呼吸病诊断ppt课件

1 Respiratory disease 放射学院 刘林祥 6222136 2 特发性肺间质纤维化 w原因不明的弥漫性纤维性肺泡炎 w又称Hamman-Rich综合征 w为肺泡壁损伤所引起的非感染性炎性反应 w近认为系免疫性疾病，可能与遗传有关 3 病 理 w急性期：肺泡内皮细胞和基底膜受损，肺泡和间质 内蛋白样物质渗出，伴透明膜形成，继而淋巴细胞 和单核细胞渗出。肺泡内皮细胞再生覆盖在渗出物 表面并使其整合入肺间质，肺泡壁增厚，胶原纤维 扭曲、紊乱而机化。病变发展，间质纤维化加重 w晚期：肺泡壁、小叶间隔及胸膜下广泛纤维化，肺 体积缩小变硬，毛细血管网和气道的终末部分被破 坏。在范围较大的纤维化区域，可有终末气道的代 偿性扩张，形成直径数mm至2cm的囊样含气腔隙 4 Hamman-Rich Syndrome w多见于中年，男、女无差别 w多起病隐匿，初期无症状 w进行性呼吸困难和干咳 w进展速度因人而异： 快者12年内出现发绀和杵状指，并发肺心病 慢者可数年甚或十几年不出现明显缺氧症状，但最终出现 缺氧及肺心病 w易合并肺部感染，反复感染可加快肺纤维化的发展 w肺功能检查呈限制性通气障碍及低氧血症 5 胸部X线平片 w早期两肺中下野细小网织阴影 w病变发展，不对称性、弥漫性网状、条索状及结节 状阴影，可扩展至上肺野 w晚期，结节影增大，伴广泛厚壁囊状阴影，蜂窝肺 w并阻塞性肺气肿时，肺野透亮度增强 w囊肿破裂可发生自发性气胸 w肺纤维化严重时可发生肺动脉高压和肺心病 6 Idiopathic pulmonary fibrosis 1.磨玻璃样影及实变影，内见含气支气管影，支 气管血管数增粗 Ground-glass attenuation 2.与胸膜面垂直的细线形影，长1-2cm，宽约1mm， 多见于两肺下叶 3.两肺中内带小叶间隔增厚，分支状细线形影， Reticular attenuation with interlobular septal thickening 4.胸膜下0.5cm内与胸壁内面弧度一致的弧线状影 ，长5-10cm，边缘较清或略模糊，见于两下肺后外 部 7 Idiopathic pulmonary fibrosis 5.蜂窝状影，数mm至2cm不等的圆形或椭圆形含气囊腔 ，壁薄而清楚，与正常肺交界面清楚。分布于两肺基 底部胸膜下区. A honeycomb pattern, predominantly basal and peripheral in distribution 6.小结节影，边缘较清楚，纤维条索在横断面的表现， 或相互交织而成 7.小叶中心性肺气肿：散在、2-4mm，肺外围部，病变 发展可渐见于肺中央部。胸膜下见1-2cm类圆形肺气囊 8.中小支气管扩张，柱状，伴支气管扭曲、并拢 Architectural distortion with associated traction bronchiectasis and bronchiolectasis 8 Idiopathic pulmonary fibrosis wF47 wperipheral GGO wInterlobular septal thickening wIrregularity of the fissures wBronchiectasis wEarly interstitial pneumonia w22m later, progression of interstitial pneumonia wDiffuse GGO, interlobular septal thickening wA honeycomb pattern 9 鉴别诊断 w肺类风湿性病的广泛性肺间质纤维化，最后发展为 蜂窝肺，与HRS相似。但前者有渐进性坏死结节即 肉芽肿及胸腔积液表现，有别于HRS w红斑狼疮的胸部表现以心肌炎所致的心脏增大、间 质性肺炎、节段性盘状肺不张和胸腔积液等所见为 特征，与HRS不同 w硬皮病的肺间质纤维化发展至晚期可出现蜂窝肺， 如有皮肤的改变以及在食管造影见其张力减低或狭 窄等表现，则有助于硬皮病的诊断 10 结节病（Sarcoidosis） wA systemic disorder of unknown cause wNoncaseating granulomas with proliferation of epithelioid cells, 多系统肉芽肿性疾病，良性经过，可累及淋巴结、肺 、胸膜、皮肤、骨、眼、脾、肝、腮腺及扁桃体等 w病理特征为非干酪性肉芽肿 w淋巴结大，但不融合。肺门LN易受累，次为气管旁和AA旁 w肺内病变沿支气管血管周围结缔组织鞘及小叶间隔发展蔓 延，肺内肉芽肿主要分布在间质，小，直径在0.4mm以下， 胸膜下肺间质内肉芽肿更密集。小肉芽肿可融合成大结节 w急性发病者肉芽肿大多经治疗消退或自行消退。慢性发病 者常导致进行性肺纤维化 11 Sarcoidosis w见于任何年龄，2040岁多见，女性多 wYoung it is closely related to the duration of the disease and suggests a chronic condition 23 Mediastinal adenopathy wM26 wSevere back pain wEnlarged right paratracheal nodes wLeft aortic- pulmonary window nodes with associated minimal hilar involvement are also seen 24 Mediastinal adenopathy wMediastinal adenopathy, 60M wCalcification in the affected hilar nodes, huge subcarinal lymph nodes wAn unusual finding in other granulomatous