肺毛玻璃样病变

肺部GGO病理解读及HRCT评价,GGO(ground-glass opacity,GGO)，肺毛玻璃样病变，是周围型肺癌最早期的CT表现容易被我们忽视或者被认为是正常的CT图像随着CT技术的发展及人们健康意识的增强，我们将面临越来越多这种的病人,一、GGO的病理解读,这是什么？,a,b,GGO的定义,GGO定义 ：在高分辨率CT(HRCT) 上表现为密度轻度增加,但其内的支气管血管束仍可显示的病变,纵隔窗上病灶往往不能显示或仅能显示磨玻璃样病灶中的实性成分,GGO的病理解读,GGO 病理：由于肺泡内气体减少、细胞数量相对增多、肺泡上皮细胞增生、肺泡间隔增厚及终末气道部分充填等因素所致的病理变化。Pathology: Ground-glass opacity may be caused by partial airspace filling; interstitial thickening with inflammation, edema, fibrosis, or neoplastic proliferation; or interstitial thickening with partial airspace filling.,a.Transverse lung-window thin-section (1.25-mm-thick) CT scan shows8-mm round, well-defined GGO nodule (arrow) in left upper lobe.b. Photomicrograph shows columnar tumor cells growing along thickened alveolar walls (lepidic growth).,a,b,AAH in 55-year-old man. a.Transverse lung-window thin-section (2.5-mm-thick) CT scan shows 12-mm round, well-defined GGO nodule (arrow) in left upper lobe. b.shows alveolar wall thickening and increased numbers of alveolar lining cells with minimal wall thickening.,a,b,GGO演变为周围型肺癌的过程,肺泡上皮不典型样增生（AAH）,原位癌（AIS）,进展期肺癌,肺癌前病变演化成原位癌的病理变化过程,基底细胞增生,轻度不典型增生,中度不典型增生,重度不典型增生,原位癌,肺泡上皮不典型样增生（AAH）,原位癌（AIS）,肺腺癌病变病理衍化过程图（腺癌）,侵袭性,AIS,AAH,二、高分辨率CT对GGO的评价,肺良好的自然对比，是CT成像的有利条件；多排螺旋CT，主要是指16排以上螺旋CT，具有高时间、高空间、高密度辨分率以及高信噪比的成像特点；任意层厚重建，能检出1mm的小病灶；高分辨率CT(HRCT)对肺内小病灶细节的显示优于常规CT，能检出0.5mm的小病灶，是评价GGO最佳的无创性方法。,肺多排螺旋CT扫描技术参数,容积扫描,准备,多层、无间隔、连续的图像,薄层，小FOV，多发方位重建,第一种分型,第二种分型,局限性GGO的CT分型,单纯型GGO(pure GGO，pGGO) : 整个病灶密度浅淡, 内见血管或支气管壁, 完全无实性组织成分, 只能在肺窗下看到,混合型GGO (mixed GGO,mGGO): 病灶内部见部分实性组织, 相应部分血管被遮盖, 实性病变部分可在纵隔窗下看到,第一种分型,:单纯磨玻璃样影:密度不均的磨玻璃样影 :中央高密度,外围淡薄模糊磨玻璃样影 :单纯结节影,第二种分型,GGO分型和肿瘤发生及CT表现,型：纯磨玻璃样结节,病理改变为肿瘤细胞沿肺泡壁生长,无肺泡塌陷,肿瘤内弹性纤维轻度增生,型：低密度不均匀结节,病理为肿瘤细胞沿肺泡壁生长,伴有散在肺泡塌陷,肿瘤内弹性纤维、重度增生,但其网状结构仍保存,型：中心高密度伴周边磨玻璃样结节,病理为肺泡塌陷,瘤体中心弹性纤维增生,伴弹性纤维网状结构断裂,周边区肿瘤细胞伏壁生长,型：均匀软组织密度结节,病理上肿瘤呈实体生长,无含气肺泡组织,肿瘤内弹性纤维增生,网状结构中断、破坏,型:单纯磨玻璃样阴影,GGO发展成肺癌的动态演变过程,型:密度不均的磨玻璃样阴影,型:中央高密度,外围淡薄模糊的磨玻璃样阴影,型:单纯结节影,GGO发展成肺癌CT表现的四步曲,pGGO：pure GGO （纯毛玻璃样病变）mGGO: mixed GGO（混合型毛玻璃样病变）SOLID SPN(3cm，肿块，实体瘤，进展期肺癌),肺腺癌的演变过程是和CT的表现相对应的,pGGO：AAH,mGGO：AIS,MASS:腺癌,从病理学角度看肺癌的CT图像的演变过程,Illustration of the relationship between the Noguchi histologic classification of adenocarcinoma of the lung (Noguchi types A though F) and corresponding CT appearances of these lesions.,Persistent nodular ground-glass opacity in an 80-year-old man with adenocarcinoma. Adenocarcinoma was found at histopathologic analysis of an excised specimen.,a. Initial thick-section CT image obtained at the level of the right inferior pulmonary vein shows a subtle nodule (arrow) in the middle lobe of the right lung. b.Follow-up CT image obtained 12 months later shows an increase in the lesion size and an additional subtle internal solid component (arrow). c.Follow-up thin-section CT image obtained at 16 months shows an increase in the size of the solid component within the lesion (arrow).,a,b,c,BAC. Sequential magnified 1-mm CT sections through the right upper lobe show minimal increase in size of a nodule with GGO over a 3-year period. The central area of higher attenuation represents a vessel bifurcation and not a solid component, which was better characterized on sequential images.,（一）肺恶性GGO的CT评价,GGO和AAH,Atypical adenomatous hyperplasia in a 53-year-old woman.a.Thin-section CT image of the right lung shows an 11-mm well-defined nodular ground-glass opacity without a solid component in the lower lobe. b. photomicrograph shows thickened alveolar walls lined by an intermittent single layer of atypical cuboidal pneumocytes.,a,b,Concurrent atypical adenomatous hyperplasia and adenocarcinoma in a 