No42七年制临床呼吸常见病2

1,Imaging Diagnosis of Rspirotary Diseasepart 2AiPing Chen,2,Lung neoplasm肺肿瘤,The incidence of primary lung carcinoma is increasing in all over the world. Most malignent lung tumors (over 98%) are bronchiogenic carcinoma 支气管肺癌.,3,Lung neoplasm肺肿瘤,Benign:良性harmatoma, adenoma, angioma, fibroma错构瘤，腺瘤，血管瘤，纤维瘤 malignancy:恶性 primary：lung carcinoma 肺癌，sarcoma 肉瘤Secondary：metastasis转移瘤,4,harmatoma,uncommon asymptomatic; symptoms typically are present with central endobronchial lesions， include hemoptysis, recurrent pneumonia, and dyspnea.,5,harmatoma,typically round, well-marginated peripheral masses smaller than 4cm (range, 1 to 30cm).typical pattern ： popcorn calcification爆米花样的钙化 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,most common malignancy risk factor ：cigarette smoking Environmental and occupational exposure （3% to 17%）Interstitial pulmonary fibrosis and focal scarring have been reported to increase the risk for bronchial carcinoma.,9,Lung carcinoma(cancer)SCLC(small cell lung cancer) 小细胞肺癌NSCLC(non-small cell lung cncer）非小细胞肺癌squamous cell carcinoma 鳞癌Adenocarcinoma 腺癌Large Cell Carcinoma大细胞癌compound carcinoma 混合癌bronchioloavelar carcinoma BAC细支气管肺泡癌,Lung neoplasm,10,Lung neoplasm,SCLC(small cell lung cancer) Small cell carcinoma is a rapidly growing tumor that has the most irrefutable association with smoking. Like squamous cell carcinoma, it is predominantly a central tumor (90%), but growth is mainly along anatomic tissue planes. metastasizes early; systemic spread is present in two-thirds of cases at presentation. 生长迅速，中央型，转移早，全身,11,Lung neoplasm,NSCLC(non-small cell lung cncer)squmous 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. Adenocarcinoma is a peripheral tumor in 75% of cases with a predilection for the upper lobes and for regions of parenchymal fibrosis (“scar” carcinomas). bronchioloavelar 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,asymptomatic ， detected incidentally most patients (up to 90%) are symptomatic 气道起源多数表现为 producing cough, hemoptysis, dyspnea, and chest pain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 Central type:Inter-tuber 管内Wall of tuber管壁Extra-tuber 管外Peripheral type:Mass inflammationDiffuse,Lung neoplasm,14,Central tumor,Direct sign of bronchial carcinoma lung massBronchial 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,lung mass in the hilumBronchial lumen支气管改变支气管壁增厚支气管腔内肿块支气管腔狭窄/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,Indirect sign间接征象：支气管阻塞所致改变阻塞性肺肺气肿阻塞性肺炎：不易吸收，同一部位反复发作阻塞性肺不张：肺不张合并肿块，肺不张合并转移是其特点,24,Partial 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,Indirect sign of bronchial carcinoma:Distal 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,Indirect sign of bronchial carcinoma:Intrathoracic spread of bronchial carcinoma.,35,Right side Central tumor,36,Central tumor,Indirect sign of bronchial carcinoma:Mediastinal 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,Hematogenous spread of bronchial carcinoma. Osteolytic 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,MRI manifestationBronchi wall thickenBronchi wall stenosisMass in the hilumEmphysema; pneumonia; atlectasis of obstructionAffect mediastinum，enlargement of lymph node(diameter15mm),44,45,46,plain film、CT、MRI,Central tumor,47,Plain film,48,CT平扫,CT scan no contrast,49,CT增强,CT scan contrast,50,MRI,51,52,53,Peripheral tumor,Peripheral pulmonary nodule. round，usually less than 5cm in diameter. 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.Lobulation，Spiculated margin.Air bronchogram.Cavitary.Bubble-like lucencies within the nodule.空泡征Retraction of pleura-pleural indentation sign胸膜凹陷征,55,Peripheral tumor,分叶征象: 生长不均衡，周围血管和支气管的限制毛刺征象: 肿瘤沿血管及间质浸润有关空洞形成: 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,Isolated mass typePneumonia typeDiffuse nodule type,67,Isolated mass type Bronchiolo-alveolar carcinoma,68,Bronchiolo-alveolar carcinomaPneumonia type,69,70,71,ill-defined margin pulmonary nodule Bronchiolo-alveolar carcinoma,72,Bronchiolo-alveolar carcinoma,73,Bronchiolo-alveolar carcinoma,74,Lung mestastasis,The most common primary tumor site was lung, followed by large bowel, prostate, breast, uterus, and esophagus. Between 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,Hematogenous mestastasisLymphatic 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 lymphomaBronchogenic cyst,Neurogenic tumors,85,Mediastinal tumor,Anterior mediastinal tumor前纵隔Intra-thoracia thyroid mass胸内甲状腺肿: upper of mediastinumThymoma胸腺瘤: anteriorTeratoma畸胎瘤：calcification; fatMiddle mediastinal tumor中纵隔Posterior mediastinal tumor后纵隔,86,Intrathoracic thyroid,Intrathoracic 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,病理：多数为结节性甲状腺肿X线表现前纵隔上部边缘光滑，与颈部肿物相连气管受肿块推压,88,Intrathoracic thyroid,89,Intrathoracic thyroid,The 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,结甲伴腺瘤样增生女，62岁肿物与甲状腺相连,91,Intrathoracic thyroid,MR 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,anterior superior mediastinum. round, lobulated or plaque-like, and produce unilateral widening of the mediastinum. Calcification or cystic degeneration may be seen in a small percentage of cases.,95,胸腺瘤thymoma,占前纵隔肿瘤50%多见于中年人多数无症状，少数有压迫或侵犯表现三分之一伴有重症肌无力良性：包膜完整，无周围浸润恶性：包膜不完整，向周围侵犯转移,96,97,Thymoma,CT 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,X线表现：单侧或双侧纵隔增宽突出，边缘一般较清晰。CT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,胸腺瘤，可疑包膜侵润 男性，47岁，查体发现,104,Thymoma,Thymomas 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,先天性肿瘤，属生殖细胞瘤好发于2040岁，绝大多数属良性病理来源于原始胚胎组织的残留物皮样囊肿：主要含有外胚层衍生物实质性畸胎瘤：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表现含有多种组织而密度不均钙化和囊变是特征性表现囊变部分CT值近似水恶性畸胎瘤常较大，边缘不规则,108,Teratoma,Most 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,精原细胞瘤男，16岁，面部浮肿1月，咳嗽20天,恶性生殖细胞肿瘤,115,Mediastinal tumor,Anterior mediastinal tumor：Middle mediastinal tumor：Malignant lymphomaBronchogenic cystPosterior mediastinal tumor,116,Malignant lymphoma,The thorax is frequently involved in patients with Hodgkins and non-Hodgkins lymphomas. It has been estimate that lymphoma constitutes about 20% of all mediastinal neoplasms in adults and 50% in children. Lymph 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,淋巴组织恶性肿瘤发热，周围淋巴结增大及全身衰弱上腔静脉阻塞综合征纵隔淋巴结增大，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,X线表现肿块向纵隔两侧突出，气管受压CT表现纵隔内多组淋巴结增大，可融合成块侵及邻近结构,119,Malignant lymphoma,120,Malignant lymphoma,121,Malignant lymphoma,CT and MRI are more sensitive than radiograph. The enlarged lymph nodes or mass mostly show