diseases such as tuberculosis 25 Pulmonary sarcoidosis wLung involvement in 20% of patients wStrong predilection for the upper lung wDyspnea and dry cough are common wSarcoid granulomas in lung are distributed along lymphatic vessels in interstitial tissues of bronchovascular bundles and subpleural and perilobular spaces wMultiple miliary nodules, bronchial wall thickening, and ground-glass attenuation wPerivascular or subpleural distribution wCoalescing granulomas can form multiple masslike nodules wNodules have irregular margins and may contain an air bronchogram 26 Pulmonary sarcoidosis wStage IV disease may manifest as conglomerated masses with marked traction bronchiectasis wUsually predominantly in the central and upper lung. this distribution is typical of sarcoidosis but can also be seen in tuberculosis and silicosis wExtensive calcification may be encountered within fibrotic granulomas wCavitation or cyst formation may also be seen 27 Pulmonary sarcoidosis wM37 wSmall nodules with a perivascular distribution and irregular thickening of bronchovascular bundles and interlobular septa 28 Pulmonary sarcoidosis wM24 wHRCT wMultiple miliary nodules and diffuse thickening of the bronchial wall wSimultaneous presence of small nodules with a perivascular distribution and along the interlobular pleura 29 Pulmonary sarcoidosis wF31 wHazy ground-glass opacity with a lower lung predominance, both of which are unusual findings. 30 Pulmonary sarcoidosis wHRCT wWidespread ground glass attenuation wReticulonodular wMild bronchiectasis peripherally 31 Pulmonary sarcoidosis wF26 wMultiple nodules bilaterally wMinimal hilar adenopathy wSimulate metastates 32 Pulmonary sarcoidosis wA nodular consolidation with ill -defined borders wAir bronchogram within the nodules 33 Stage IV pulmonary sarcoidosis wM60, Extensive fibrotic change and cavitary lesions with a central distribution distorting lung parenchyma wIrregular thickening of pleura and overinflation of peripheral lung parenchyma 34 Primary Bronchogenic Cancer Macro-pathology XCentral type：主支气管、肺叶支气管 及肺段支气管的肺癌 XPeripheral type：肺段以下支气管直到 细支气管以上的肺癌 XAlveolar type：发生于细支气管或肺 泡上皮的肺癌 35 Histological types of lung cancer w来自支气管表面上皮的癌 鳞状上皮癌 Squamous cell carcinoma 腺癌 Adenocarcinoma 腺鳞癌 大细胞癌 Large cell carcinoma w来自神经内分泌细胞的癌 高分化：类癌 carcinoid 中分化：不典型类癌 atypical carcinoid 低分化：小细胞癌 Small cell carcinoma w来自细支气管Clara细胞和型肺细胞的癌 细支气管肺泡癌 bronchial alveolar carcinoma 36 中心型肺癌 l l 临床表现临床表现：刺激性干咳、痰中带血，胸痛：刺激性干咳、痰中带血，胸痛 、发热、发热 l l 直接征象：直接征象：肺门肿块，支气管狭窄与阻塞肺门肿块，支气管狭窄与阻塞 l l 间接征象间接征象：支气管阻塞或狭窄后引起的阻：支气管阻塞或狭窄后引起的阻 塞性肺炎、肺不张、肺气肿塞性肺炎、肺不张、肺气肿 l l 转移征象转移征象 37 右肺上叶中心型肺癌 38 右肺上叶中心型肺癌 39 右肺上叶中心型肺癌 40 中心型 肺癌 纵隔增宽、肺门增 大，为肺癌的淋巴 结转移 41 中心型肺癌：右肺门及右上纵隔不规则肿块， 中上肺野片絮状密度增高影。