71-year-old woman. Thin-section CT image at the level of the carina shows an 18-mm-diameter mixed nodular ground-glass opacity with a solid component in the upper lobe of the right lung and a 10-mm pure nodular ground-glass opacity in the lower lobe of the left lung.,AAH,carcinoma of the bronchioloalveolar,Multiple AAHs in a 42-year-oldwoman. CT scans show round well-defined, pure GGO nodules (arrow).Photomicrograph of the nodule in the left upper lobe show AAH.,a,b,c,bronchioloalveolar carcinoma in a 63-year-old woman.a.the right upper anterior segmental bronchus shows a 10-mm well-defined nodular ground-glass opacity without a solid component in the lower lobe of the right lung. Note the presence of pulmonary vessels in the lesion. b. Photomicrograph specimen shows replacement of the alveolar lining by neoplastic columnar epithelium, without evidence of stromal invasion.,GGO 和 BAC (AIS),a,b,bronchioloalveolar carcinoma in a 49-year-old woman. a.The level of the right bronchus intermedius shows a 14-mm well-defined nodular ground-glass opacity with a solid component (arrow) in the lower lobe of the right lung, abutting the vertebral body. b. Photomicrograph shows BAC (AIS),a,b,Adenocarcinoma with mixed acinar and bronchioloalveolar carcinoma in a 50-year-old woman. a. Thin-section CT image shows a 28-mm well-defined mixed ground-glass opacity lesion with peripheral ground-glass opacity in the upper lobe of the left lung. The mass abuts the pleura.b. Photomicrograph of a histologic specimen shows BAC (AIS).,a,b,BAC and AAH in a 63-year-old woman. a. lung-window CT scan shows a 19-mm ovoid, well-defined, pure GGO nodule in the left lower lobe. This lesion was confirmed as BAC after basal segmentectomy.b. lung-window thin-section CT scan shows a 9-mm round, well-defined, pure GGO nodule (arrow) in the left upper lobe. This lesion was confirmed as AAH after wedge resection. c. Nodule in the left lower lobe shows columnar or cuboidal cell lining thickened alveolar walls without evidence of stromal, vascular, or pleural invasion.,a,b,c,a. Transverse lung-window thin-section (1-mm-thick) CT scan shows a 22-mm irregular GGO nodule with bubble-lucency in the left lower lobe. This lesion was confirmed as adenocarcinoma with a predominant BAC component after lobectomy.b. Transverse lung-window thin-section (1-mm) CT scan shows a 12- mm round, well-defined pure GGO nodule in the right upper lobe. This lesion was confirmed as BAC.,A,Adenocarcinoma with a predominant BAC component and BAC in a 48-year old woman.,a,b,65-year-old-woman with multiple pure ground-glass opacities (PGGOs)a. Multiple small PGGOs were found in all lobes of lung. Computed tomographic slice reveals three PGGOs (arrows) in the right upper lobe. The lobe, including the maximal PGGO (10 mm in diameter), was removed. b. Comprehensive histologic examination of resected specimens demonstrated existence of many smaller lesions revealing bronchioloalveolar carcinoma or atypical adenomatous hyperplasia. During 37 months of postoperative follow-up, only a slight increase in size or density was recognized in some residual PGGOs scattered in all lobes.,a,b,Adenocarcinoma in a 56-year-old man.a.Thin-section CT image obtained shows a 14-mm nodular ground-glass opacity with no solid component in the upper lobe of the right lung.b.Photomicrograph of a histologic specimen shows adenocarcinoma with dense sclerosis.,GGO与腺癌,a,b,CT scan (1-mm section) of mixed subtype adenocarcinoma with BAC component (Noguchi type C lesion) shows a nodule with pure GGO, demonstrating that although