医学影像学诊断2

医学影像学诊断浅谈RespiratorytractNosePharynxLarynxTracheaBronchiLungThemainfunctionoftherespiratorysystemisexchanginggasesupperrespiratorytractlowerrespiratorytractnasalcavityoralcavitylarynx

pharynx

trachearightprincipalbronchus

leftprincipalbronchussuperiorlobe(leftlung)

diaphragm

inferiorlobe(leftlung)ThenoseTheexternalnose呼吸困难时，鼻翼扇动TheNasalCavity鼻前庭固有鼻腔鼻中隔鼻腔外侧壁上、中、下鼻甲上、中、下鼻道鼻粘膜Mucousmembraneofnose嗅区Olfactoryregion：上鼻甲及其对应的鼻中隔的黏膜，含嗅细胞呼吸区：对吸入空气加温、加湿、净化FrontalsinusSphenoidsinusMaxillarysinusEthmoidalsinuses鼻旁窦鼻旁窦开口部位上颌窦中鼻道额窦中鼻道筛窦前组中组中鼻道后组上鼻道蝶窦蝶筛隐窝咽部咽部应用解剖上起颅底，下达第六颈椎平面，长约12cm。鼻咽：颅底至软腭下缘口咽：软腭至舌骨水平面喉咽：舌骨水平面至环状软骨下缘鼻咽

顶壁：由蝶骨体和枕骨底部构成前壁：通后鼻孔后壁：与第1、2颈椎相对在顶壁与后壁交界处，有淋巴组织团块--腺样体鼻咽两侧壁有咽鼓管开口----咽口恰在下鼻甲后缘后方约1cm处咽口后上方的钩状隆起----咽鼓管隆起或圆枕，圆枕后方隆起的粘膜皱襞称咽鼓管皱襞。在该皱襞与圆枕的后方有深陷的隐窝----咽隐窝口咽：

后壁以椎前软组织与第2、3颈椎相对

•两侧壁前方皱襞----舌腭弓

后方皱襞----咽腭弓•两弓之间为扁桃体隐窝喉咽：

前壁为喉后面，自上而下为会厌喉面、喉口，与喉室相通

会厌前方左右各一个会厌溪鼻咽矢状位鼻咽顶部和咽后壁的软组织厚度成人顶壁2~4mm

5岁以下＜8mm

成人＜5mm鼻咽部正常影像表现

CT（软组织窗）翼外肌腭帆张肌腭帆提肌颞下窝翼突内外侧板咽鼓管咽口圆枕咽隐窝头长肌咽旁间隙鼻咽部正常影像表现

CT（骨窗）棘孔卵圆孔斜坡颈动脉管骨性咽鼓管破裂孔眶下裂翼上颌间隙颈静脉孔舌下神经孔成人腺样体肥大腺样体位于鼻咽顶后壁中线处为咽淋巴环内环的组成部分。腺样体肥大儿童腺样体肥大鼻咽左侧壁软组织肿块。T1WI（A）肿块呈均匀等信号，T2WI（B）呈稍高信号；增强扫描（C）肿块中度均匀强化。左侧咽隐窝及咽骨管咽口消失，左侧腭帆张肌及腭帆提肌受压向外侧推移，左侧头长肌受累；左侧乳突小房信号增高。v【影像诊断】：鼻咽癌并左侧中耳乳突炎。男性17岁，因鼻出血就诊，耳鼻喉科检查示右侧鼻腔新生物。

CT平扫病灶呈均匀软组织密度，边界尚清，邻近骨质（上颌窦后内侧壁、翼突内板及鼻中隔）受压，但无破坏征象。CT增强病灶显度强化。鼻咽纤维血管瘤是鼻咽部最常见的良性肿瘤与一般纤维瘤不同为致密结缔组织大量弹性纤维和血管组成常发生于10～25岁青年男性故又名“男性青春期出血性鼻咽血管纤维瘤”病因不明。鼻咽纤维血管瘤的病理：