断层示上叶支气 管鼠尾状狭窄 42 中心型肺癌 左肺肺癌，右肺代 偿性肺气肿 43 Central type-CT findings w管壁型：管壁增厚，管腔不规则狭窄 w管内型：腔内软组织肿块，偏心性狭窄或闭塞，杯 口状截断 w管外型：管壁环形增厚，腔外软组织肿块 w管腔狭窄或闭塞，继发远端肺炎症、不张或气肿 w肺门纵隔淋巴结转移，呈软组织样等密度，单个或 多个融合成分叶状，增强扫描无强化 w肺内，胸膜及远处转移 44 中心型肺癌 45 Central type-CT findings 46 Central type-CT findings 47 Central type 48 Squamous cell carcinoma 49 Squamous cell carcinoma 50 Squamous cell carcinoma 51 Lung cancer-peripheral type 临床表现：可无症状或胸痛、咳嗽 直接征象：肺内结节和肿块 边缘分叶，脐样切迹，毛刺 小于2cm的孤立结节，内部密度不均匀。大于3cm时，密 度较均匀 厚壁空洞 间接征象：小叶范围的阻塞性肺炎、肺不张，彗尾 征。胸膜凹陷 转移征象 52 H右肺见结节性病灶，CT示分叶与毛刺 53 厚壁空洞，体层示空洞内壁凹凸不平 54 周围型肺癌-癌性空洞 55 Peripheral type H肺内肿块，下 缘与胸膜间有 牵拽，箭头所 指为慧尾征 56 Peripheral typeCT findings w肺内结节，肿块 w软组织密度，均匀或不均匀，空泡征，钙化少 w肺窗：边缘毛刺，胸膜凹陷征，血管集束征 w纵隔窗：深分叶，偏心空洞，小棘状突起，脐征 w肺门纵隔淋巴结转移 w远处转移 57 周围型肺癌 58 Peripheral carcinoma 59 Peripheral carcinoma ground-glass opacity 60 Peripheral carcinoma Soft tissue mass Spicula 61 Peripheral carcinoma 62 Peripheral carcinoma 63 Peripheral carcinoma-lobulation 64 Hilar metastases 65 Peripheral carcinoma 66 Peripheral carcinoma 67 Peripheral carcinoma 68 Peripheral carcinoma 69 Peripheral carcinoma-cavity 70 Pancoast tumors wArise from lung apex wInvade costovertebral groove in superior sulcus wInvade parietal pleura, causing nonspecific shoulder pain radiating down medial aspect of scapula wInvolve T1 nerve root, causing pain radiating along medial aspect of arm and forearm as far as wrist wInvade stellate ganglion, causing Horner syndrome, include ptosis (narrowing of the palpebral fissure), miosis (pupillary constriction), and anhidrosis (absence of sweating on one side of the face) 71 Pancoast tumors wInvade first, second, and third ribs posteriorly wSuperior extension encasing C8 nerve root, with resultant pain in medial two digits of hand and atrophy of intrinsic muscles of hand wAnterior extension into tracheoesophageal groove result in vagal or recurrent laryngeal nerve palsy wSuperomedial extension may result in involvement of vertebral artery, vertebral bodies, neurovertebral foramina, and spinal canal, with a consequent risk of paraplegia 72 右肺上沟癌 右肺上野片状阴影， 第一、二肋骨溶骨性 破坏 73 Pancoast tumor 74 M48，left interscapular chest wall pain suggeste T1 nerve root invasion 75 Superior sulcus tumor wM48 w/o neurologic signs in left upper extremity but with left interscapular chest wall pain suggestive of T1 nerve root invasion wM48，left interscapular chest wall pain suggeste T1 nerve