七年制临床呼吸常见病2ppt课件

1 Imaging Diagnosis of Rspirotary Disease part 2 AiPing Chen 2 Lung neoplasm肺肿瘤 nThe incidence of primary lung carcinoma is increasing in all over the world. nMost malignent lung tumors (over 98%) are bronchiogenic carcinoma 支气管肺癌. 3 Lung neoplasm肺肿瘤 nBenign:良性 qharmatoma, adenoma, angioma, fibroma q错构瘤，腺瘤，血管瘤，纤维瘤 n malignancy:恶性 q primary：lung carcinoma 肺癌，sarcoma 肉瘤 qSecondary：metastasis转移瘤 4 harmatoma nuncommon nasymptomatic; nsymptoms typically are present with central endobronchial lesions， include hemoptysis, recurrent pneumonia, and dyspnea. 5 harmatoma ntypically round, well-marginated peripheral masses smaller than 4cm (range, 1 to 30cm). ntypical pattern ： popcorn calcification爆米 花样的钙化 n Calcification钙化 probably is present in less than 5% of lesions, Fat 脂肪can be detected by CT (attenuation ,-40 to -120 HU) in up to 50% of cases and is a diagnostic feature. 6 7 8 primary bronchogenic carcinoma 原发性支气管肺癌 nmost common malignancy nrisk factor ： ncigarette smoking nEnvironmental and occupational exposure （ 3% to 17%） nInterstitial pulmonary fibrosis and focal scarring have been reported to increase the risk for bronchial carcinoma. 9 nLung carcinoma(cancer) qSCLC(small cell lung cancer) 小细胞肺癌 qNSCLC(non-small cell lung cncer）非小细胞肺癌 nsquamous cell carcinoma 鳞癌 nAdenocarcinoma 腺癌 nLarge Cell Carcinoma大细胞癌 ncompound carcinoma 混合癌 nbronchioloavelar carcinoma BAC细支气管肺泡癌 Lung neoplasm 10 Lung neoplasm qSCLC(small cell lung cancer) qSmall cell carcinoma is a rapidly growing tumor that has the most irrefutable association with smoking. qLike squamous cell carcinoma, it is predominantly a central tumor (90%), but growth is mainly along anatomic tissue planes. qmetastasizes early; systemic spread is present in two- thirds of cases at presentation. q生长迅速，中央型，转移早，全身 11 Lung neoplasm qNSCLC(non-small cell lung cncer) nsqumous cell carcinoma is most commonly a central tumor developing at the level of the segmental and subsegmental bronchi in 66% of cases. These tumors are frequently lobulated and have a tendency to cavitate. nAdenocarcinoma is a peripheral tumor in 75% of cases with a predilection for the upper lobes and for regions of parenchymal fibrosis (“scar” carcinomas). nbronchioloavelar carcinoma grows mainly within the alveoli respecting interstitial boundaries,may be unifocal or multifocal, when multifocal, it may produce alveolar cell carcinosis. 12 bronchial carcinoma nasymptomatic ， detected incidentally n most patients (up to 90%) are symptomatic 气道起源多数表现为 producing cough, hemoptysis, dyspnea, and chest pain n约33% 会出现胸外转移症状，多见于骨骼系统 和神经系统。其他，肾上腺，肝脏，淋巴结。 。 13 According to type of growth nCentral type: qInter-tuber 管内 qWall of tuber管壁 qExtra-tuber 管外 nPeripheral type: qMass qinflammation qDiffuse Lung neoplasm 14 Central tumor n n Direct sign of bronchial carcinomaDirect sign of bronchial carcinoma n n lung masslung mass nBronchial lumen : Bronchial stenosis，endoluminal or transmural growth 15 Central tumor: mass in the right low lober and right hilar enlarge, 16 mass in the right hilar 17 Central tumor nlung mass in the hilum n n Bronchial lumenBronchial lumen n支气管改变 q支气管壁增厚 q支气管腔内肿块 q支气管腔狭窄/闭塞 18 Mouse tail Irregular stenosis Filling defect Cup like 19 20 Mouse tail Central tumor 21 Filling defect 22 Bronchial stenosis 23 Central tumor nIndirect sign n间接征象：支气管阻塞所致改变支气管阻塞所致改变 q阻塞性肺肺气肿 q阻塞性肺炎：不易吸收，同一部位反复发作 q阻塞性肺不张：肺不张合并肿块，肺不张合并 转移是其特点 n 24 nPartial or complete atelectasis ： Segments, lobes, or an entire lung are no longer aerated and undergo partial (dystelectasis) or complete collapse (atelectasis). This is manifest as patchy or homogeneous pulmonary opacification of lobar or segmental distribution. 