孤立性肺结节的诊断现状ppt课件

孤立性肺结节的诊断现状 1 SolitaryPulmonaryNodule SPN 定义 coinleision 任何肺内或胸膜的病灶 在X线上表现直径在2 30mm 边缘清晰或不清晰的圆形或类圆形阴影 FleischerSocietyGlossary肺实质内直径 3cm圆形或类圆形的病灶 不伴有淋巴结肿大 阻塞性肺炎或肺不张 Chest2003 123 89 96 2 概况 0 09 0 20 所有胸片150 000 年 预计 病因 肉芽肿性疾病 肺癌 错构瘤恶性结节 10 70 占手术切除肺结节的60 80 IA期肺癌术后5年生存率61 75 良性结节 感染性肉芽肿80 错构瘤10 3 病因 4 Figure1a Ribfractureina50 year oldwomanwithmultiplemyeloma a Close upposteroanteriorradiographoftherightupperlungshowsapoorlymarginatednodularareaofincreasedopacityoverlyingtheanterioraspectoftherightsecondrib arrow b CTscanshowsahealedfractureoftherightsecondrib arrow Notethelyticlesionsinthevertebralbodysecondarytomultiplemyeloma 5 Figure2a Pseudonoduleina50 year oldman a Close upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednodularareaofincreasedopacityprojectingoverthelung arrow Notetheadjacentelectrocardiographicleadattachmentpad arrowhead Onafollow upradiographobtainedafterremovaloftheattachmentpad notshown nonodulewasobserved b Frontandbackviewsoftheelectrocardiographicleadattachmentpadshowaneccentricallylocatedsilvernitratepad whichexplainsthecontiguousnodularareaofincreasedopacityonthechestradiograph 6 Figure4a Osteophyteoftheleftfirstribina60 year oldwoman a Posteroanteriorchestradiographshowsapoorlydefinednodularareaofincreasedopacityoverlyingtheanterioraspectoftheleftfirstrib arrow b Posteroanteriorchestradiographobtained2yearsearliershowsthatintervalgrowthhasoccurred cfa Thisintervalgrowthraisedsuspicionformalignancy c ContiguouschestCTscans imageonrightobtainedatalowerlevel revealthattheareaofincreasedopacityisalargeosteophyteofthefirstrib Hadfluoroscopybeenperformed costlyCTcouldhavebeenavoided 7 Figure5a Cutaneousnodulesina51 year oldmanwithneurofibromatosisandprostaticadenocarcinoma a Posteroanteriorradiographshowsnumerouswell marginatednodularareasofincreasedopacityprojectingovertheloweraspectofthethoraxandapoorlymarginatednoduleoverlyingtheupperaspectofthelefthemithorax arrow Becausethelocationoftheuppernodulewasuncertain CTwasperformed b CTscanhelpsconfirmtheintraparenchymallocationofthenoduleintheleftupperlobe c CTscandemonstratesmultiplecutaneousnodules 8 Figure6a Segmentalbronchialatresiaina17 year oldgirl a Close upposteroanteriorradiographoftherightlowerlungshowsanodularareaofincreasedopacityinthelowerlobe arrow b ChestCTscans imageonleftobtainedatalowerlevel showabranchingtubularareaofincreasedattenuationintherightlowerlobeaswellaspulmonaryparenchymawithlowerthanexpectedattenuation Thesefindingsarecharacteristicofsegmentalbronchialatresiaandobviatedfurtherwork up 9 Figure7a Multiplearteriovenousmalformationsina23 year oldwomanwithhereditaryhemorrhagictelangiectasia