root invasion 76 Alveolar cancinoma l双肺布满 结节性病 灶 l病理证实 为肺泡癌 77 肺泡癌 78 Alveolar cancinoma 79 Alveolar cancinoma 80 Alveolar cancinoma 81 Bronchioloalveolar carcinoma A 53-year-old man wInitial (1mm) CT at the level of the bronchus intermedius wa small nodular area of ground- glass attenuation in the right upper lobe wFollow-up CT (5mm) 48 months later wincreased nodule size. 82 肺转移瘤 宫颈癌术后 ，肺内数个 转移病灶 83 Lung metastases 84 Lung metastases, rectal cancer 85 Lung metastases 86 食道癌肺转移 87 Lung metastases, colon cancer 88 错构瘤(hamartoma) P非真性肿瘤，内胚层与间胚层发育异常形成 P根据部位，分为周围型和中央型 P局限于某一肺叶或肺段的反复发作感染 P肺内球形软组织肿块，见爆米花样钙化 PCT扫描：钙化、钙化、脂肪 89 错构瘤 左肺门外上 肿块内可见 爆米花样钙 化 90 Hamartoma 91 错 构 瘤 92 Hamartoma 93 肺栓塞(pulmonary emboli) w肺动脉分支被栓子堵塞引起的肺供血障碍 w常见栓子是深静脉脱落的血栓 w久病卧床、妊娠、大手术后和心功能不全 可发生深静脉血栓 w风心病，原发于肺动脉的血栓 w进入血循环的脂肪、肿瘤栓子和气体 94 Pulmonary embolism wThe third most common acute cardiovascular disease after myocardial infarction and stroke wResults in thousands of deaths each year because it often goes undetected wCTA has sensitivities of 53%100% and specificities of 83%100% wPulmonary angiography, the diagnostic standard of reference for confirming or refuting diagnosis 95 病理 w双重供血，正常时两组有丰富的吻合支 w当肺动脉的某一分支栓塞后，肺组织因支 气管动脉的侧枝供血而不发生异常，栓子 较小未能完全堵塞肺动脉分支时也不易发 生供血障碍 w多数小栓子进入肺循环可引起肺动脉小分 支多发性栓塞 96 临床表现 w多无明显症状，或有轻微不适 w可为突发的呼吸困难和胸痛 w肺动脉大分支或主干栓塞或广泛的肺动脉小 分支栓塞可出现严重的呼吸困难、发绀、休 克或死亡 w较大的栓子堵塞肺动脉大分支或主干可引起 急性右心衰竭或心肌梗死而致死亡 97 X线表现 w肺动脉较大分支栓塞或多发性小分支栓塞X线平 片可出现异常阴影，较小分支栓塞即使出现症状 并经血管造影证实，X线仍可正常 w肺缺血又称Westermark征，当肺叶或肺段动脉 栓塞时，相应区域内肺血管纹理减少或消失，透 亮度增加 w多发性肺小动脉栓塞引起广泛性肺缺血，显示肺 纹理普遍减少和肺野透亮度增加，但无肺体积膨 胀现象 98 X线表现 w嵌塞在肺动脉内的血栓使相应部位血管阴影增宽 ，阻塞远端致血流减少而变细 w多发于下叶且以右下叶多见，下叶体积缩小，膈 肌升高，叶间裂下移。并盘状肺不张 w较大肺动脉栓塞或多发性小动脉栓塞可引起心影 增大，主要是右心室增大，同时有肺动脉高压 w右心功能不全时心影增大更为显著，奇静脉和上 腔静脉增粗 99 X线血管造影 w肺动脉分支内充盈缺损或截断 w局限性血管减少或无血管区，血灌流缓慢 w小分支多发性栓塞引起肺动脉外围分支迂曲 ，突然变细，呈剪枝样 w细小分支的栓塞血管造影不能显示 w血栓24hs后开始溶解，故48hs后造影可正常 w继发肺动脉高压和肺心病时，肺动脉干和大 分支扩张，周围分支变细 100 CT w平扫：较大肺动脉栓塞见血管内高密度或 低密度病灶。高密度为新鲜血栓，低密度 为陈旧性血栓 w增强：血栓为长条状及不规则形充盈缺损 w栓塞的肺动脉可有不同程度的扩张 w较大肺血管栓塞可见相应区域肺血管分布 减少 101 Acute pulmonary embolism wArterial occlusion with failure to enhance the entire lumen due to a large filling defect wArtery may enlarged vs. adjacent patent vessels wA partial filling defect surrounded by contrast material, “polo mint“ sign, “railway track“ sign wPeripheral wedge shaped areas of hyperattenuation represent infarcts, along with linear bands are significant ancillary findings 102 Acute occlusive pulmonary embolism wF32 wChest pain wA pulmonary embolus within posterobasal segment of right lower lobe artery wArtery enlarge vs. adjacent patent vessels 