《肺毛玻璃样病变》PPT课件

肺部GGO病理解读及HRCT评价 GGO ground glassopacity 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 glassopacitymaybecausedbypartialairspacefilling interstitialthickeningwithinflammation edema fibrosis orneoplasticproliferation orinterstitialthickeningwithpartialairspacefilling a Transverselung windowthin section 1 25 mm thick CTscanshows8 mmround well definedGGOnodule arrow inleftupperlobe b Photomicrographshowscolumnartumorcellsgrowingalongthickenedalveolarwalls lepidicgrowth a b AAHin55 year oldman a Transverselung windowthin section 2 5 mm thick CTscanshows12 mmround well definedGGOnodule arrow inleftupperlobe b showsalveolarwallthickeningandincreasednumbersofalveolarliningcellswithminimalwallthickening 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 pureGGO 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 mixedGGO 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 pureGGO 纯毛玻璃样病变 mGGO mixedGGO 混合型毛玻璃样病变 SOLIDSPN 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 IllustrationoftherelationshipbetweentheNoguchihistologicclassificationofadenocarcinomaofthelung NoguchitypesAthoughF andcorrespondingCTappearancesoftheselesions Persistentnodularground glassopacityinan80 year oldmanwithadenocarcinoma Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen a Initialthick sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule arrow inthemiddlelobeoftherightlung b Follow upCTimageobtained12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent arrow c Follow upthin sectionCTimageobtainedat16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion arrow a b c BAC Sequentialmagnified1 mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGOovera3 yearperiod Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent whichwasbettercharacterizedonsequentialimages 一 肺恶性GGO的CT评价 GGO和AAH Atypicaladenomatoushyperplasiaina53 year oldwoman a Thin sectionCTimageoftherightlungshowsan11 mmwell definednodularground glassopacitywithoutasolidcomponentinthelowerlobe b photomicrographshowsthickenedalveolarwallslinedbyanintermittentsinglelayerofatypicalcuboidalpneumocytes a b Concurrentatypicaladenomatoushyperplasiaandadenocarcinomaina71 year oldwoman Thin sectionCTimageatthelevelofthecarinashowsan18 mm diametermixednodularground glassopacitywithasolidcomponentintheupperlobeoftherightlunganda10 mmpurenodularground glassopacityinthelowerlobeoftheleftlung AAH carcinomaofthebronchioloalveolar MultipleAAHsina42 year oldwoman CTscansshowroundwell defined pureGGOnodules arrow PhotomicrographofthenoduleintheleftupperlobeshowAAH a b c bronchioloalveolarcarcinomaina63 year oldwoman a therightupperanteriorsegmentalbronchusshowsa10 mmwell definednodularground glassopacitywithoutasolidcomponentinthelowerlobeoftherightlung Notethepresenceofpulmonaryvesselsinthelesion b Photomicrographspecimenshowsreplacementofthealveolarliningbyneoplasticcolumnarepithelium withoutevidenceofstromalinvasion GGO和BAC AIS a b bronchioloalveolarcarcinomaina49 year oldwoman a Theleveloftherightbronchusintermediusshowsa14 mmwell definednodularground glassopacitywithasolidcomponent arrow inthelowerlobeoftherightlung abuttingthevertebralbody b PhotomicrographshowsBAC AIS a b Adenocarcinomawithmixedacinarandbronchioloalveolarcarcinomaina50 year oldwoman a Thin sectionCTimageshowsa28 mmwell definedmixedground glassopacitylesionwithperipheralground glassopacityintheupperlobeoftheleftlung Themassabutsthepleura b PhotomicrographofahistologicspecimenshowsBAC AIS a b BACandAAHina63 year oldwoman a lung windowCTscanshowsa19 mmovoid well defined pureGGOnoduleintheleftlowerlobe ThislesionwasconfirmedasBACafterbasalsegmentectomy b lung windowthin