ContiguouschestCTscansrevealmultiplesmallnodularareasofincreasedattenuationbilaterallywithenlargedfeedinganddrainingvessels findingsthatarediagnosticforarteriovenousmalformations Achestradiographobtainedearlier notshown demonstratedapossiblesmallsolitarypulmonarynoduleintherightlowerlobe 10 Figure2a a Chestradiographshowsanincidentalsmallnodule arrow attheleftcostophrenicangle b Thin sectionCTscanshowscentralfatattenuation 43HU inthenodule Hamartomawasdiagnosed 11 Figure4 CTscanina90 year oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresentacongestedintrapulmonarylymphnode arrow Follow upCTwasnotperformedbecauseofthepatient sadvancedage 12 胸部CT检测情况 Radiology2003 228 70 75 13 14 SPN恶性危险因素 15 SPN大小 常规胸片仅能辨别直径9mm以上结节80 良性结节直径小于2cm42 恶性结节直径小于2cm 15 恶性结节直径小于1cm 直径8mm左右结节经随访恶性发生率10 20 直径 4mm结节恶性发生率 1 非钙化直径小于1cm结节 42 92 为良性 Radiology2006 239 34 49 Radiographics 2000 20 43 58 Radiology2005 237 395 400 16 SPN部位 良性结节分布无规律性肺癌 右肺 左肺1 5 上叶占70 IPF患者合并肺癌好发于下叶外周或发生纤维化部位50 腺癌位于外周 鳞癌多为中央型 Radiology2006 239 34 49 17 TransverseCTscanina75 year oldmanwithidiopathicpulmonaryfibrosisshowsasolidleftlowerlobenodule arrow FNABofthenodulerevealedsquamouscellcarcinoma 18 SPN边缘 光滑 21 恶性结节边界清 多见于转移瘤分叶 25 良性结节有分叶 恶性组织生长非均质性不规整 倾向于恶性 可见于肉芽肿性疾病 类脂性肺炎等毛刺 19 Figure8a LungnodulecausedbyDirofilaria canineheartworm inanasymptomatic70 year oldman a Close upCTscanoftherightlungshowsaperipheral smoothlymarginated noncalcifiedlungnodule b Photographofaspecimenobtainedwithwedgeresectionshowsawell circumscribed 2 cmnodulewithyellowareasofgeographicnecrosis c High powerphotomicrograph originalmagnification x175 hematoxylin eosinstain showsintravascularDirofilaria Mostinfectionsmanifestaslungnodulesfromembolicinfarctioncausedbyintravascularworms 光滑 20 Figure9 Solitarymetastasisfrombladdercancerina45 year oldwoman ChestCTscanshowsasmoothlymarginated 1 cmperipheralnodule Metastaticdiseasewasconfirmedatresection Solitarymetastasesaccountfor3 5 ofallresectedsolitarypulmonarynodules 21 分叶 Figure10 Non smallcelllungcancerina63 year oldwoman Close upchestCTscanoftherightlungshowsalobulatedandspiculatednoduleinthelowerlobe 22 Figure11a Arteriovenousmalformationina34 year oldmanwithhereditaryhemorrhagictelangiectasia a Close upposteroanteriorradiographoftherightlungshowsalobulated well marginatednoduleinthelowerlobe arrows b ChestCTscandemonstratesafeedingartery arrow andanenlargeddrainingvein arrowhead c CTscanshowsthenidusofthemalformation d Pulmonaryangiogramhelpsconfirmarteriovenousmalformation Notetheearlydrainingvein arrows 23 Figure12 Intralobarsequestrationina14 year oldboy ChestCTscanshowsalobulated well marginatednodulewithhomogeneousattenuationintherightlowerlobe Intrapulmonarysequestrationwasconfirmedatresection 24 边缘不规整或细毛刺 Figure13 