肿瘤起源于枕骨底部蝶骨体及翼突内侧的骨膜瘤体由胶原纤维及多核成纤维细胞组成网状基质其间分布大量管壁薄且无收缩能力的血管这种血管受损后极易出血肿瘤常向邻近组织扩张生长通过裂孔侵入鼻腔鼻旁窦眼眶翼腭窝及颅内

影像学表现：

1、X线平片：鼻咽部肿块影，下缘多光滑锐利，基底接近鼻咽上后壁，肿物相邻骨结构受压移位、吸收。

2、CT表现：鼻咽腔内软组织密度肿块，外缘光滑锐利，增强明显、不均。肿瘤常突入后鼻孔、翼腭窝、颞下窝甚至上颌窦，相邻骨壁压迫吸收，受累肌间隙显示不清。

3、MR表现：肿瘤T1权重像与质子密度像为低～中等信号强度，T2权重像与梯度回波像中～高信号强度。瘤内较多流空血管。注射钆造影剂后肿瘤增强明显。矢状层面可见肿瘤来源于鼻咽顶～后壁。

鼻咽纤维血管瘤的临床表现：

1、出血阵发性鼻腔或口腔出血且常为病人首诊主诉由于反复大出血病人常有不同程度的贫血

2、鼻塞肿瘤堵塞后鼻孔并侵入鼻腔引起一侧或双侧鼻塞常伴有流鼻涕闭塞性鼻音嗅觉减退等

3、其他症状由于瘤体不断增长引起邻近骨质压迫吸收和相应器官的功能障碍肿瘤侵入邻近结构则出现相应症状如侵入眼眶则出现眼球突出视神经受压视力下降；侵入翼腭窝引起面颊部隆起；侵入鼻腔可引起外鼻畸形；侵入颅内压迫神经引起头痛及脑神经麻痹

Thelarynxisdividedinto3anatomicregions:thesupraglotticlarynx,theglottis,andthesubglotticregion.Thecartilaginousframeworkofthelarynxincludesthethyroidcartilage,cricoidcartilage,arytenoidcartilage,andcorniculatecartilage,asshownintheimagesbelow.喉腔前庭襞声襞喉前庭喉中间腔声门下腔喉室喉腔前庭襞——前庭裂声襞——声门裂声襞与声带声门裂为喉腔最狭窄的部位声门下腔炎症时易发生水肿喉前庭喉中间腔声门下腔喉室喉腔Lateralradiographoftheneckshowingthedifferentstructuresofthelarynx:a,vallecula;b,hyoidbone;c,epiglottis;d,pre-epiglotticspace;e,ventricle(air-spacebetweenfalseandtruecords);f,arytenoid;g,cricoid;andh,thyroidcartilageNormalanatomy.ThiscoronalT1-weightedscanshowstheseparationofthesupraglottisfromtheglottisbythelaryngealventricle(shortarrow).Notethattheparaglottictissueatthelevelofthefalsevocalcordsandaboveishighintensityfat(longarrow).Belowtheventricle,theparaglottictissueislow-intensitymuscle.舌根舌骨体舌骨小角舌骨大角下颌下腺咽腔胸锁乳突肌会厌豀颈总动脉颈内静脉甲状软骨上角颈阔肌甲状软骨左板舌骨下肌咽腔梨状隐窝颈长肌会厌杓状会厌襞甲状软骨声襞声门裂环状软骨杓状软骨颈总动脉颈内静脉甲状软骨环状软骨声门下腔甲状软骨下角甲状腺环状软骨声门下腔舌骨下肌胸锁乳突肌甲状腺食管甲状腺气管食管颈总动脉颈内静脉【临床】男，47岁，声嘶一年余。【影像表现】CT扫描示声门平面右侧声带可见软组织密度影，病变边界清楚，形态尚规则，病变部分突入声门腔，致声门腔局限性狭窄，平扫呈等密度，增强扫描病变轻度强化。骨窗示甲状软骨及环状软骨骨质未见明显破坏。【诊断】（喉腔）中－低分化鳞癌，侵及甲状软骨表层。（病理确诊）气管和主支气管气管Trachea上接环状软骨，向下入胸腔，至胸骨角平面分为左右主支气管分叉处称气管杈内面为气管隆嵴，支气管镜检查的定位标志“C”形气管软骨环，缺口由膜壁封闭临床气管切开部位第3、4或4、5气管软骨环气管隆嵴气管和主支气管主支气管principalbronchus