nonsolid nodules are likely to represent AAH or BAC, an invasive component may rarely be present as in this case.,CT scan in a 64-year-old man shows an oval 2.1-cm left lower lobe nonsolid nodule (arrow). FNAB revealed adenocarcinoma.,支气管充气造影征,轴位示：左上肺毛玻璃阴影,冠状位,毛刺征,矢状位,BAC,CT:左上肺毛玻璃阴影,短毛刺征,冠状位重建,矢状位重建,典型胸膜凹陷征,BAC,左上肺尖段纯毛玻璃结节:1.00.9cm,冠状位重建：局灶性纯磨玻璃密度影(Focal pure groundglass opacity，pGGO,矢状位,局部放大,BAC,峰值时间后移,F， 68，腺鳞癌,HRCT动态增强特征,（二）肺良性GGO的CT评价,肺局灶性间质纤维化与GGO,Focal interstitial fibrosis in a 40-year-old womana.Thin-section CT image shows a 25-mm well-defined nodular ground-glass opacity with no solid component in the lower lobe of the left lung. b.Photomicrograph of a histologic shows the lesion (arrow) with alveolar septal thickening and fibrosis and with intraalveolar infiltration by inflammatory cells.,a,b,A 36-year-old woman with two nodular GGOsa.Transverse thin-section CT scan shows a 5.1-mm well defined round pure GGO nodule in the right middle lobe. focal interstitial fibrosis. b.The other 9-mm mixed GGO nodule containing a central solid portion is shown in the right lower lobe. bronchioloalveolar carcinoma,a,b,Focal nonspecific interstitial pneumonia. a, b.Thin-section CT scans at the level of the left pulmonary artery and aortic arch, respectively, show three foci of persistent GGO. c.Histologic specimen shows thickening of the alveolar wall with chronic inflammatory infiltrates. No tumor was identified.,a,b,c,A 34-year-old woman with focal interstitial fibrosis showing a round pure GGO lesion a.Transverse thin-section CT scan shows an 8.5-mm well-defined round nodule with pure GGO. There was no evidence of spiculation or vascular convergence around the lesion. b.Photomicrograph of resection specimen shows alveolar interstitial thickening with fibrosis and type II pneumocyte proliferation,a,b,A 50-year-old woman with focal interstitial fibrosis appearing as mixed GGO with a spiculated margin and pleural traction. a.Transverse thin-section CT scan shows a mixed GGO nodule in the left upper lobe. Note the spiculated margin and pleural retraction. b.This follow-up thin-section CT taken 2 months later shows a similar appearance. The lesion was resected under the impression of primary lung cancer. The pathologic diagnosis was of focal interstitial fibrosis without evidence of malignancy,a,b,A 66-year-old man with focal interstitial fibrosis with a polygonal shape and peri-lobular linear density. Transverse thinsection CT scan shows a nodular GGO lesion with peri-lobular linear opacities (arrow) around the lesion in the right upper lobe. Note the pleural traction around the lesion,Nodular fibrosis with concave margins in 67-year-old man. Both reviewers interpreted lesion as having concave margins (arrow), air bronchograms (arrowheads), and predominantly ground-glass appearance on transverse high-resolution CT images. Lesion size was measured 8 mm by reviewer 1 and 8.5 mm by reviewer 2. Pathologic diagnosis was nodular fibrosis.,Nodular fibrosis with polygonal shape in 72-year-old man. Both reviewers interpreted lesion (arrow ) as having coarse spiculation, pleural tag, and polygonal shape, and as being predominantly solid on transverse high resolution CT images. Lesion size was measured as 8 mm by reviewer 1 and 9 mm by reviewer 2. Pathologic diagnosis was nodular fibrosis.,Intrapulmonary lymph nodethat showed peripheral subpleurallesion in 53-year-old woman.Both reviewers regarded lesion(arrow ) as predominantly solid lesion attached to major fissure on transverse high-resolution CT images. Lesion size was measured 9 mm