No七年制臨床呼吸常見病

1、Imaging Diagnosis of Rspirotary Diseasepart 2AiPing Chen1Lung neoplasm肺腫瘤The incidence of primary lung carcinoma is increasing in all over the world. Most malignent lung tumors (over 98%) are bronchiogenic carcinoma 支氣管肺癌.2Lung neoplasm肺腫瘤Benign:良性harmatoma, adenoma, angioma, fibroma錯構瘤，腺瘤，血管瘤，纖維瘤 m

2、alignancy:惡性 primary：lung carcinoma 肺癌，sarcoma 肉瘤Secondary：metastasis轉移瘤3harmatomauncommon asymptomatic; symptoms typically are present with central endobronchial lesions， include hemoptysis, recurrent pneumonia, and dyspnea.4harmatomatypically round, well-marginated peripheral masses smaller than 4

3、cm (range, 1 to 30cm).typical pattern ： popcorn calcification爆米花樣的鈣化 Calcification鈣化 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. 567primary bronchogenic carcinoma原發(fā)性支氣管肺癌most common malig

4、nancy 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. 8Lung carcinoma(cancer)SCLC(small cell lung cancer) 小細胞肺癌NSCLC(non-small cell lung cncer）非小細胞肺癌s

5、quamous cell carcinoma 鱗癌Adenocarcinoma 腺癌Large Cell Carcinoma大細胞癌compound carcinoma 混合癌bronchioloavelar carcinoma BAC細支氣管肺泡癌Lung neoplasm9Lung neoplasmSCLC(small cell lung cancer) Small cell carcinoma is a rapidly growing tumor that has the most irrefutable association with smoking. Like squamous c

6、ell 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. 生長迅速，中央型，轉移早，全身10Lung neoplasmNSCLC(non-small cell lung cncer)squmous cell carcinoma is most commonly a

7、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

8、 (“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.11bronchial carcinoma asymptomatic ， detected incidentally most patients (up to 90%) are symptom

9、atic 氣道起源多數(shù)表現(xiàn)為 producing cough, hemoptysis, dyspnea, and chest pain約33% 會出現(xiàn)胸外轉移癥狀，多見于骨骼系統(tǒng)和神經(jīng)系統(tǒng)。其他，腎上腺，肝臟，淋巴結。12According to type of growth Central type:Inter-tuber 管內Wall of tuber管壁Extra-tuber 管外Peripheral type:Mass inflammationDiffuseLung neoplasm13Central tumorDirect sign of bronchial carcinoma lu

10、ng massBronchial lumen : Bronchial stenosis，endoluminal or transmural growth14Central tumor: mass in the right low lober and right hilar enlarge,15mass in the right hilar16Central tumorlung mass in the hilumBronchial lumen支氣管改變支氣管壁增厚支氣管腔內腫塊支氣管腔狹窄/閉塞17Mouse tail Irregular stenosisFilling defectCup li

11、ke 1819Mouse tail Central tumor20Filling defect21Bronchial stenosis22Central tumorIndirect sign間接征象：支氣管阻塞所致改變阻塞性肺肺氣腫阻塞性肺炎：不易吸收，同一部位反復發(fā)作阻塞性肺不張：肺不張合并腫塊，肺不張合并轉移是其特點 23Partial or complete atelectasis ： Segments, lobes, or an entire lung are no longer aerated and undergo partial (dystelectasis) or comple

12、te collapse (atelectasis). This is manifest as patchy or homogeneous pulmonary opacification of lobar or segmental distribution.24Right upper lobe atelectasis 25Right upper lobe atelectasis26left upper lobe atelectasis27Left low lobe atelectasis28Left low lobe atelectasisBronchial stenosis29Left low

13、 lobe atelectasis30Central tumorIndirect 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 ce

14、ntral endobronchial tumor is merited.31Distal pneumonia32pneumoniamassPleural effusion33Central tumorIndirect sign of bronchial carcinoma:Intrathoracic spread of bronchial carcinoma. 34Right side Central tumor35Central tumorIndirect sign of bronchial carcinoma:Mediastinal lymph node enlargement. Med

15、iastinal widening may be the first radiographic sign of lung cancer, especially in cases of small cell carcinoma.3637Central tumorHematogenous spread of bronchial carcinoma. Osteolytic bone lesions and pathologic fractures 溶骨性的破壞和病理性的骨折signify hematogenous spread of disease.血行播散38Costal bone damage