左主支气管-细、长、走向水平右主支气管-粗、短、走向陡直故异物易落入右主支气管肺TheLungs位置形态一尖：肺尖一底两面肋面纵隔面：肺门、肺根三缘分叶左肺：上、下叶右肺：上、中、下叶形态肺门thehilumoflung

：肺纵隔面中部的凹陷，有主支气管、肺动脉、肺静脉、淋巴、神经等出入。肺根therootoflung：出入肺门的主支气管、肺动脉、肺静脉、淋巴、神经等被结缔组织包绕形成的结构。支气管树Bronchialtree分级支气管肺段

Bronchopulmonarysegments

1，传送部自气管起，经至少16次分支后终于终末细支气管。作用为传送气体，无肺泡。为解剖死腔，气流速率高，气流容积低，约150mL。2，过渡部为呼吸细支气管，肺泡管。有传送和呼吸双重作用。

3，呼吸部为气道盲端由肺泡囊组成，作用为气体交换，气流速率低，气流容积高，约3L。呼吸系统(respiratorysystem)—气道(airpassage)呼吸系统(respiratorysystem)-小气道的解剖和生理

>2-3mm的气道为中央气道，<2-3mm者为周围气道。一个终末细支气管及其以下分支构成一个腺泡，3-12腺泡为一个肺小叶。肺小叶直径1-2.5cm，呈多角形，边缘为小叶间隔。小叶中心有肺小动脉及终末细支气管。终末细支气管壁厚0.1mm，在HRCT的分辨率(0.2mm)以下，不可见。直径>0.2mm的小肺动脉，可见。呼吸系统---肺实质和肺间质肺实质：具有气体交换功能的含气间隙和结构肺间质：肺的支架组织网。位于支气管、血管周围（支气管血管鞘，又称轴位间质），小叶间隔和胸膜下（又称周围间质），两者之间的间质网，包括肺泡间隔，又称实质性间质EfficiencyofBreathing:Normal&HighDemand肺实质与肺间质肺实质具有气体交换功能的肺含气间隙及结构主要是肺泡及肺泡壁肺间质肺组织的支架结构主要由血管、支气管及肺泡间隔的结缔组织构成ThePleura胸膜壁胸膜脏胸膜胸膜腔负压壁胸膜的分部肋胸膜膈胸膜纵隔胸膜胸膜顶

Parietalpleura

coversthesurfaceofchestwalldiaphragmmediastinumreceivesbloodfromsystemiccirculationcontainssensorynerves

Visceralpleura

coversandadheresto

surfaceofbothlungsreceivesbloodfrompulmonarycirculationcontainsnosensorynervesNormalAnatomyVisceralpleuraisadherenttothelungSpacebetweenvisceralandparietalpleuraisapotentialspaceInfoldingsofvisceralpleuraformfissuresLooseconnectivetissuebeneathvisceralpleura=subpleuralspacetwopleuralsurfacesareseparatedbyapotentialspace—apleuralspace--exists5-10mloffluidmeanpressureinspaceis–5cmH2OEtiology&Physiology

hydrostaticpressure

colloidosmoticpressure

capillarypermeability

absorptionoffluidbylymphatics

pressureinpleuralspaceTransportofperitonealfluidthroughdiaphragmorvialymphatics1.Hydrostaticpressures