sectionCTscanshowsa9 mmround well defined pureGGOnodule arrow intheleftupperlobe ThislesionwasconfirmedasAAHafterwedgeresection c Noduleintheleftlowerlobeshowscolumnarorcuboidalcellliningthickenedalveolarwallswithoutevidenceofstromal vascular orpleuralinvasion a b c a Transverselung windowthin section 1 mm thick CTscanshowsa22 mmirregularGGOnodulewithbubble lucencyintheleftlowerlobe ThislesionwasconfirmedasadenocarcinomawithapredominantBACcomponentafterlobectomy b Transverselung windowthin section 1 mm CTscanshowsa12 mmround well definedpureGGOnoduleintherightupperlobe ThislesionwasconfirmedasBAC A AdenocarcinomawithapredominantBACcomponentandBACina48 yearoldwoman a b 65 year old womanwithmultiplepureground glassopacities PGGOs a MultiplesmallPGGOswerefoundinalllobesoflung ComputedtomographicslicerevealsthreePGGOs arrows intherightupperlobe Thelobe includingthemaximalPGGO 10mmindiameter wasremoved b Comprehensivehistologicexaminationofresectedspecimensdemonstratedexistenceofmanysmallerlesionsrevealingbronchioloalveolarcarcinomaoratypicaladenomatoushyperplasia During37monthsofpostoperativefollow up onlyaslightincreaseinsizeordensitywasrecognizedinsomeresidualPGGOsscatteredinalllobes a b Adenocarcinomaina56 year oldman a Thin sectionCTimageobtainedshowsa14 mmnodularground glassopacitywithnosolidcomponentintheupperlobeoftherightlung b Photomicrographofahistologicspecimenshowsadenocarcinomawithdensesclerosis GGO与腺癌 a b CTscan 1 mmsection ofmixedsubtypeadenocarcinomawithBACcomponent NoguchitypeClesion showsanodulewithpureGGO demonstratingthatalthoughnonsolidnodulesarelikelytorepresentAAHorBAC aninvasivecomponentmayrarelybepresentasinthiscase CTscanina64 year oldmanshowsanoval2 1 cmleftlowerlobenonsolidnodule arrow FNABrevealedadenocarcinoma 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 0 0 9cm 冠状位重建 局灶性纯磨玻璃密度影 Focalpureground glassopacity 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 Focalinterstitialfibrosisina40 year oldwomana Thin sectionCTimageshowsa25 mmwell definednodularground glassopacitywithnosolidcomponentinthelowerlobeoftheleftlung b Photomicrographofahistologicshowsthelesion arrow withalveolarseptalthickeningandfibrosisandwithintraalveolarinfiltrationbyinflammatorycells a b A36 year oldwomanwithtwonodularGGOsa Transversethin sectionCTscanshowsa5 1 mmwelldefinedroundpureGGOnoduleintherightmiddlelobe focalinterstitialfibrosis b Theother9 mmmixedGGOnodulecontainingacentralsolidportionisshownintherightlowerlobe bronchioloalveolarcarcinoma a b Focalnonspecificinterstitialpneumonia a b Thin sectionCTscansattheleveloftheleftpulmonaryarteryandaorticarch respectively showthreefociofpersistentGGO c Histologicspecimenshowsthickeningofthealveolarwallwithchronicinflammatoryinfiltrates Notumorwasidentified a b c A34 year oldwomanwithfocalinterstitialfibrosisshowingaroundpureGGOlesiona Transversethin sectionCTscanshowsan8 5 mmwell definedroundnodulewithpureGGO Therewasnoevidenceofspiculationorvascularconvergencearoundthelesion b PhotomicrographofresectionspecimenshowsalveolarinterstitialthickeningwithfibrosisandtypeIIpneumocyteproliferation a b A50 year oldwomanwithfocalinterstitialfibrosisappearingasmixedGGOwithaspiculatedmarginandpleuraltraction a Transversethin sectionCTscanshowsamixedGGOnoduleintheleftupperlobe Notethespiculatedmarginandpleuralretraction b Thisfollow upthin sectionCTtaken2monthslatershowsasimilarappearance Thelesionwasresectedundertheimpressionofprimarylungcancer Thepathologicdiagnosiswasoffocalinterstitialfibrosiswithoutevidenceofmalignancy a b A66 year oldmanwithfocalinterstitialfibrosiswithapolygonalshapeandperi lobularlineardensity TransversethinsectionCTscanshowsanodularGGOlesionwithperi