by both reviewers. Pathologic diagnosis wasintrapulmonary lymph node.,肺内淋巴结与GGO,CT scan in a 90-year-old woman with chronic congestive heart failure shows a tiny nodule adjacent to the right major fissure that is likely to represent a congested intrapulmonary lymph node (arrow).,GGO与霉菌灶,Thin-section CT image at the level of the main pulmonary artery shows a 23-mm poorly defined nodular ground-glass opacity in the upper lobe of the left lung. The lesion includes several peripheral solid portions (arrows) and a subtle groundglass opacity (arrowhead).,Eosinophilic pneumonia in a 36-year-old man with peripheral blood eosinophilia. a.Thin-section CT image at the level of the aortic arch shows an ill-defined area of nodular ground-glass opacity in the upper lobe of the right lung. b.Thin-section CT image at the level of the upper lobar bronchus in the left lung shows a similar nodular ground-glass opacity.,a,b,GGO与结核灶,False positive PET in patient with tuberculosis. a.Thin-section axial CT scan through the upper lobes at lung windows shows a left upper lobe nodule with irregular margins. b.Fused image from PET-CT shows increased metabolic activity within the nodule. Surgical resection revealed a granuloma with cultures positive for Mycobacterium tuberculosis.,a,b,（三）GGO的CT处理原则和步骤,CT随访GGO变化的重要性体积不变体积变大体积变小密度变实代谢较低,1、体积不变,Persistent nodular ground-glass opacity in a 69-year-old man.a.Thin-section CT image obtained at the level of the left brachiocephalic vein shows a 14-mm poorly defined round nodular ground-glass opacity in the upper lobe of the left lung. b.Follow-up thin-section CT image obtained 4 months later shows the persistence and stable appearance of the lesion. The pathologic diagnosis, obtained after a wedge resection, was focal interstitial fibrosis.,a,b,Pure nodular ground-glass opacity confirmed as focal interstitial fibrosis A.Thin-section CT shows 30 mm pure nodular ground-glass opacity in the right upper lobe.B.On follow-up CT scan after seven months, an interval change was not noted.,a,b,Pure nodular ground-glass opacity confirmed as atypical adenomatous hyperplasia in a 58-year-old man. A.Initial thin-section CT shows a 15 mm pure nodular ground-glass opacity B.On thin-section CT after 2 months, an interval change was not noted. All lesions were pathologically confirmed as atypical adenomatous hyperplasia by multifocal wedge resection.,a,b,Pure nodular ground-glass opacity confirmed as atypical adenomatous hyperplasia a. Initial CT shows 8 mm pure nodular ground-glass opacity in the right upper lobe.b. Thin-section CT after 10 months shows persistent pure nodular ground glass opacity with the same size.,a,b,2、体积变大,体积变大一般为恶性病变,Small adenocarcinoma detected on screening CT.Initial axial thin section CT at the level of the right upper lobe bronchus shows a 4 mm nodule in the right upper lobe. .Repeat CT scan 3 months later at the same level shows slight enlargement of the nodule. Biopsy revealed adenocarcinoma.,a,b,Growth of small nodule on follow up CT. (adenocarcinoma).Initial thin-section axial CT coned to the left lung shows a small left upper lobe nodule measuring approximately 4 mm in diameter. . Repeat scan 6 months later shows interval growth of the lesion . An invasive adenocarcinoma was found at surgery.,a,b,BAC. Sequential magnified 1-mm CT sections through the right upper lobe show minimal increase in size of a nodule with GGO over a 3-year period. The central area of higher attenuation represents a vessel bifurcation and not a solid component, which was better characterized on sequential images.,Sequential