CongestiveheartfailureConstrictivepericarditisObstructeduppercavaCauses

hydrostaticforces

filtrates

transudatesPulmonarycirculationSystemiccirculation2.ColloidoncoticpressureHypoalbuminemiaCirrhosisnephroticsyndromeCauses

oncoticpressures

filtrates

transudates3.PermeabilityInflammation(TB,pneumonia)Rhumaticdiseases(SLE,rheumatoid)Malignancy(metastasis,mesotheliomas)EmbolismCauses

pleuralcapillariesaredamaged

infiltration

reabsorptionarebrokendown

exudates4.Disordersoflymphaticflowinparietalpleuramalignancyabnormallymphaticsdevelopment5.TraumaAortictumorbloodyEsophaguspurulentThoracicductmilkyClinicalmanifestation症状原发病所致的症状胸闷、气短、胸痛、心悸体征气管移位患侧胸廓饱满叩诊浊音或实音呼吸音减弱或消失胸膜摩擦音classifacationAppearance:hemothoraxbloodEmpyemapuschylothorax

chyle

Characteristic:Transudativeexudative

ImigiologicFindings1.RadiologicalfindingsaBluntingcostophrenicangleaconcaveshadowwithitshighestmarginalongthepleuralsurface

apseudotumor

a“highdiaphragm”withapeakmorelateral.thanusual---Subpulmoniceffusionanair-fluidlevelNormalPhysiologyNormallythereare2-10ccoffluidinthepleuralspaceEachhour,asmuchas100ccoffluidisproduced,mostlyatparietalpleuraFluiddrainsmostlytovisceralpleuraandvialymphaticsThelungcancer

一、组织学起源支气管肺癌大多起源于支气管黏膜上皮，包括细支气管和肺泡上皮，少数起源于大支气管的腺体上皮。二、病理

1、肺癌的大体分型

中央型肺癌：发生于主支气管和叶支气管，引起支气管的改变，产生“三阻”。

周围型肺癌：发生于段及段支气管以远的肺癌，在肺内形成肿块。

2、肺癌的组织学分型

鳞癌：中央型居多；

腺癌：周围型多见，包括细支气管肺泡癌；

未分化癌：大细胞癌和小细胞癌；

混合型：鳞腺癌

少见类型：类癌、腺样囊性癌

3、临床上分为小细胞性和非小细胞性。

ClassificationsAccordingtoanatomy:(1)Centrallungcancer,mostlyissquamouscellcarcinomaandsmallcellcarcinoma.(2)peripherallungcancer,mostlyisadenocarcinoma.Accordingtohistologicclassification:Smallcelllungcancer(SCLC)andNon-smallcelllungcancer(NSCLC).NSCLCincludesSquamouscellcarcinoma,largecellcarcinoma,adenocarcinoma,adenosquamouscarcinoma.Classifications

Squamouscellcarcinoma:Itisthemostcommonsubtype.Itarisesfromalteredbronchialepitheliumandgrowthinsitu.Itisrelatedtocigarettesmoking.Cavitationcanoccureinthedistaltotheobstructingmass.Adenocarcinoma:Itarisesfromthesubmucosalglands,locatedinperipheralairwaysandalveoli.Peripheraladenocarcinomasareusuallywell-circumscribed,grey-whitemassesthatrarelycavitate.Classification

Large-cellcarcinoma,areusuallylocatedperipherally.Theycanbequitelargeandnotinfrequentlycavitate.Theyhavelargenuclei,prominentnucleoli,abundantcytoplsma.Therearetwotypes,Giant-cellcarcinomaandclear-cellcarcinoma.Adenosquamous:Therearedefinitefeaturesofadenocarcinomaandsquamouscecarcinoma.Classification