25 Right upper lobe atelectasis 26 Right upper lobe atelectasis 27 left upper lobe atelectasis 28 Left low lobe atelectasis 29 Left low lobe atelectasis Bronchial stenosis 30 Left low lobe atelectasis 31 Central tumor nIndirect sign of bronchial carcinoma: nDistal pneumonia presents as lobar or segmental consolidation, which may partially resolve with antibiotic therapy. In patients with appropriate risk factors and recurrent or persistent pneumonia, further evaluation to exclude a central endobronchial tumor is merited. 32 Distal pneumonia 33 pneumonia mass Pleural effusion 34 Central tumor nIndirect sign of bronchial carcinoma: nIntrathoracic spread of bronchial carcinoma. 35 Right side Central tumor 36 Central tumor nIndirect sign of bronchial carcinoma: nMediastinal lymph node enlargement. Mediastinal widening may be the first radiographic sign of lung cancer, especially in cases of small cell carcinoma. 37 38 Central tumor nHematogenous spread of bronchial carcinoma. nOsteolytic bone lesions and pathologic fractures 溶骨性的破坏和病理性的骨折 signify hematogenous spread of disease.血 行播散 39 Costal bone damage 40 Right lung metastasis 41 42 43 Central tumor nMRI manifestation qBronchi wall thicken qBronchi wall stenosis qMass in the hilum qEmphysema; pneumonia; atlectasis of obstruction qAffect mediastinum，enlargement of lymph node(diameter15mm) 44 45 46 nplain film、CT、MRI Central tumor 47 Plain film 48 CTCT平扫平扫 CT scan no contrast 49 CTCT增强增强 CT scan contrast 50 MRIMRI 51 52 53 Peripheral tumor n Peripheral pulmonary nodule. n round，usually less than 5cm in diameter. n The following features suggest a diagnosis of bronchial carcinoma: ill-defined margin in 85% of malignant tumors; radial striated markings at the interface with lung parenchyma representing tumor spread along the lymphatics; notching of the contour; a cavitating lesion typical of squamous cell carcinoma. 54 Peripheral tumor Pulmonary nodule in the early stage. nLobulation，Spiculated margin. nAir bronchogram. nCavitary. nBubble-like lucencies within the nodule.空泡征 nRetraction of pleura-pleural indentation sign胸膜凹陷征 55 Peripheral tumor n分叶征象: 生长不均衡，周围血管和支气管 的限制 n毛刺征象: 肿瘤沿血管及间质浸润有关 n空洞形成: 偏心性，内壁不规则或呈结节状 56 notching of the contour 57 notching of the contour 58 Cavitary. 59 Retraction of pleura. Spiculate margin. notching of the contour 60 Retraction of pleura. Spiculate margin. notching of the contour 61 Retraction of pleura. Spiculate margin. notching of the contour 62 Spiculate margin. notching of the contour 63 Spiculate margin. notching of the contour 64 Bone metastasis 65 66 Bronchiolo-alveolar carcinoma nIsolated mass type nPneumonia type nDiffuse nodule type 67 Isolated mass type Bronchiolo- alveolar carcinoma 68 Bronchiolo-alveolar carcinoma Pneumonia type 69 70 71 ill-defined margin pulmonary nodule Bronchiolo-alveolar carcinoma 72 Bronchiolo-alveolar carcinoma 73 Bronchiolo-alveolar carcinoma 74 Lung mestastasis nThe most common primary tumor site was lung, followed by large bowel, prostate, breast, uterus, and esophagus. nBetween 20% and 40% of primary carcinomas of the lung produced pulmonary metastases. Tumors with the greatest rate of metastases to the lung include choriocarcinoma绒毛膜癌, germinal tumors of the testis睾丸的生殖细胞瘤, melanoma黑色素瘤, Ewings sarcoma尤文氏肉瘤, osteosarcoma, 骨肉瘤 carcinoma of the thyroid, 甲状腺癌carcinoma of the breast乳腺癌, and rhabdomyosarcoma横纹肌肉瘤. 75 Lung mestastasis nHematogenous mestastasis nLymphatic vessel mestastasis 76 Hematogeneous mestastasis 77 Hematogeneous mestastasis 78 Hematogeneous mestastasis 79 Hematogeneous mestastasis 80 Lymphatic vessel mestastasis 81 Pleural carcinomatosis 82 83 Mediastinal tumor纵隔肿瘤 主要诊断依据： position, shape， density. 84 Tumor of the anterior mediastinum Thymoma Teratoma Intrathoracic thyroid Malignant lymphoma Bronchogenic cyst Neurogenic tumors 85 Mediastinal tumor n n Anterior mediastinal tumorAnterior mediastinal tumor前纵隔前纵隔 qIntra-thoracia thyroid mass胸内甲状腺肿: upper of mediastinum qThymoma胸腺瘤: anterior qTeratoma畸胎瘤：calcification; fat nMiddle mediastinal tumor中纵隔中纵隔 nPosterior mediastinal tumor后纵隔后纵隔 86 Intrathoracic thyroid nIntrathoracic thyroid is usually a downward prolongation or outgrowth of a cervical thyroid enlargement. On radiolograph most cases show widening of one or other side of the anterior superior mediastinum and displacement of the trachea to the opposite side and compression of the trachea on the side of the tumor. 