103 Acute pulmonary embolism wF45 wchest pain wA pulmonary embolus affects the segmental artery of the laterobasal segment of right lower lobe wPartial filling defect surrounded by contrast material produces the polo mint sign 104 Acute pulmonary embolism wM66 wChest pain and dyspnea wAcute pulmonary embolus causes a partial filling defect surrounded by contrast material wAnother acute pulmonary embolus affects the left main pulmonary artery 105 Acute pulmonary embolism wF58 wChest pain and dyspnea wA pulmonary embolus results in an eccentrically positioned partial filling defect wSurrounded by contrast material and forms acute angles with the arterial wall 106 Acute pulmonary embolism wF58 wchest pain and dyspnea wAncillary findings of a peripheral wedge-shaped area of hyperattenuation 107 Acute pulmonary embolism wMorphologic abnormalities suggest right ventricular failure can be quantified with CT pulmonary angiography RV dilatation (RV cavity is wider than LV cavity in the short axis), w/o contrast material reflux into hepatic veins Deviation of interventricular septum toward LV A pulmonary embolism index greater than 60% 108 Acute pulmonary embolism wM42 wchest pain and severe dyspnea short axis of RV is wider than that of LV, caused by acute pulmonary embolism and created RV strain 109 Acute central pulmonary embolism wF87 asymptomatic wSubtle regions of hyperattenuation wCTA: acute pulmonary embolism within the right main and left interlobar pulmonary arteries 110 Chronic Pulmonary Embolism Diagnostic criteria wComplete occluded vessel is smaller than adjacent patent vessels wA peripheral, crescent shaped intraluminal defect forms obtuse angles with vessel wall wContrast material flowing through thickened, often smaller arteries due to recanalization wA web or flap within a contrast filled artery wSecondary signs Extensive bronchial collateral vessels An accompanying mosaic perfusion pattern Calcification within eccentric vessel thickening 111 Chronic pulmonary embolism w27M wdyspnea wComplete occluded vessels in left lung are smaller than adjacent patent vessels wCollateral blood supply from a branch of right hemidiaphragmatic artery 112 Chronic pulmonary embolism wM62 wDyspnea wAn eccentrically located thrombus forms obtuse angles with vessel wall wDilated collateral bronchial artery 113 Chronic pulmonary embolism wA small, recanalized pulmonary artery with contrast material in the central lumen 114 Chronic pulmonary embolism wM56 wdyspnea wA flap within a small right interlobar pulmonary artery wCollateral