Smallcellcarcinomahasthreesubtypes,oat-cellcarcinoma,intermediatecelltypeandcombinedoat-cellcarcinoma.SCLCbelongsinagroupoftumorsderivedfromneuroendocrinecellsthatareresponsiblefortheproductionandsecretionofspecificpeptideproduct.theymayrelatedtoparaneoplasticsyndrome.三、肺癌的转移

1、淋巴道转移：常见，支气管、血管周围淋巴间隙——肺段、肺叶淋巴结——肺门——锁骨上淋巴结（可与原发灶同侧，但通常以右侧居多）；

2、血行转移：侵犯肺静脉或经胸导管引流入血液；

3、直接侵犯：

4、气道转移：如肺泡癌可经过支气管或肺泡孔扩散。肺癌的症状学发生发展表现肺癌形成无症状累及小支气管咳嗽累及粘膜微血管血痰侵及胸膜胸壁胸闷胸痛阻塞支气管气促发热胸膜播散胸水非特异性症状:食欲不振体重下降

临床表现1、局部症状：咳嗽、咳痰、咳血、胸痛、胸闷、气急、喘鸣；2、全身症状：发热、乏力、消瘦；3、肺外表现：肺癌的异位内分泌的作用产生的肺外症状——副癌综合征，如骨关节肥大、杵状指和类癌综合征等；4、局部侵犯和转移：胸膜、心包、神经、SVC等。intracanaliculartypetubalwalltypetubalwallofoutsidetypeThecentraltypelungcancer左主支气管鳞癌AIRTRAPPING右基底干腺癌伴阻炎隐性肺癌：腺癌，右上叶支气管隐性周围型,开始无,现长大腺癌：沿管壁生长穿透管壁生长Thisisasquamouscellcarcinomaofthelungthatisarisingcentrallyinthelung(asmostsquamouscellcarcinomasdo).Itisobstructingtherightmainbronchus.Theneoplasmisveryfirmandhasapalewhitetotancutsurface.ThesechestCTscanviewsdemonstratesalargesquamouscellcarcinomaoftherightupperlobethatextendsaroundtherightmainbronchusandalsoinvadesintothemediastinumandinvolveshilarlymphnodes磨玻璃征瘤结节或部分区呈磨玻璃状，不掩盖肺纹理病理基础：肿瘤沿肺泡间隔生长、肺泡壁增厚，肺泡腔未闭塞，内有黏液或脱落肿瘤细胞主要见于早期BACTheperipherallungcancer空泡征空泡征的病理基础：未被肿瘤组织占据的肺组织未闭合的细支气管乳头状癌结构间的含气腔隙未闭或融解、破坏、扩大的肺泡腔细支气管充气征：细条状，直径约1mm的空气密度影病理基础：扩张的细支气管分叶征与肿瘤细胞分化程度不一，各部位生长速度不同有关在支气管、血管进出肿瘤及胸膜陷入部位可形成明显凹陷、分叶棘状突起（spiculateprotuberance)介于分叶和毛刺之间的一种较粗大而钝的“杵状”结构有肺癌细胞的浸润胸膜凹陷征肿瘤与胸膜之间的线形或三角形影像腺癌和细支气管肺泡癌多见形成条件：瘤体方向的纤维化收缩，胸膜无增厚粘连瘤体内纤维化——根本动力影响因素：瘤体与壁层胸膜的距离Theperipherallungcancer小支气管截断征

CTscaninan83-year-oldmanshowsa2.3-cmleftupperlobecavitarynodule.Thewallisvariableandthecavitywallisasthickas8mm.FNABrevealedsquamouscellcarcinoma.血管集束征一支或几支血管到达瘤体内或穿过瘤体、肺血管被牵拉向肿瘤移位、血管到达肿瘤边缘截止等对比增强特征Swensenetal:强化CT值：>20HU

提示恶性(敏感性100%,特异性76.9%)