Bronchioloalveolarcellcarcinomaina65 year oldman ChestCTscanshowsanirregularnoduleabuttingthemajorfissure Notetheindentationoftheadjacentportionofthemajorfissureowingtodesmoplasticreactionaroundthetumor Figure14 Non smallcelllungcancerina61 year oldwoman Close upchestCTscanoftherightlungshowsaspiculatednodulewitheccentriccavitationintheupperlobe 25 SPN内部特征 钙化脂肪密度结节衰减空洞空泡征支气管充气征 26 钙化 55 良性结节有钙化结节直径小于3cm 有下列钙化形式之一考虑良性 中心性 分层 弥漫性 爆米花样 超过结节面积10 13 肺癌有不同程度的钙化 偏心样钙化类癌 转移性骨肉瘤 软骨肉瘤 结肠癌 卵巢癌也可表现为良性钙化 27 Figure21 Granulomainanasymptomatic64 year oldman Close upchestCTscanoftheleftlungshowsasoft tissuenodulewithcentralcalcificationintheupperlobe Notetheeccentriccavitationwithinthenodule Figure23 Pulmonarychondrohamartomaina40 year oldman Close upchestCTscanoftherightlungshowsalobulatednodulewithcentralpopcornlikecalcificationintheupperlobe 28 Figure22a Histoplasmomainanasymptomatic50 year oldman a Close uptomogramoftheleftlungdemonstratesasmooth well marginatednodule b Photographofaresectedspecimenhelpsconfirmcentralcalcificationandlaminatedfibroustissue 29 Figure28a Granulomatousdiseaseina48 year oldwoman a ChestCTscan 10 mmcollimation showsanodulewithperipheralcalcificationandacalcifiedrighthilarnode b Thin sectionCTscan 3 mmcollimation betterdemonstratesthediffusesolidcalcificationinthenodule afindingthatistypicalofabenigncause 30 Figure8 TransverseCTscanshowsa1 cm diameterleftlowerlobenodulewithcentralniduscalcification Thisfindingisindicativeofbenigndisease 31 Figure9a a Chestradiographshowsarightupperlobenodulewithcentralcalcification Themarginsareirregular b CTscanshowsarightupperlobenodulewithirregularmarginsthatrepresentspulmonarycarcinoma blackarrow Thecalcificationseenontheradiographiscausedbyacalcifiedgranulomaanteriortothetumor whitearrow 32 Figure10 CTscaninan80 year oldmanshowsa2 2 cm diameternoduleintheleftupperlobewitheccentriccalcification FNABofthenodulerevealedadenocarcinoma Figure11 CTscanshowseccentricdensecalcificationinarightlowerlobecarcinoidtumor 33 Figure12 CTscanshowscalcifiedrightlowerlobenodulethatresemblesabenigngranuloma arrow Thepatienthadahistoryofosteosarcoma Openlungbiopsyrevealedmetastaticdisease 34 Figure24 Typicalpulmonarycarcinoidtumorina68 year oldwoman ChestCTscanshowsalobulatedlesionwithscatteredpunctatecalcificationsintheleftlowerlobe 35 Figure25a Non smallcelllungcancerina45 year oldwoman a Close upchestradiographoftherightlungshowsalobulated sharplymarginatednoduleintheupperlobe Notethepresenceofemphysemaandupperlobebullae b Close upchestCTscanoftherightlungrevealsamorphouscalcificationinthenodule apatternthatistypicalofmalignancy Adenocarcinomawasconfirmedatresection 36 Figure26 Lungcancerina72 year oldman Close