lobularlinearopacities arrow aroundthelesionintherightupperlobe Notethepleuraltractionaroundthelesion Nodularfibrosiswithconcavemarginsin67 year oldman Bothreviewersinterpretedlesionashavingconcavemargins arrow airbronchograms arrowheads andpredominantlyground glassappearanceontransversehigh resolutionCTimages Lesionsizewasmeasured8mmbyreviewer1and8 5mmbyreviewer2 Pathologicdiagnosiswasnodularfibrosis Nodularfibrosiswithpolygonalshapein72 year oldman Bothreviewersinterpretedlesion arrow ashavingcoarsespiculation pleuraltag andpolygonalshape andasbeingpredominantlysolidontransversehighresolutionCTimages Lesionsizewasmeasuredas8mmbyreviewer1and9mmbyreviewer2 Pathologicdiagnosiswasnodularfibrosis Intrapulmonarylymphnodethatshowedperipheralsubpleurallesionin53 year oldwoman Bothreviewersregardedlesion arrow aspredominantlysolidlesionattachedtomajorfissureontransversehigh resolutionCTimages Lesionsizewasmeasured9mmbybothreviewers Pathologicdiagnosiswasintrapulmonarylymphnode 肺内淋巴结与GGO CTscanina90 year oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresentacongestedintrapulmonarylymphnode arrow GGO与霉菌灶 Thin sectionCTimageatthelevelofthemainpulmonaryarteryshowsa23 mmpoorlydefinednodularground glassopacityintheupperlobeoftheleftlung Thelesionincludesseveralperipheralsolidportions arrows andasubtlegroundglassopacity arrowhead Eosinophilicpneumoniaina36 year oldmanwithperipheralbloodeosinophilia a Thin sectionCTimageattheleveloftheaorticarchshowsanill definedareaofnodularground glassopacityintheupperlobeoftherightlung b Thin sectionCTimageattheleveloftheupperlobarbronchusintheleftlungshowsasimilarnodularground glassopacity a b GGO与结核灶 FalsepositivePETinpatientwithtuberculosis a Thin sectionaxialCTscanthroughtheupperlobesatlungwindowsshowsaleftupperlobenodulewithirregularmargins b FusedimagefromPET CTshowsincreasedmetabolicactivitywithinthenodule SurgicalresectionrevealedagranulomawithculturespositiveforMycobacteriumtuberculosis 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 Persistentnodularground glassopacityina69 year oldman a Thin sectionCTimageobtainedattheleveloftheleftbrachiocephalicveinshowsa14 mmpoorlydefinedroundnodularground glassopacityintheupperlobeoftheleftlung b Follow upthin sectionCTimageobtained4monthslatershowsthepersistenceandstableappearanceofthelesion Thepathologicdiagnosis obtainedafterawedgeresection wasfocalinterstitialfibrosis a b Purenodularground glassopacityconfirmedasfocalinterstitialfibrosisA Thin sectionCTshows30mmpurenodularground glassopacityintherightupperlobe B Onfollow upCTscanaftersevenmonths anintervalchangewasnotnoted a b Purenodularground glassopacityconfirmedasatypicaladenomatoushyperplasiaina58 year oldman A Initialthin sectionCTshowsa15mmpurenodularground glassopacityB Onthin sectionCTafter2months anintervalchangewasnotnoted Alllesionswerepathologicallyconfirmedasatypicaladenomatoushyperplasiabymultifocalwedgeresection a b Purenodularground glassopacityconfirmedasatypicaladenomatoushyperplasiaa InitialCTshows8mmpurenodularground glassopacityintherightupperlobe b Thin sectionCTafter10monthsshowspersistentpurenodulargroundglassopacitywiththesamesize a b 2 体积变大 体积变大一般为恶性病变 SmalladenocarcinomadetectedonscreeningCT InitialaxialthinsectionCTattheleveloftherightupperlobebronchusshowsa4mmnoduleintherightupperlobe RepeatCTscan3monthslateratthesamelevelshowsslightenlargementofthenodule Biopsyrevealedadenocarcinoma a b GrowthofsmallnoduleonfollowupCT adenocarcinoma Initialthin sectionaxialCTconedtotheleftlungshowsasmallleftupperlobenodulemeasuringapproximately4mmindiameter Repeatscan6monthslatershowsintervalgrowthofthelesion