bronchial artery dilatation is also noted 115 Chronic pulmonary embolism wA large chronic pulmonary embolus in the main and left main pulmonary arteries wArrows indicate collateral bronchial arteries 116 Chronic pulmonary embolism wF60, dyspnea. A mosaic perfusion pattern: Dark regions of underperfused lung contain vessels that are smaller than adjacent patent vessels in normally perfused lung 117 Chronic pulmonary embolism wM62 wDyspnea wPulmonary arterial wall calcification wA secondary sign of chronic pulmonary embolism 118 Pulmonary arterial hypertension secondary to chronic pulmonary embolism wAncillary findings pulmonary artery diameter33mm pericardial fluid wPulmonary artery measures 41mm in diameter indicates hypertension 119 Chronic pulmonary embolism wPericardial fluid associated with pulmonary arterial hypertension wSecondary to chronic pulmonary embolism 120 尘 肺 wPneumocomosis w肺通过气道与外界相通，吸入在空气中悬浮 的无机和有机尘粒，这些尘粒部分可致病 w正常肺有很强的能力来清除这些尘粒 w但过多的生产性粉尘则可引起气道和肺泡的 损伤，导致肺部弥漫性纤维化，称为尘肺 121 国家现行规定的12种尘肺 w矽肺 wsilicosis w煤工尘肺 wcoalworker pneumoconiosis w石墨尘肺 wgraphite pneumoconiosis w炭黑尘肺 wanthracosis w石棉肺 wabestosis w滑石尘肺 wtalc pneumoconiosis w水泥尘肺 wcement pneumoconiosis w云母尘肺 wmica pneumoconiosis w陶工尘肺 wkaolin pneumoconiosis w铝尘肺 waluminum pneumoconiosis w电焊工尘肺 welectric and welder pneumoconiosis w铸工尘肺 wfoundry worker pneumoconiosis 122 尘肺的诊断原则 根据目前我国现行政策的规定：尘肺的诊断必须是 由国家卫生行政部门指定的尘肺诊断小组来进行， 任何个人作出的诊断都是无效的 许多疾病可形成类似尘肺的肺部弥漫性改变，因此 作为影像专业医师，应对引起尘肺的病因学、生产 现场的流行病学调查及其临床病理资料有所了解 尘肺诊断的前提是病人必须有明确的生产性粉尘接 触史，并且有同行业人发病年龄作为参考资料 123 基本影像学表现 w类圆形小阴影：最常见和最重要表现，见于矽肺 w不规则形小阴影：网状，有时呈蜂窝状 w大阴影：指直径超过10mm的阴影，边界清楚，周围 有明显的肺气肿；多出现于两肺上、中区，常对称 出现；大阴影的长轴常与后肋垂直，不受叶间裂的 限制。“八字形”或长条形大阴影常见于典型矽肺 w胸膜斑：不同程度的胸膜肥厚、粘连及钙化等改变 ，局限性胸膜斑则是石棉肺的主要表现之一。局限 胸膜增厚的厚度大于3mm时称为胸膜斑，多见于侧胸 壁，亦见于部分心缘和膈面，可发生钙化 124 基本影像学表现 w肺门改变：早期肺门阴影增大增浓，有时见肿大淋 巴结影。淋巴结蛋壳样钙化多于两侧肺门对称出现 ，也可见于一侧，呈圆形、椭圆形或不整形，常数 个同时出现；壳壁可呈断续的残缺状 w肺纹理改变：早期有肺纹理增强、变粗等改变。肺 间质纤维化的进一步发展，使肺纹理变形。随着小 阴影出现和逐渐增多，特别是不规则小阴影的增多 ，肺纹理则逐渐变成模糊、减少或消失 125 矽肺 Silicosis w二氧化硅粉尘引起的肺部弥漫性纤维化 w尘肺中最多见且危害最大的一种，多见于采 矿、玻璃、陶瓷、耐火材料、石英制粉、机 械制造业工人 w基本改变是慢性进行性肺间质纤维化及矽结 节形成 w多个小结节可相互融合形成大结节或融合团 块，周围有肺气肿，是矽肺晚期常见改变 126 Silicosis w粉尘中游离二氧化硅含量越高，肺内改变越 以结节为主，矽结节越致密清楚。游离二氧 化硅含量越低，间质性纤维改变越明显，矽 结节淡而轮廓模糊 w早期可无症状 w晚期则可有呼吸困难，甚至发绀、咯血 w合并结核及慢性炎症者症状更为严重 w最后因肺源性心脏病而致心肺功能衰竭 127 X线表现 w肺纹理增强并伸展至肺外带，细网状纹理，在网格 交叉处见有极小颗粒，肺野透亮度减低呈磨玻璃样 w矽结节：诊断矽肺和混合性矽肺的主要依据。多在 两侧中、下肺野内中带区域开始出现 w典型表现为直径约3mm左右，轮廓清楚，致密孤立的 结节阴影，多与肺纹理分离 w病变发展，矽结节渐增大增多，融合成致密而均匀 的团块，即大结节影，常见于两上肺野外带，轮廓 清楚。典型大结节阴影在两肺分布对称，呈翼状 128 X线表现 w肺门影增大，密度增高。晚期可见肺门上提或外移 。肺门呈残根样。肺门淋巴结蛋壳样钙化 w肺纹理增多增粗，延长到肺野外带。病程进展，肺 纹理发生扭曲变形、紊乱及中断现象。