upchestCTscanoftherightlungshowsalobularlesionwithperipheralpunctatecalcificationintheupperlobe afindingthatisconsistentwith engulfed granuloma Unlikethatincalcifiedgranulomas calcificationinengulfedgranulomaistypicallyperipheralandconstitutesonlyasmallpartofthenodule 37 Figure27a Metastaticosteosarcomaina21 year oldman a Close upchestCTscanoftheleftlungshowsasmall high attenuationnoduleinthelowerlobe arrow Thisfindingwassuggestiveofabenigncause b ChestCTscanobtained8monthslaterrevealsintervalgrowthofthenodule whichhashighattenuationandalobulatedcontour Resectionrevealedmetastaticosteosarcoma 38 脂肪密度 良性 错构瘤 脂肪瘤恶性 脂肉瘤 肾透明细胞癌 39 Figure19a Hamartomainanasymptomaticman a ChestCTscanshowsaheterogeneous sharplymarginatedlesionwithsmallfocalareasofcalcificationandfat Thesefindingsaretypicalfeaturesofhamartoma b Photographofaresectedspecimendemonstratesayellowish glistening lobularcutsurface afindingthatisconsistentwithfat c Photomicrograph originalmagnification x100 hematoxylin eosinstain helpsconfirmthepresenceofadiposetissue arrow andshowsepithelialtissuecontaininganislandofbasophiliccartilage arrowhead Thismixtureofepithelialandmesenchymaltissueisdiagnosticforhamartoma 40 Figure20a Pulmonaryhamartomaina74 year oldwoman a ChestCTscanobtainedwith10 mmcollimationdemonstratesanodule arrow butitsinternalmorphologicfeaturesarepoorlyvisualized b Thin sectionCTscanobtainedwith1 mmcollimationbetterdemonstratesapunctateareaoffatwithinthenodule arrow afindingthatisdiagnosticforhamartoma 41 结节衰减 非实性 毛玻璃样 34 为恶性 直径大于1 5cm圆形恶性风险度增加 多见于BAC 腺癌有BAC特征 良性 炎症性病变 癌前病变 不典型腺瘤样增生 支气管肺泡过度增生 部分实性 40 50 直径小于1 5cm结节为恶性 实性成分位于中央区提示侵袭性腺癌实性 15 直径小于1cm病灶为恶性 转移性病灶多为实性 42 Figure14 CTscaninan81 year oldmanshowsa2 8 cmirregular partlysolidleftupperlobenodulewithpleuraltags FNABrevealedbronchioloalveolarcellcarcinoma Figure13 CTscanina64 year oldmanshowsanoval2 1 cmleftlowerlobenonsolidnodule arrow FNABrevealedadenocarcinoma 43 空洞 5mm 良性空洞 壁光滑 薄 16mm 15 肺癌有空洞 病灶直径 3cm 44 Figure16 Aspergillusinfectionina48 year oldmanwithleukemia Close upchestCTscanoftherightlungshowsathin walledcavitarynodule Figure17 Squamouscelllungcancerina60 year oldwoman Close upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednoduleinthelowerlobe Notetheeccentriccavitationandthickwalls 45 Figure18 CTscaninan83 year oldmanshowsa2 3 cmleftupperlobecavitarynodule Thewallisvariableandthecavitywallisasthickas8mm FNABrevealedsquamouscellcarcinoma Figure19 CTscaninan80 year oldmanshowsarightupperlobe2 9 cmcavitarynodulewithasmooth uniform2 5 mm thickcavitywall FNABrevealednon smallcelllungcancer 46 Figure18 Bullettrackfromagunshotwoundina20 year oldman Close upposteroanteriorradiographoftherightlungshowsasmoothlymarginated thick