<20HU

提示良性

20±5HU

慎重

>60HU

提示炎性结节动态增强:肺癌的强化峰出现时间约:2-5分钟正常肺组织和良性结节为:2分钟内SSDMPR三维表面重建（SSD）示病灶表面形态凹凸不平，与支气管关系密切。多平面重建（MPR）显示病灶位于小支气管之间，并起源于其中一支支气管壁，不均匀性环形生长，病变向腔外生长，推挤邻近支气管，并形成一小结节，向腔内生长，导致管腔狭窄和阻塞。肺癌SSD:shadedsurfacedisplay

多平面重建（MPR）显示支气管征，该例为低分化腺癌最小密度投影(MIP)显示血管聚集征，该例为中分化鳞癌容积成像（VR）显示胸膜凹陷、结节形态，该例为细支气管肺泡癌MPR:MultiplePlanarReconstruction深分叶，胸膜凹陷——腺癌VR:VolumeReconstruction

AdenocarcinomaAdenocarcinomarepresents31%ofalllungcancers,includingbronchoalveolarcarcinoma.Adenocarcinomasaretypicallyperipherallylocatedandmeasure＜4cmindiameter;only4%showcavitation.Hilaorhilaandmediastinalinvolvementisseenin51%ofcasesonchestradiographyandarecentstudydescribestwocharacteristicappearancesonCT:eitheralocalizedgroundglassopacitywhichgrowsslowly(doublingtime＞1yr)orasolidmasswhichgrowsmorerapidly(doublingtime＜1yr).

A48-yr-oldmanwithadenocarcinoma.(A)Lungwindowofinitialscreeninglow-doseCTscanobtainedatlevelofrightupperlobarbronchusshows10-mm-sizedground-glassopacitynodule(arrow)inrightupperlobe.(B)Lungwindowofthin-section(2.5-mmthickness)CTscanobtainedatsimilarleveltoAshowsclearlyground-glassopacitynatureofnodule(arrow).Rightupperlobectomydisclosedadenocarcinoma.

CTscaninan80-year-oldmanshowsa2.2-cm-diameternoduleintheleftupperlobewitheccentriccalcification.FNABofthenodulerevealedadenocarcinoma.

BronchoalveolarcarcinomaThisisregardedasasubtypeofadenocarcinomaandrepresents2–10%ofallprimarylungcancers.Therearethreecharacteristicpresentations:mostcommonisasinglepulmonarynoduleormassin41%;in36%theremaybemult-icentricordiffusedisease;finally,in22%thereisalocalizedareaofparenchymalconsolidation.Bubble-likeareasoflowattenuationwithinthemassareacharacteristicfindingonCT.Hilarandmediastinallymphadenopathyisuncommon.Persistentperipheralconsolidationwithassociatednodulesinthesamelobeorinotherlobesshouldraisethepossibilityofbronchoalveolarcarcinoma.Diffusealveolarshadowingintherightlowerlobeofa58‐yr-oldmalepresentingasanunresolvingpneumonia.Airbronchograms(blackarrows)andlowattenuationlucencies(openarrow)inapical“consolidation”,laterconfirmedasbronchoalveolarcarcinoma.AdenosquamouscarcinomaAdenosquamouscarcinomarepresents2%ofalllungcancers.Thiscelltypeistypicallyidentifyasasolitary,peripheralnodule.Overone-halfare1–3cminsizeandcavitationisseenin13%.Evidenceofparenchymalscarsorfibrosisinornexttothetumourisseenin50%.SquamouscellcarcinomaSquamouscellcarcinomarepresents30%ofalllungcancers.Thesetumoursaremoreoftencentrallylocatedwithinthelungandmaygrowmuchlargerthan4cmindiameter.Cavitationisseeninupto82%.Theycommonlycausesegmentalorlobarlungcollapseduetotheircentrallocationandrelativefrequency.

