Italian priest 意大利牧师with an abnormal chest radiograph and cough咳嗽,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,random Correct. This patient shows a random pattern随机分布. Subpleural nodules are visible peripherally and in relation to the major fissures胸膜下结节（外围、叶裂）. Overall, the nodules appear diffuse弥漫性.,胸膜下结节,Although the differential diagnosis would include miliary TB, miliary fungal infection, or hematogenous metastases as most likely尽管鉴别诊断包括（结核、真菌感染粟粒状,血行转移瘤） lung biopsy revealed sarcoidosis病理为结节病. Diagnosis: Sarcoidosisiejie结节病, with random nodules随机分布。,Case 50, in a 53-year-old man with productive生产的 cough咳嗽,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,centrilobular Correct. This patient shows a centrilobular pattern小叶中心性分布. Subpleural nodules are not seen胸膜下结节未见, and the most peripheral nodules外围结节 visible range from 5 to 10 mm from the pleural surface and fissure胸膜表面、叶裂下5-10MM. Overall, the nodules appear diffuse and uniform in distribution弥漫均匀分布.,外围结节（胸膜下5-10MM）,Diagnosis:Infectious 感染性的bronchiolitis细支气管炎 with centrilobular nodules小叶中心性结节.,Case 51 in a 48-year-old man with common variable immunodeficiency免疫缺陷 and productive生产的 cough咳嗽,Multiple许多 ill-defined lung nodules不清楚的肺结节 are visible. The nodule distribution is结节分布: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,centrilobular Correct. This patient shows a centrilobular pattern小叶中心性分布. Subpleural nodules are not seen胸膜下结节未见, and the most peripheral nodules visible range from 5 to 10 mm from the pleural surface and fissure外围结节位于胸膜下5-10MM.,胸膜下结节（胸膜下5-10MM）,Overall, the nodules appear patchy in distribution分布不均, and some are clearly related to thick-walled bronchi增厚的支气管壁. Lucencies within several nodules represent centrilobular bronchioles小叶中心细支气管, which are somewhat dilated稍扩大. Diagnosis: Infectious bronchiolitis感染性细支气管炎 and bronchopneumonia支气管肺炎 with centrilobular nodules小叶中心结节.,增厚的细支气管壁,小叶中心细支气管,Case 52 in a 46-year-old man with a fever and productive cough发热咳嗽,The nodule distribution is结节分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,centrilobular Correct. This patient shows a centrilobular pattern小叶中心分布. Subpleural nodules are not visible胸膜下结节未见, and some nodules are clearly related to small airways or contain a central lucency中心透亮, representing a centrilobular bronchiole小叶中心细支气管.,小叶中心透亮区,Larger areas of opacity大不透亮区, having a patchy distribution are visible in the lung bases在肺底部不均分布. These represent lobular areas of consolidation肺小叶, some containing a central air bronchogram (i.e. the centrilobular bronchiole). Diagnosis: Bacterial细菌的 bronchopneumonia支气管肺炎 with peribronchial支气管周围 and lobular areas of consolidation肺小叶.,肺小叶,Case 53 in a 57-year-old woman with progressive shortness of breath over several weeks憋气几周以上, a nonproductive 非生产性咳嗽cough, and low-grade fever低热,Multiple ill-defined lung nodules of ground-glass opacity are visible多发边界不清磨玻璃密度结节. The nodule distribution is分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心性分布,centrilobular Correct. This patient shows a centrilobular pattern小叶中心分布. Subpleural nodules are not seen胸膜下结节未见, and the most peripheral nodules外围结节 visible range可见区 from 5 to 10 mm from the pleural surface and major fissure. Overall, the nodules appear diffuse in distribution and evenly spaced弥漫均匀分布. Abnormal 异常bronchi and frank consolidation are not seen.,外围结节,Additional history revealed that the patient lived with several birds患者有养鸟史. In patients with a history of exposure, this appearance is highly suggestive of hypersensitivity pneumonitis高度暗示过敏性肺炎. Diagnosis: Hypersensitivity pneumonitis, subacute stage亚急性期, with centrilobular nodules.,过敏性肺炎,1.斑片状边缘模糊影：肺泡腔内空气被浆液渗出物取代肺泡炎。 2.弥漫分布粟粒影：鸽子肺。 3.线、网状、粟粒状影：为间质性渗出性改变。,Case 54, in a 78-year-old man with progressive shortness of breath进行性喘憋,Multiple ill-defined lung nodules are visible许多边界不清的肺结节. The nodule distribution is分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,centrilobular Correct. This patient shows a centrilobular pattern小叶中心分布. The most peripheral nodules are centered 5-10 mm from the pleural surface外围结节胸膜下5-10MM. Although the largest nodules in the posterior lung touch the pleural surface尽管后部接胸膜面, no nodules appear to arise at the pleural surface. Overall, the nodules appear diffuse in distribution and evenly spaced弥漫分布均匀间隔. No abnormal bronchi are visible.,This appearance is nonspecific该表现无特殊性. Bronchoscopy yielded bronchioloalveolar carcinoma支气管镜检为肺泡癌. Diagnosis: Bronchioloalveolar carcinoma, diffuse nodular form, with centrilobular nodules,Bronchioloalveolar carcinoma细支气管肺泡癌 (BAC) can result in: 1) a solitary nodule or mass单发结节或肿块 (40% of patients); 2) focal or diffuse consolidation (30%); or 3) diffuse ill-defined nodules 弥漫(30%). When multiple nodules are present, they may be centrilobular, as in this case, due to endobronchial spread气道播散, or may mimic模仿 the appearance of hematogenous metastasis血行转移.,Case 55, in a 35-year-old man with a fever and productive 生产性的cough,Multiple ill-defined lung nodules多发边界不清的肺结节, of varying size大小不一, are visible. The nodule distribution is分布方式: (a) perilymphatic淋巴管周围分布 (b) random随机分布 (c) centrilobular小叶中心分布,centrilobular Correct. This patient shows a centrilobular pattern (Figure 1). Subpleural nodules are not visible胸膜下结节未见. Some of the subpleural opacities have an irregular branching appearance胸膜下可见树芽征. This appearance, mimicking a branching tree, is termed “tree-in-bud.“,“tree-in-bud.” 树芽征,What is the most likely diagnosis最可能的诊断? (a) Infection感染 (b) Bronchioloalveolar carcinoma细支气管肺泡癌 (c) Hypersensitivity pneumonitis过敏性肺炎,Infection Correct. Bronchoscopy revealed镜检显示 infection感染 with Hemophilus influenza流感.,Diagnosis: Bacterial 细菌的bronchopneumonia支气管肺炎 with a centrilobular pattern 小叶中心分布and “tree-in-bud.” 树芽征（为细支气管内粘液栓）,Case 56 in a 53-year-old woman with a right lung transplantation 肺移植for emphysema 肺气肿and productive 生产性的cough咳嗽,The left lung shows typical findings of panlobular emphysema左肺为典型的全小叶型肺气肿. Multiple small, well-defined 明确的centrilobular nodules 小叶中心结节(Figure 1) are visible in the transplanted right lung移植的右肺. Subpleural nodules are not visible胸膜下结节未见. Tree-in-bud i