No七年制临床呼吸常见病课件

1、Imaging Diagnosis of Rspirotary Diseasepart 2AiPing Chen1Imaging Diagnosis of RspirotaLung 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.2Lung neoplasm肺肿瘤The incidence Lung neoplasm肺肿瘤Be

2、nign: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3Lung neoplasm肺肿瘤Benign:良性3harmatomauncommon asymptomatic; symptoms typically are present with central endobronchial lesions， include hemoptysis, recurrent pneumonia, an

3、d dyspnea.4harmatomauncommon 4harmatomatypically 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

4、 to 50% of cases and is a diagnostic feature. 5harmatomatypically round, well6677primary 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 inc

5、rease the risk for bronchial carcinoma. 8primary bronchogenic carcinomaLung 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 neop

6、lasm9Lung carcinoma(cancer)Lung neoLung neoplasmSCLC(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 pla

7、nes. 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10Lung neoplasmSCLC(small cell lLung neoplasmNSCLC(non-small cell lung cncer)squmous cell carcinoma is most commonly a central tumor developing at the level of the segmental and subsegmental br

8、onchi 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 a

9、lveoli respecting interstitial boundaries,may be unifocal or multifocal, when multifocal, it may produce alveolar cell carcinosis.11Lung neoplasmNSCLC(non-small cbronchial carcinoma asymptomatic ， detected incidentally most patients (up to 90%) are symptomatic 气道起源多数表现为 producing cough, hemoptysis,

10、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。12bronchial carcinoma asymptomatAccording to type of growth Central type:Inter-tuber 管内Wall of tuber管壁Extra-tuber 管外Peripheral type:Mass inflammationDiffuseLung neoplasm13According to type of growth Central tumorDirect sign of bronchia

11、l carcinoma lung massBronchial lumen : Bronchial stenosis，endoluminal or transmural growth14Central tumorDirect sign of brCentral tumor: mass in the right low lober and right hilar enlarge,15Central tumor: mass in the rigmass in the right hilar16mass in the right hilar16Central tumorlung mass in the

12、 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17Central tumorlung mass in the Mouse tail Irregular stenosisFilling defectCup like 18Mouse tail Irregular stenosisF1919Mouse tail Central tumor20Mouse tail Central tumor20Filling defect21Filling defect21Bronchial stenosis22Bronchial stenosis22Central

13、tumorIndirect 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 23Central tumorIndirect sign23Partial 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 pa

14、tchy or homogeneous pulmonary opacification of lobar or segmental distribution.24Partial or complete atelectasiRight upper lobe atelectasis 25Right upper lobe atelectasis 2Right upper lobe atelectasis26Right upper lobe atelectasis26left upper lobe atelectasis27left upper lobe atelectasis27Left low l

15、obe atelectasis28Left low lobe atelectasis28Left low lobe atelectasisBronchial stenosis29Left low lobe atelectasisBroncLeft low lobe atelectasis30Left low lobe atelectasis30Central tumorIndirect sign of bronchial carcinoma:Distal pneumonia presents as lobar or segmental consolidation, which may part

16、ially 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.31Central tumorIndirect sign ofDistal pneumonia32Distal pneumonia32pneumoniamassPleural effusion33pneumoniama

17、ssPleural effusion3Central tumorIndirect sign of bronchial carcinoma:Intrathoracic spread of bronchial carcinoma. 34Central tumorIndirect sign ofRight side Central tumor35Right side Central tumor35Central tumorIndirect sign of bronchial carcinoma:Mediastinal lymph node enlargement. Mediastinal widen

18、ing may be the first radiographic sign of lung cancer, especially in cases of small cell carcinoma.36Central tumorIndirect sign of3737Central tumorHematogenous 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38Ce

19、ntral tumorHematogenous sprCostal bone damage 39Costal bone damage 39Right lung metastasis40Right lung metastasis4041414242Central tumorMRI manifestationBronchi wall thickenBronchi wall stenosisMass in the hilumEmphysema; pneumonia; atlectasis of obstructionAffect mediastinum，enlargement of lymph no

20、de(diameter15mm)43Central tumorMRI manifestation44444545plain film、CT、MRICentral tumor46plain film、CT、MRICentral tumorPlain film47Plain film47CT平扫CT scan no contrast48CT平扫CT scan no contrast48CT增强CT scan contrast49CT增强CT scan contrast49MRI50MRI5051515252Peripheral tumor Peripheral pulmonary nodule.