晚期由于矽 结节增多，肺气肿加剧，肺纹理减少 w肺气肿可为弥漫性或局限性或灶性肺气肿 w胸膜改变：早期以肋膈角变钝或消失最多见，随病 变进展，肺底胸膜肥厚，表现膈面毛糙，或膈胸膜 粘连所形成幕顶样改变，纵隔胸膜增厚粘连表现为 纵隔阴影增宽，边缘平直或呈不规则状。 129 矽肺合并结核 w早期矽肺或混合矽肺并发的结核病灶大都趋 向于一侧或两侧肺尖或锁骨上下区 w晚期，各肺野包括肺尖区都已散布有明显矽 结节时，并发一侧或两侧结核病灶与矽结节 早期融合鉴别较为困难，伴有空洞者支持结 核的诊断 130 Simple silicosis w59M, worked in hard-rock mining for 10 years wdiffuse nodular opacities, relative sparing of basal lung zones 131 Simple silicosis wnumerous micronodules in both upper lungs with posterior zonal predominance. multiple subpleural nodules and pseudoplaques 132 尘肺的胸部X线片表现分期 w无尘肺（0） w0：X线胸片无尘肺表现 w0 ：胸片表现尚不够诊断为者 w一期尘肺（ ） w：有总体密集度1级的小阴影，分布范围至少达到两个肺区 w ：有总体密集度1级的小阴影，分布范围超过4个肺区或有总体密 集度2级的小阴影，分布范围达到4个肺区 w二期尘肺（） w：有总体密集度2级的小阴影，分布范围超过4个肺区；或有总体密集 度3级的小阴影，分布范围达到4个肺区 w ：有总体密集度3级的小阴影，分布范围超过4个肺区；或有小阴 影聚集；或有大阴影，但尚不够诊断为者 w：有大阴影出现，其长径不小于20mm，短径不小于10mm w ：单个大阴影的面积或多个大阴影面积的总和超过右上肺区面积者 133 矽肺0-I期 双肺门扩大增浓 ，肺门角隆起 双肺纹理增多， 隐约可见小粟状 结节 134 矽肺期 两肺门散在 大小不等， 互相重叠的 圆形、卵圆 形钙化影， 上纵隔增宽 ，中上野有 片状影 135 矽肺-期 _两肺野散在 大小不等致 密影，两肺 门区有大小 不等的蛋壳 样淋巴结钙 化 136 煤工尘肺 wCoalworker pneumoconiosis w煤矿工人长期吸入生产环境中的粉尘引起的尘肺 w岩石掘进工作面工人接触游离二氧化硅含量较高的 硅尘，所患尘肺有典型矽结节，为矽肺。采煤工作 面工人，主要接触煤尘，游离二氧化硅含量不足5% ，所患尘肺有典型的煤尘灶，为煤尘肺 w煤尘肺在肺内只引起弥漫的间质性纤维改变，可见 到数量不等，直径大小不一的煤斑，并伴有散在的 局限性肺气肿改变，即单纯煤尘肺，通常不形成矽 结节病变或大块纤维病灶。合并结核则可见进行性 大块纤维改变 137 Coalworker pneumoconiosis w早期无症状。劳动时气急、吐痰、咳嗽和胸痛是最 常见的主诉。无阳性体征 w胸片可见两肺有广泛的肺纹理改变和纤维条纹以及 网织阴影，肺野透亮度减低呈磨玻璃样 w混合矽结节的直径比较小，形态不规则，密度较低 ，边缘不如典型矽结节那样锐利 w肺内有散在局灶性肺气肿透亮区域存在 w大阴影仅见煤矽肺 138 Coalworker pneumoconiosis HRCT 以间质性肺纤维化为主，小结节影不如矽肺明显 w两肺广泛不规则线条状阴影或网状影，肺血管纹理 扭曲、紊乱 w晚期随肺气肿的发展，肺纹理减少 w小结节影以两肺中、下野分布为主。混合矽结节的 直径较小，形态不规则，密度低，边缘不如矽结节 锐利，一般不融合。可见局限性肺气肿 w胸膜改变不如矽肺明显 139 CWP, 48M, HRCT, numerous small nodules that are less well defined than those seen in silicosis 140 wComplicated CWP : 57M wA conglomeration of small nodules with sparing of the bibasilar area and egg-shell calcifications in both hila 141 Complicated CWP wHRCT wConglomerate masses (progressive massive fibrosis) and adjacent small nodules A thoracostomy tube was placed in the left hemithorax for a pneumothorax. 142 Calcified progressive massive fibrosis wM60, retired coal worker wA densely calcified right parahilar mass 143 Complicated silicosis, 58M wA cavitary conglomerate mass in the left upper lobe wthe paracicatricial emphysema wAlthough tuberculosis may complicate silicosis or CWP, progressive massive fibrosis sometimes demonstrates cavitation due to ischemic necrosis 144 Silicoproteinosis wM52, quarry worker wHRCT wPatchy areas of ground-glass attenuation with fine intralobular reticulation wBiopsy confirmed the alveolar proteinosis and silica