wallednodulewitheccentriclucencyinthemidlung Notethebulletfragmentsoverlyingtherightlung Thesefindingsareconsistentwithparenchymalhematomaandabullettrack 47 空泡征 空泡征为肿瘤内小的低密度影 多为2 3mm大小 1个或多个 CT扫描仅限于1 2个层面见到 空泡征是未闭塞的小支气管或肺泡 主要原因同支气管空气征一样 为癌细胞呈伏壁生长 部分肺泡腔和细支气管未被肿瘤组织填充 肿瘤内的纤维组织或瘢痕组织的牵拉而扩张 多见于BAC或腺癌 48 支气管充气征 是指结节内见到充气的支气管 CT表现为气体密度小管影 此征多见于中高分化的腺癌 癌细胞沿着支气管呈伏壁生长 肺的支架结构未被破坏 肿瘤内的支气管结构仍保存 有此征象的肿瘤与无此征象的肿瘤相比 具有相对低度恶性的生物学行为 在恶性SPN的发生率为26 9 65 0 而在良性SPN 其发生率仅为0 0 5 9 49 SPN与支气管的关系 I型 支气管被SPN截断II型 支气管进入SPN呈锥状中断 型 支气管在SPN内呈长段开放状 并可进一步分叉 型 支气管紧贴SPN边缘走行 管腔形态正常V型 支气管紧贴SPN边缘走行 管腔受压变扁 ClinicalRadiology 2004 59 1121 1127 50 I型 支气管被SPN截断 51 II型 支气管进入SPN呈锥状中断 52 型 支气管在SPN内呈长段开放状 并可进一步分叉 53 型 支气管在SPN内呈长段开放状 并可进一步分叉 54 型 支气管紧贴SPN边缘走行 管腔形态正常 55 V型 支气管紧贴SPN边缘走行 管腔受压变扁 56 I型 支气管被SPN截断II型 支气管进入SPN呈锥状中断 型 支气管在SPN内呈长段开放状 并可进一步分叉 型 支气管紧贴SPN边缘走行 管腔形态正常V型 支气管紧贴SPN边缘走行 管腔受压变扁 ClinicalRadiology 2004 59 1121 1127 57 恶性结节最常见的肿瘤一支气管关系是I型 其次为 型 V型最少见 良性结节最常见的是V型 其次为I型 未见到 型 就肿瘤一支气管关系类型而言 I型恶性SPN多于良性SPN 后者主要见于结核球 型仅见于恶性SPN 型可见于恶性和良性SPN 但前者的支气管形态僵硬 管腔保持通畅甚或轻度扩张 后者支气管形态柔软 走向自然 管腔扩张度不如恶性肿瘤 并常见支气管有多个树枝状分又及支气管呈断续状表现 IV型以恶性SPN占绝大多数V型则以良性SPN多见 58 SPN一支气管关系类型的病理基础 膨胀性生长 瘤细胞增殖 堆积 呈实性压迫 推移邻近肺组织 由于肿瘤为支气管源性 故导致支气管在肿瘤边缘截断 伏壁性生长 以肺结构为支架 瘤细胞沿肺泡壁和肺泡隔爬行 经肺泡孔扩展 同时可经淋巴道 小气道或以直接浸润的方式从1个肺小叶扩展到另1个肺小叶 而支气管仍保持通畅 形成支气管充气征 59 支气管管壁由外向内的肿瘤浸润 管壁产生的纤维性增殖性反应使支气管管壁增厚 僵硬 加上瘤内成纤维化反应的牵拉 使瘤内的支气管不仅未被肿瘤压扁 反而保持高度的通畅 甚至有所扩张 形成恶性肿瘤的含气支气管征特有的表现 良性结节边缘的支气管未受肿瘤侵犯和成纤维化反应的影响 管壁仍很柔软 易受膨胀性生长的结节压迫 导致管腔变扁甚至闭塞 结核球引起支气管截断是由于后者参与形成包膜 炎性假瘤的含气支气管征由肺实质的渗出 实变 机化衬托引起 支气管形态自然 常见树枝状分叉 管腔内可有分泌物 出血或血栓 使支气管表现为断续状 60 SPN血管特征 恶性结节增强超过良性结节CT增强值低于15HU倾向于良性CT净增值超过25HU 清除值5 31HU倾向恶性 61 AJR2007 188 57 68 62 Graphoffourdifferenttypesoftime attenuationcurveofnodulehemodynamicsinconsiderationofbothwash inandwashoutphasesofdynamicCT Radiology2005 237 675 683 63 PatternsofNoduleEnhancementatEarlyandDelayedEnhancementCT 64 PatternsofNoduleEnhancementaccordingtoHistologicDiagnosis 65 Fig 4A Metastaticadenocarcinomain57 year oldmanwithrectalcancershowsnetenhancementof25Handwashoutof5 31HondynamichelicalCTandpositiveuptakeonintegratedPET CT Lungwindowoftransversethin section 2 5 mmcollimation CTscanshows9 mmnodule arrow inleftupperlobe 66 Fig 3A Adenocarcinomain67 year oldmanshowsnetenhancementof25Handwashoutof5 31HatdynamichelicalCTandpositiveuptakeatintegratedPET CT Lungwindowoftransversethin section 2 5 mmcollimation CTscanshows16 mmnodule arrow inleftupperlobehaslobulatedandspiculatedmargin 67 Figure3a CTscansoftuberculomawithtypeIIenhancement 25HUwash in ina58 year oldman a Transversethin section 2 5 mmcollimation scanobtainedwithlungwindowattheleveloftherightmainbronchusshows21 mmnodulewithlobulatedandspiculatedmarginintherightupperlobe b Serialimageswithdynamicenhancementcurveforthenodule