A65-yr-oldmanwithsquamouscellcarcinoma.(A)Lungwindowofinitialscreeninglow-doseCT(5-mmcollimation)scanobtainedatlevelofbronchusintermediusshows5-mm-sizednodule(arrow)inbottomofanteriorsegmentofrightupperlobe.(B)RepeatCTscanobtainedatsameleveltoand6monthsafterAshowsintervalincreaseinnodulesize(arrow).Rightupperlobectomydisclosedsquamouscellcarcinoma.

A50‐yr-oldfemalewithirregularcavitatingsquamouscellcarcinomaintherightupperlobe(arrows).ScurveofGoldenThetranseversefissureis"S"shaped.Theproximalportionofthefissureisconvexbecausethetumormasspreventsthefissurefrommovingtowardshilum.ThelungofsuperiorsulcustumorThelungofsuperiorsulcustumorInspiratoryfilmwithasymmetricalvascularity.b)Expiratoryfilmconfirmingairtrappingduetocarcinoid

tumourintheleftmainbronchus.

SmallcelllungcancerSmallcelllungcancer(SCLC)represents18%ofalllungcancers.SCLCoftenpresentwithbulkyhilaandmediastinallymphnodemasses.Anon-contiguousparenchymalmasscanbeidentifiedinupto41%atCTthatveryrarelycavitates.Theyformthemalignantendofaspectrumofneuroendocrinelungcarcinomaswithtypicalcarcinoidtumoursbeingatthemorebenignend.AmassinoradjacenttothehilumischaracteristicofSCLCandthetumourmaywellshowmediastinalinvasion.CarcinoidtumourCarcinoidtumourrepresents1%ofalllungcancers.Atypicalcarcinoidtumourstendtobelarger(typicallyw2.5cmatCT)withtypicalcarcinoidtumoursbeingmoreoftenassociatedwithendobronchialgrowthandobstructivepneumonia.Carcinoidstendtobecentrallyratherthanperipherallylocatedandcalcificationisseenin26–33%.The5-yrsurvivalfortypicalcarcinoidsis95%against57–66%foratypicalcarcinoids.

A55‐yr-olddyspnoeicfemale.Chestradiographdemonstratingwidenedmediastinumparticularlyontherightwithreducedvascularityoftherightlung.Contrastenhancedcomputedtomographyshowingcentralmediastinalmassinvadingtherightpulmonaryartery.Smallcellcarcinomawasconfirmedonpercutaneousbiopsy.

LargecellcarcinomaLargecellcarcinomarepresents9%ofalllungcancers.Largeorgiantcellcarcinomaisapoorlydifferentiatednonsmallcellcarcinoma(NSCLC)andisdiagnosedhistologicallyafterexclusionofadenocarcinomatousorsquamousdifferentiation.Itmaygrowextremelyrapidlytoalargesizebutmetastasizesearlytothemediastinumandbrain.Itshouldbenotedthatthereseemstobeachangeoccurringintheprevalenceofthedescribedhistologicalsubtypes.Twolargerecenttrialshavereportedprevalencesforadenocarcinomaof78%and58%whilstsquamouscellcarcinomasaccountedforonly4%and11%respectively.

Middle-aged-femalewitha)righthilarmass(arrow)andb)equivocalprecarinallymphnode(arrow).c)Positronemissiontomography(PET)scanshowsincreaseduptakeinmediastinalnodes(arrows)andsmallperipheralnodule(openarrow).Biopsyofhilarmassconfirmednon-smallcelllungcancer.

Computedtomographyscanofenhancingcerebralmetastasiswithmarkedoedemaandmasseffect.Coronalreformatfrommultislicecomputedtomography(CT)demonstratingmediastinallymphnodes(arrow)andanecrotictumourmasswithinthelung.b)Three-dimensional-reconstructionofalungtumourwithpleuraltag(arrow).c)ThinslicereconstructionintheaxialplanefromspiralCTdatapermitsthecorrectidentificationofaninhaledfishbone(arrow),inadifferentpatient,presumedtobeatumouratbronchoscopy.

