呼吸系统影像诊断-肿瘤部分.ppt

呼吸系统影像诊断,肺肿瘤,分为原发性和转移性两大类原发性又分为良性、恶性恶性肺肿瘤98%为原发性支气管肺癌（primarybronchogeniccarcinoma）简称肺癌Lungcancer,一肺癌(Lungcancer),临床表现：早期无症状.最常见症状:呛咳无痰或偶有白色粘液痰表现,偶有痰中血丝副肿瘤综合征肿瘤累及其它组织出现的症状与体征,Lungcancer,肺癌,组织学类型Histologycategory：小细胞肺癌SCLC=smallcelllungcarcinoma非小细胞肺癌non-small-celllungcarcinoma鳞癌Squamouscellcarcinoma腺癌adenocarcinoma腺鳞癌adenosquamousCarcinoma大细胞癌LargeCellCarcinoma,Lungcancer,按发生部位分型,中央型centralbronchogeniccarcinoma：肺段或肺段以上的支气管，包括主、叶、段支气管周围型peripheralbronchogeniccarcinoma：肺段以下-细支气管以上的支气管弥漫型diffusebronchogeniccarcinoma：细支气管或肺泡,肺癌的扩散途径,淋巴转移lymphaticmetastasis:最常见.血行转移blood-bornemetastasis:常转移至脑肾上腺骨肝与肺直接蔓延directspread.,中央型肺癌centralbronchogeniccarcinomaX线表现X-rayfeatures,直接征象directsigns支气管改变：腔内充盈缺损intraluminalfillingdefect管壁增厚increasedthickness不规则狭窄irregularstenosis管腔截断interrupt杯口状锥状鼠尾状肺门区块影hilarmass肺门影增大、密度增高,Lungcancer,centralbronchogeniccarcinoma,Lungcancer,支气管改变示意图,centralbronchogeniccarcinoma,X线间接征象indirectsigns管腔阻塞-阻塞征象:阻塞性肺气肿obstructiveemphysema阻塞性肺不张obstructiveatelectasis阻塞性肺炎obstructivepneumonia:病变使支气管阻塞,阻塞以远肺组织发生的肺炎阻塞性支气管扩张与粘液嵌塞obstructivebronchiectasis,Lungcancer,centralbronchogeniccarcinoma,左上叶阻塞性肺不张obstructiveatelectasis,Lungcancer,InvertedScurvesign反S征或横S征,obstructiveatelectasis,centralbronchogeniccarcinomaCTfeatures,肺门肿块hilarmass：边缘呈分叶状或不规则支气管壁改变，超过3mmbronchialwallthickingorintraluminalfillingdefect,luminalcavityirregularstenosisorinterrupt阻塞性肺炎、肺气肿、肺不张obstructiveemphysema,obstructiveatelectasisobstructivepneumoniaobstructivebronchiectasis肺门、纵隔淋巴结肿大enlargementofhilarlymphnodesormediastinallymphnodes侵犯纵隔,Lungcancer,中央型肺癌CT表现,支气管杯口状阻塞,Lungcancer,中央型肺癌centralbronchogeniccarcinomaCT表现,右下叶支气管闭塞obliteration右下肺不张atelectasis肺门、纵膈淋巴结增大enlargementoflymphnodes侵犯右肺动脉,Lungcancer,周围型肺癌peripherallungcancer基本表现：肺肿块性或结节病变noduleandmass早期癌earlycarcinoma肿块直径小于2cm，无他处转移,肺内球形肿块,周围型肺癌肿块特点Imagingfeatures,Lungcancer,ShapeMargedensity,Lobulationsign,周围型肺癌肿块特点,细、短的毛刺,Lungcancer,spiculation,胸膜凹陷征pleuralindentationsign,Lungcancer,周围型肺癌peripherallungcancer肿块特点,MPR重建胸膜凹陷征pleuralindentationsign,Lungcancer,血管集束征convergenceofbronchovascularstructures,月晕征halosign,结节周围环以磨玻璃影病理为出血性肺梗塞肿瘤细胞浸润见于曲菌球,周围型肺癌等,病灶胸膜侧小片状浸润,不规则的厚壁空洞irregularthickwalledcavity：多见于较大肿块内壁厚、偏心、内壁不规则、有壁结节,Lungcancer,周围型肺癌肿块特点carcinomatouscavity,Lungcancer,周围型肺癌肿块特点小圆形空泡征vacuolesign管状支气管充气征airbronchogram多见3cm肿块内,peripherallungcancer肿块特点小结,肺内球形肿块分叶征signoflobulation：不规则毛刺征spiculationandspike：短、细，放射状癌性空洞carcinomatouscavity：壁厚、内壁不规则空泡征vacuolesign与支气管充气征胸膜凹陷征pleuralindentationsign血管集束征convergenceofbronchovascularstructures月晕征(halosign)病灶胸膜侧小片状浸润钙化少见CT增强均匀或不均匀强化,Lungcancer,肺上沟癌(Pancoasttumor)发生于肺尖的肺癌,Lungcancer,胸部正侧位片(含DRCR)用于筛查肺癌,胸部CT为肺癌诊断的首选,MRI一般不用于诊断肺癌,体检筛查肺癌可选用胸部正侧位片DRCR低剂量CT.早期中央型肺癌X线胸片常无异常表现,胸部CT能显示支气管管腔与管壁的异常.纵隔结构浸润的胸部CT表现为肿块与纵隔间脂肪间隙消失,肿块与纵隔结构分界不清.MRI对支气管病变与阻塞性改变显示不佳,但可显示肺门肿块与纵隔转移和浸润.肺癌的血供主要为支气管动脉,DSA可用于肺癌血供的显示,用于肺癌介入治疗前后.,肺癌TNM分期,见P216,弥漫型肺癌diffusetype,两肺广泛不对称分布的细小结节，边缘模糊，可融合呈肿块或大片实变,内可见支气管充气征airbronchogram中下肺野较多,Lungcancer,细支气管肺泡癌bronchioloalveolarcarcinoma,肺癌转移肺门纵隔淋巴结转移Mediastinallymphnodemetastasis胸膜转移pleuralmetastasis肺内转移directextension直接蔓延或转移至胸壁远处转移metastasis,转移性肺癌metastaticlungcancer肺转移瘤pulmonarymetastasis,许多部位的恶性肿瘤可以转移至肺,如绒癌、乳腺癌、肝癌、胃癌、骨肉瘤等。转移途径有血行、淋巴或临近器官直接蔓延等,X线表现,metastaticlungcancer,双肺多发棉球样结节大小不等密度均匀边界清楚中下肺野外带较多,血行转移,CT表现,双肺弥漫性结节或多发球形病灶密度均匀，边缘光滑中下肺野及胸膜下区较多,metastaticlungcancer,metastaticlungcancer,淋巴转移癌性淋巴管炎lymphangitiscarcinomatosa,常有肺门或纵膈淋巴结增大自肺门向外呈放射状分布的条索状影串珠状小点影,肺内结节性疾病的鉴别诊断P216.表4-2-1-6,纵隔肿瘤mediastinaltumor,种类很多CT、MRI有明显优势定位很重要:纵隔肿瘤有特定或好发部位,定位后有助于定性,纵隔的分区和常见肿瘤,前纵隔胸骨后缘-心脏大血管前方常见肿瘤胸内甲状腺胸腺瘤畸胎瘤心包囊肿,甲状腺瘤胸内延伸,mediastinaltumor,胸腺瘤thymoma,mediastinaltumor,胸腺瘤thymoma,mediastinaltumor,畸胎瘤teratoma,mediastinaltumor,畸胎瘤teratoma,mediastinaltumor,心包囊肿PericardialCyst,mediastinaltumor,纵隔的分区和常见肿瘤,中纵隔前纵隔后缘-食管前方常见肿瘤淋巴瘤支气管囊