magnified 5-mm CT sections through the left upper lobe show GGOinitially measuring 8mm in size over a 3-year period. Histologic analysis showed mixed subtype adenocarcinoma composed of acinar adenocarcinoma (40%) and BAC (60%).,Computed tomogram from 57-year-old man (patient 1) with long-term follow-up of pure ground-glass opacity (PGGO) for more than 10 years. Patient had undergone operation for adenocarcinoma originating in right upper lobe 10 years previously. .Small PGGO in left upper lobe (arrow) was pointed out as a function of the retrospective review of conventional CT taken at that operation. .On follow-up 124 months later, high-resolution computed tomography shows enlargement of PGGO from 8 mm (A) to 25 mm in diameter. . Most of the resected specimen reveals bronchioloalveolar carcinoma,a,b,c,Mixed subtype adenocarcinoma, progression of GGO to a nodule with mixed solid component and GGO. a.Magnified 1-mm CT section shows a discrete GGO (arrows). b.Follow-up CT scan obtained 1 year later shows clear progression of the disease, with the development of a central solid component, although there is no appreciable enlargement of the lesion (arrows).,a,b,Mixed subtype adenocarcinoma.a Magnified 1-mm CT section through the left lower lobe shows a nodule with mixed solid component and GGO.b Follow-up CT scan obtained 6 months later shows increase in the extent of the solid component within the nodule.,a,b,Persistent nodular ground-glass opacity in an 80-year-old man with adenocarcinoma. Initial thick-section CT image obtained at the level of the right inferior pulmonary vein shows a subtle nodule (arrow) in the middle lobe of the right lung. Follow-up CT image obtained 12 months later shows an increase in the lesion size and an additional subtle internal solid component (arrow).Follow-up thin-section CT imageobtained at 16 months shows an increase in the size of the solid component within the lesion (arrow). Adenocarcinoma was found at histopathologic analysis of an excised specimen.,a,b,c,a.Transverse CT scan in a 75-year-old man shows a 2.0-cm-diameter nonsolid left upper lobe nodule. FNAB revealed no malignant cells. b.The lesion was followed up with serial CT; 25 months later, the nodule was slightly increased in size and had converted to a partly solid attenuation lesion with air bronchograms. Volumetric measurement showed the doubling time of the opacity to be 1375 days. Repeat FNAB showed bronchioloalveolar cell carcinoma.,a,b,、体积变小,体积变小一般为良性病变,Resolution of nodular ground-glass opacity over time helps determine the benignity of a lesion in a 50-year-old man. Initial thin-section CT image at the level of the inferior pulmonary vein shows a 12-mm poorly defined nodular ground-glass opacity in the right lower lobe. Follow-up CT image obtained approximately 2 months later shows that the lesion in a has resolved.,a,b,Focal inflammation mimicking adenocarcinoma. a.Magnified 1-mm CT section through the right upper lobe shows nodules with GGO initially diagnosed as probable BAC. b. Follow-up CT scan obtained 3 months later shows near complete resolution of the lesion (arrow),(focal nonspecific inflammation).,a,b,Transverse thin-section CT scans show transient PSN with multiplicity in a 43-year-old man.a.Scan shows a 16-mm PSN (arrow) in the left upper lobe. This patient had eosinophilia (eosinophil count, 574 per microliter). b. Follow-up scan obtained 1 month later shows disappearance of the PSN.,a,b,Transverse thin-section CT scans show transient PSN with ill-defi ned border in 37-year-old man.a.Scan shows a