Necroticmediastinallymphnodeswithirregularenhancingrims(arrows).

Increasedretrocardiacdensityduetoleftlowerlobecollapsewithinferomedialdisplacementofthehilum.a)Mediastinalmassnarrowingleftlowerlobebronchusandinvadingleftatrium.b)Distalfluid-filledbronchi(arrows)areseeninthecollapsedlowerlobeduetotheproximaltumour.Collapseoftheleftlungwithmediastinalshiftandarightmiddlezonenodule(arrow).b)Perihilarlowattenuationadenocarcinoma(arrows)withdistalenhancingcollapsedlunginsamepatient.CentralmasswithGolden“S”signofproximaltumour(arrows)anddistalcollapse.BowingSignInLULatelectasisorfollowingresection,theobliquefissurebowsforwardsinthelateralview.Bowingsignreferstothisfeature.(A)Forwardmovementofleftobliquefissure(C)AtelectaticLUL(B)HerniatedlungfromrightNotehazinessofleftupperlungfieldwithobliteraionofleftheartmargin.Noteforwardmovementofleftobliquefissreinthelateralview.

Coronalmagneticresonanceimagingshowinganadenocarcinomainayoungmaleinfiltratingtheaortopulmonarywindow.Thereislossofthefatplaneagainsttheaorta(arrows)andinvasionofthemainpulmonaryartery(arrowhead).

T1‐weightedimagesdemonstratingsuperiorabilityofmagneticresonanceimagingindemonstratinglossoffatplane(arrow)ina)axialandb)sagittalplanes.

Aviduptakeof18F‐2‐deoxy‐d‐glucoseinleftapicaltumour(arrow).Spiculatedmasstypicalofacarcinoma..a)Riberosion(largearrow)duetoperipheraltumour(smallarrows)suggestingatleastT3disease.b)Correspondingcomputedtomographyshowingmasserodingribandvertebralbody(arrows)confirmingT4statusandinoperability.

Largecentralmass(arrows)narrowingleftmainbronchusandencasingleftpulmonaryartery,indicatingT4status.Apleuraleffusionisnoted.Frankchestwallinvasionbylargeperipheraltumour.a)Computedtomographyscansuggestinginfiltrationofpleuralfat(arrows).b)Lackofmovementrelativetochestwall(arrows)confirmsinvasion.CoronalT1‐weightedmagneticresonanceimagingshowingsubtlePancoasttumour(openarrow)withextensionintothesuperiorsulcusanderosionoftheadjacentvertebralbody(arrow).

Massiveleftadrenal(openarrow)andhepaticmetastases(arrows).M1disease,stageIV.Vertebralbodymetastasis.

Characteristicseptalnodularthickeningonhigh-resolutionscanstypicaloflymphangitiscarcinomatosa.

Versatilityoftransthoracicneedlebiopsywithneedletipina)mediastinalmass(notesafeapproach)andb)peripheralsolitarynodule.a)Lowattenuationadrenalmass(arrows)withnormalrightadrenal(openarrow)whichatbiopsy,b)confirmedmetastaticdeposits.结核球厚壁空洞肺脓肿厚壁空洞肺鳞癌厚壁空洞Thesmallmilletseedsizedgranulomasinthislungaretypicalformiliarytuberculosis.男性,36岁,因被人以拳头砸鼻骨骨折住院,常规胸透发现双肺病变,随作CT检查.胸部无不适,无咳嗽,职业是出租司机.

穿刺活检结果：肺结核Atuberculomatypicallyappearsasafairlydiscretenoduleormassinwhichrepeatedextensionsofinfectionhavecreatedacoreofcaseousnecrosissurroundedbyamantleofepithelioidcellsandcollagenwithperipheralroundcellinfiltration.Mosttuberculomasare＜3cmindiameter,althoughlesion