Peakenhancementis49HU netenhancement 3HU andabsolutelossofenhancement washout 1HU 68 Figure4a CTscansoforganizingpneumonia focalpneumoniawithoutspecificmicroorganism withtypeIIIenhancement 25HUwash inwithpersistentenhancement ina58 year oldwoman a Transversethin section 2 5 mmcollimation scanobtainedwithlungwindowatthelevelofthehepaticdomeshows14 mmnodule arrow inrightlowerlobe Bronchiectasisisalsoseeninbothlowerlobes b Serialimageswithdynamicenhancementcurveforthenodule Peakenhancementis118HU netenhancement 69HU Thisnoduleshowedpersistentenhancementwithoutabsolutelossofenhancement 69 Figure5 CTscansofleiomyomawithtypeIVenhancement 25HUwash in 31HUwashout ina45 year oldwoman Serialimageswithdynamicenhancementcurvefortheleftlowerlobenoduleshowpeakenhancementis165HU netenhancement 133HU absolutelossofenhancement washout 90HU andtimetopeakenhancement 1minute 70 71 72 病理学基础 周围型肺癌的血供源于支气管动脉 肿瘤间质内血管丰富 且分化不成熟 血管分布紊乱 基底膜不完整 管壁通透性高 有利于大分子造影剂渗入细胞间隙 部分肺癌微血管扩张 利于造影剂在血管内停留 结核球是中央的干酪坏死区为纤维包膜所包裹 干酪坏死因乏血管而无强化 周围型肺癌明显高于结核球 从时间 密度曲线观察 两者截然不同 结核球的曲线低平 无明显峰值 而周围型肺癌动态增强后2min内达到高峰 周围型肺癌的主要强化形态是完全强化 少部分周围性强化 结核球的主要强化形态是无强化及包膜样强化 结核球的不同强化形态取决于包膜的富血管 完整度及厚度 炎性结节形成过程中 肺动脉水平上发生弥漫性血栓 血供直接源于支气管动脉 造影剂通过相对较直的 结构正常的血管进入间质 进入血管周围间质的造影剂因淋巴管的通畅加快了引流 部分恶性及良性病灶持续强化无清除可能与局部组织纤维化的程度数量相关 73 SPN生长速度评价 大部分恶性结节倍增时间30 400天2年随访病灶稳定 倍增时间至少730天倾向良性疾病倍增时间小于7天 超过465天倾向良性直径小于1cm病灶较难评价 Radiographics 2000 20 59 66 74 Td Ti log2 3 log Di Do Ti intervaltimeDi initialdiameterDo finaldiameter 75 Figure1 Effectofinitialnodulesizeonperceptionofgrowth Schematicillustratestwovolumedoublingsofa4 mmnoduleanda3 cmnodule Becausetheeyeperceivesthearithmeticincreaseindiameterratherthanthechangeinvolume thesmallernoduleappearstobegrowingmoreslowlythanthelargerone eventhoughbotharedoublinginvolumeatthesamerate 76 Figure21a a CTscaninan80 year oldmanshowsa2 5 cmrightupperlobenoduleattheposteriorsegment b RepeatCTscanobtainedpriortotreatmentperformed2monthslatershowsrapidintervalenlargement Thevolumetricdoublingtimewas26days FNABrevealedmixedsmallcellandnon smallcellcarcinoma 77 BayesianAnalysis 临床 影像学资料 78 79 EffectofageandsmokinghistoryonpCainanindeterminatepulmonarynodule Close upchestCTscanoftherightlungshowsa7 mm smoothlymarginated noncalcifiednoduleinthemiddlelobe Onthebasisofdecisionanalysis observationwouldbethemostcost effectivemanagementstrategyina35 year oldnonsmoker pCa 0 01 orcurrentsmoker pCa 0 05 andbiopsywouldbethemostcost effectivemanagementstrategyina70 year oldnonsmoker pCa 0 07 orcurrentsmoker pCa 0 50 80 其他辅助检查对于SPN诊断价值 PET核素显像 81 PET 直径1 3cm实性结节 敏感性94 特异性83 SUV值超过2 5即为阳性假阳性 局部感染 炎症 肉芽肿性疾病假阴性 病灶直径小于1cm 类癌 BAC 82 Figure7a Non smallcelllungcancerina65 year oldman a ChestCTscanshowsasmallnodulei