Aninvasiveadenocarcinomawasfoundatsurgery a b BAC Sequentialmagnified1 mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGOovera3 yearperiod Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent whichwasbettercharacterizedonsequentialimages Sequentialmagnified5 mmCTsectionsthroughtheleftupperlobeshowGGO initiallymeasuring8mminsizeovera3 yearperiod Histologicanalysisshowedmixedsubtypeadenocarcinomacomposedofacinaradenocarcinoma 40 andBAC 60 Computedtomogramfrom57 year oldman patient1 withlong termfollow upofpureground glassopacity PGGO formorethan10years Patienthadundergoneoperationforadenocarcinomaoriginatinginrightupperlobe10yearspreviously SmallPGGOinleftupperlobe arrow waspointedoutasafunctionoftheretrospectivereviewofconventionalCTtakenatthatoperation Onfollow up124monthslater high resolutioncomputedtomographyshowsenlargementofPGGOfrom8mm A to25mmindiameter Mostoftheresectedspecimenrevealsbronchioloalveolarcarcinoma a b c Mixedsubtypeadenocarcinoma progressionofGGOtoanodulewithmixedsolidcomponentandGGO a Magnified1 mmCTsectionshowsadiscreteGGO arrows b Follow upCTscanobtained1yearlatershowsclearprogressionofthedisease withthedevelopmentofacentralsolidcomponent althoughthereisnoappreciableenlargementofthelesion arrows a b Mixedsubtypeadenocarcinoma aMagnified1 mmCTsectionthroughtheleftlowerlobeshowsanodulewithmixedsolidcomponentandGGO bFollow upCTscanobtained6monthslatershowsincreaseintheextentofthesolidcomponentwithinthenodule a b Persistentnodularground glassopacityinan80 year oldmanwithadenocarcinoma Initialthick sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule arrow inthemiddlelobeoftherightlung Follow upCTimageobtained12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent arrow Follow upthin sectionCTimageobtainedat16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion arrow Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen a b c a TransverseCTscanina75 year oldmanshowsa2 0 cm diameternonsolidleftupperlobenodule FNABrevealednomalignantcells b ThelesionwasfollowedupwithserialCT 25monthslater thenodulewasslightlyincreasedinsizeandhadconvertedtoapartlysolidattenuationlesionwithairbronchograms Volumetricmeasurementshowedthedoublingtimeoftheopacitytobe1375days RepeatFNABshowedbronchioloalveolarcellcarcinoma a b 体积变小 体积变小一般为良性病变 Resolutionofnodularground glassopacityovertimehelpsdeterminethebenignityofalesionina50 year oldman Initialthin sectionCTimageattheleveloftheinferiorpulmonaryveinshowsa12 mmpoorlydefinednodularground glassopacityintherightlowerlobe Follow upCTimageobtainedapproximately2monthslatershowsthatthelesioninahasresolved a b Focalinflammationmimickingadenocarcinoma a Magnified1 mmCTsectionthroughtherightupperlobeshowsnoduleswithGGOinitiallydiagnosedasprobableBAC b Follow upCTscanobtained3monthslatershowsnearcompleteresolutionofthelesion arrow focalnonspecificinflammation a b Transversethin sectionCTscansshowtransientPSNwithmultiplicityina43 year oldman a Scanshowsa16 mmPSN arrow intheleftupperlobe Thispatienthadeosinophilia eosinophilcount 574permicroliter b Follow upscanobtained1monthlatershowsdisappearanceofthePSN a b Transversethin sectionCTscansshowtransientPSNwithill definedborderin37 year oldman a Scanshowsa27 mmPSN arrow withanill definedborderintherightupperlobe Thispatienthadbloodeosinophilia eosinophilcount 1577permicroliter b Atfollow upCTperformed3weekslater thePSNhasdisappeared a b ResolutionofspiculatedSPNcausedbyinfection a AxialCTscanatleveloftrachealcarinaina52 year oldsmokerwhohasfever cough andhemoptysisshowsaspiculatednoduleintheleftupperlobe b RepeataxialCT5weekslatershowsmarkeddecreaseinthesizeofthenodule Thepatienthadbeentreatedintheintervalwithbroa