87 胸内甲状腺肿 intrathoracic goiter n病理：多数为结节性甲状腺肿 nX线表现 q前纵隔上部 q边缘光滑，与颈部肿物相连 q气管受肿块推压 88 Intrathoracic thyroid 89 Intrathoracic thyroid nThe CT appearances of thyroid goiters are specific. Anatomical continuity usually can be demonstrated with the cervical thyroid. Focal calcifications and inhomogeneity are frequent features. After injecting contrast material, there is a definite prolonged rise in the CT Hounsfield number. 90 l结甲伴腺瘤样增生 l女，62岁 l肿物与甲状腺相连 91 Intrathoracic thyroid nMR imaging particularly in the coronal and sagittal planes, can show the extent of intrathoracic thyroid tissue and its relationship to adjacent structures. Multinodular goiters have heterogeneous signal characteristics on T1W1 and T2W1. 92 93 94 Thymoma胸腺瘤 nanterior superior mediastinum. nround, lobulated or plaque-like, and produce unilateral widening of the mediastinum. nCalcification or cystic degeneration may be seen in a small percentage of cases. 95 胸腺瘤thymoma n占前纵隔肿瘤50%多见于中年人 n多数无症状，少数有压迫或侵犯表现 n三分之一伴有重症肌无力 n良性：包膜完整，无周围浸润 n恶性：包膜不完整，向周围侵犯转移 96 97 Thymoma nCT is the imaging method of choice for evaluating the possibility of thymic disease. Differentiation between thymoma and thymic hyperplasia is difficult in patients less than 40 years of age. Thymic hyperplasia tends to enlarge but preserve the normal shape of the gland. However, exceptions to this are encountered in which hyperplasia is found in nodular glands, simulating the presence of a thymoma. 98 胸腺瘤 nX线表现：单侧或双侧纵隔增宽突出，边缘 一般较清晰。 nCT表现：前纵隔内类圆形肿块，恶性表现为 包膜不完整，累及周围组织，胸膜和肺，淋 巴结增大 99 Thymoma 100 Thymoma 101 Thymoma 102 103 l胸腺瘤，可疑包膜侵润 l男性，47岁，查体发现 104 Thymoma nThymomas have intermediate signal intensity (equal to that of skeletal muscle) in T1W1 and increased signal intensity (approaching that of fat) on T2W1. Cystic regions are areas of hemorrhage have low signal intensity on T1W1 and high signal intensity on T2W1. 105 胸腺瘤MRI 106 畸胎瘤 teratoma n先天性肿瘤，属生殖细胞瘤 n好发于2040岁，绝大多数属良性 n病理 q来源于原始胚胎组织的残留物 q皮样囊肿：主要含有外胚层衍生物 q实质性畸胎瘤：含有内、中、外三个胚层衍生物， 可为良性或恶性 107 畸胎瘤 teratoma X线表现及CT表现 n含有多种组织而密度不均 n钙化和囊变是特征性表现 q囊变部分CT值近似水 n恶性畸胎瘤常较大，边缘不规则 108 Teratoma nMost mediastinal teratomas are seen on radiograph as a localized mass in the anterior compartment close to the origin of the major vessels from the heart. Calcification is evident on radiograph in mature teratomas. On CT, most tumors have well- defined margins that were smooth or lobulated with round or oval in shape and have heterogeneous attenuation with soft tissue, fluid and fat. Fat- depressed MRI sequences can demonstrate fat better than CT. occasionally a fat-fluid level is seen on radiograph and CT scan. 109 teratoma 110 teratoma 111 teratoma 112 113 114 l精原细胞瘤 l男，16岁，面部浮肿1月，咳嗽20天 恶性生殖细胞肿瘤 115 Mediastinal tumor nAnterior mediastinal tumor： nMiddle mediastinal tumor： qMalignant lymphoma qBronchogenic cyst nPosterior mediastinal tumor 116 Malignant lymphoma nThe thorax is frequently involved in patients with Hodgkins and non-Hodgkins lymphomas. nIt has been estimate that lymphoma constitutes about 20% of all mediastinal neoplasms in adults and 50% in children. nLymph node enlargement is evident on the initial radiograph of approximately 50% of patients, especially bilateral enlargement of hilar and paratracheal lymph nodes. 117 恶性淋巴瘤 n淋巴组织恶性肿瘤 n发热，周围淋巴结增大及全身衰弱 n上腔静脉阻塞综合征 n纵隔淋巴结增大，常见于血管前、气管旁、主 肺动脉窗、肺门等部位 118 恶性淋巴瘤 nX线表现 q肿块向纵隔两侧突出，气管受压 nCT表现 q纵隔内多组淋巴结增大，可融合成块 q侵及邻近结构 119 Malignant lymphoma 120 Malignant lymphoma 121 Malignant lymphoma nCT and MRI are more sensitive than radiograph. The enlarged lymph nodes or mass mostly sh