21、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 cavitat

22、ing lesion typical of squamous cell carcinoma.53Peripheral tumor Peripheral puPeripheral tumorPulmonary 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 54Peripheral tumorPulm

23、onary noduPeripheral 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55Peripheral tumor分叶征象: 生长不均衡，周围notching of the contour56notching of the contour56notching of the contour57notching of the contour57Cavitary.58Cavitary.58Retraction of pleura. Spiculate margin. notching of the con

24、tour59Retraction of pleura. SpiculaRetraction of pleura. Spiculate margin. notching of the contour60Retraction of pleura. SpiculaRetraction of pleura. Spiculate margin. notching of the contour61Retraction of pleura. Spicula Spiculate margin. notching of the contour62 Spiculate margin. notching ofSpi

25、culate margin. notching of the contour63Spiculate margin. notching of Bone metastasis64Bone metastasis646565Bronchiolo-alveolar carcinomaIsolated mass typePneumonia typeDiffuse nodule type66Bronchiolo-alveolar carcinomaIIsolated mass type Bronchiolo-alveolar carcinoma 67Isolated mass type Bronchiolo

26、-Bronchiolo-alveolar carcinomaPneumonia type68Bronchiolo-alveolar carcinoma69697070ill-defined margin pulmonary nodule Bronchiolo-alveolar carcinoma71ill-defined margin pulmonary nBronchiolo-alveolar carcinoma72Bronchiolo-alveolar carcinoma7Bronchiolo-alveolar carcinoma73Bronchiolo-alveolar carcinom

27、a7Lung mestastasisThe 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, g

28、erminal 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. 74Lung mestastasisThe most commoLung mestastasisHematogenous mestastasisLymphatic vessel mestastasis 75Lung mestastasisHemato

29、genous mHematogeneous mestastasis76Hematogeneous mestastasis76Hematogeneous mestastasis77Hematogeneous mestastasis77Hematogeneous mestastasis78Hematogeneous mestastasis78Hematogeneous mestastasis79Hematogeneous mestastasis79Lymphatic vessel mestastasis80Lymphatic vessel mestastasis80Pleural carcinom

30、atosis 81Pleural carcinomatosis 818282Mediastinal tumor纵隔肿瘤主要诊断依据：position, shape， density.83Mediastinal tumor纵隔肿瘤主要诊断依据：8Tumor of the anterior mediastinumThymoma TeratomaIntrathoracic thyroid Malignant lymphomaBronchogenic cystNeurogenic tumors 84Tumor of the anterior mediastiMediastinal tumorAnter

31、ior 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85Mediastinal tumorAnterior medIntrathoracic thyroidIntrathoracic thyroid is usually a downward prolongation or ou

32、tgrowth 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. 86Intrathoracic thyroidIntrathor胸内甲状腺肿intrathora

33、cic 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87胸内甲状腺肿intrathoracic goiter87Intrathoracic thyroid88Intrathoracic thyroid88Intrathoracic thyroidThe CT appearances of thyroid goiters are specific. Anatomical continuity usually can be demonstrated with the cervical thyroid. Focal calcifications an

34、d inhomogeneity are frequent features. After injecting contrast material, there is a definite prolonged rise in the CT Hounsfield number.89Intrathoracic thyroidThe CT ap结甲伴腺瘤样增生女，62岁肿物与甲状腺相连90结甲伴腺瘤样增生90Intrathoracic thyroidMR imaging particularly in the coronal and sagittal planes, can show the exte

35、nt of intrathoracic thyroid tissue and its relationship to adjacent structures. Multinodular goiters have heterogeneous signal characteristics on T1W1 and T2W1. 91Intrathoracic thyroidMR imagin92929393Thymoma胸腺瘤anterior superior mediastinum. round, lobulated or plaque-like, and produce unilateral wi

36、dening of the mediastinum. Calcification or cystic degeneration may be seen in a small percentage of cases.94Thymoma胸腺瘤anterior superior me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95胸腺瘤thymoma占前纵隔肿瘤50%多见于中年人959696ThymomaCT is the imaging method of choice for e

37、valuating 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

38、found in nodular glands, simulating the presence of a thymoma.97ThymomaCT is the imaging metho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。98Thymoma99Thymoma99Thymoma100Thymoma100Thymoma101Thymoma101102102胸腺瘤，可疑包膜侵润 男性，47岁，查体发现103胸腺瘤，可疑包膜侵润 103

39、ThymomaThymomas 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 T2W1.104ThymomaThymomas have intermedi

40、胸腺瘤MRI105胸腺瘤MRI105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106畸胎瘤 teratoma先天性肿瘤，属生殖细胞瘤106畸胎瘤 teratomaX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107畸胎瘤 teratomaX线表现及CT表现107TeratomaMost mediastinal teratomas are seen on radiograph a

41、s 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 attenuatio

42、n 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.108TeratomaMost mediastinal teratteratoma109teratoma109teratoma110teratoma110teratoma111teratoma111112112113113精原细胞瘤男，16岁，面部浮肿1月，咳嗽20天恶性

43、生殖细胞肿瘤 114精原细胞瘤恶性生殖细胞肿瘤 114Mediastinal tumorAnterior mediastinal tumor：Middle mediastinal tumor：Malignant lymphomaBronchogenic cystPosterior mediastinal tumor115Mediastinal tumorAnterior mediMalignant lymphomaThe thorax is frequently involved in patients with Hodgkins and non-Hodgkins lymphomas. It

44、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. 116Malignant lymphom

45、aThe thorax i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117恶性淋巴瘤淋巴组织恶性肿瘤117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118恶性淋巴瘤X线表现118Malignant lymphoma119Malignant lymphoma119Malignant lymphoma120Malignant lymphoma120Malignant lymphomaCT and MRI are more sensitive than radiograph. The enlarged lymph nodes or mass mostly show soft tissue density or s