16、39Right lung metastasis404142Central tumorMRI manifestationBronchi wall thickenBronchi wall stenosisMass in the hilumEmphysema; pneumonia; atlectasis of obstructionAffect mediastinum，enlargement of lymph node(diameter15mm)434445plain film、CT、MRICentral tumor46Plain film47CT平掃CT scan no contrast48CT增

17、強CT scan contrast49MRI505152Peripheral 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 represen

18、ting tumor spread along the lymphatics; notching of the contour; a cavitating lesion typical of squamous cell carcinoma.53Peripheral 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

19、indentation sign胸膜凹陷征 54Peripheral tumor分葉征象: 生長不均衡，周圍血管和支氣管的限制毛刺征象: 腫瘤沿血管及間質浸潤有關空洞形成: 偏心性，內壁不規(guī)則或呈結節(jié)狀55notching of the contour56notching of the contour57Cavitary.58Retraction of pleura. Spiculate margin. notching of the contour59Retraction of pleura. Spiculate margin. notching of the contour60Retrac

20、tion of pleura. Spiculate margin. notching of the contour61 Spiculate margin. notching of the contour62Spiculate margin. notching of the contour63Bone metastasis6465Bronchiolo-alveolar carcinomaIsolated mass typePneumonia typeDiffuse nodule type66Isolated mass type Bronchiolo-alveolar carcinoma 67Br

21、onchiolo-alveolar carcinomaPneumonia type686970ill-defined margin pulmonary nodule Bronchiolo-alveolar carcinoma71Bronchiolo-alveolar carcinoma72Bronchiolo-alveolar carcinoma73Lung mestastasisThe most common primary tumor site was lung, followed by large bowel, prostate, breast, uterus, and esophagu

22、s. 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絨毛膜癌, germinal tumors of the testis睪丸的生殖細胞瘤, melanoma黑色素瘤, Ewings sarcoma尤文氏肉瘤, osteosarcoma, 骨肉瘤carcinoma of the thyroid, 甲狀腺癌carcin

23、oma of the breast乳腺癌, and rhabdomyosarcoma橫紋肌肉瘤. 74Lung mestastasisHematogenous mestastasisLymphatic vessel mestastasis 75Hematogeneous mestastasis76Hematogeneous mestastasis77Hematogeneous mestastasis78Hematogeneous mestastasis79Lymphatic vessel mestastasis80Pleural carcinomatosis 8182Mediastinal t

24、umor縱隔腫瘤主要診斷依據(jù)：position, shape， density.83Tumor of the anterior mediastinumThymoma TeratomaIntrathoracic thyroid Malignant lymphomaBronchogenic cystNeurogenic tumors 84Mediastinal tumorAnterior mediastinal tumor前縱隔Intra-thoracia thyroid mass胸內甲狀腺腫: upper of mediastinumThymoma胸腺瘤: anteriorTeratoma畸胎瘤

25、：calcification; fatMiddle mediastinal tumor中縱隔Posterior mediastinal tumor后縱隔85Intrathoracic thyroidIntrathoracic 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 mediastin

26、um and displacement of the trachea to the opposite side and compression of the trachea on the side of the tumor. 86胸內甲狀腺腫intrathoracic goiter病理：多數(shù)為結節(jié)性甲狀腺腫X線表現(xiàn)前縱隔上部邊緣光滑，與頸部腫物相連氣管受腫塊推壓87Intrathoracic thyroid88Intrathoracic thyroidThe CT appearances of thyroid goiters are specific. Anatomical continuit

27、y 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.89結甲伴腺瘤樣增生女，62歲腫物與甲狀腺相連90Intrathoracic thyroidMR imaging particularly in the corona

28、l 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. 919293Thymoma胸腺瘤anterior superior mediastinum. round, lobulated or plaque-like, and produce unilate

29、ral widening of the mediastinum. Calcification or cystic degeneration may be seen in a small percentage of cases.94胸腺瘤thymoma占前縱隔腫瘤50%多見于中年人多數(shù)無癥狀，少數(shù)有壓迫或侵犯表現(xiàn)三分之一伴有重癥肌無力良性：包膜完整，無周圍浸潤惡性：包膜不完整，向周圍侵犯轉移9596ThymomaCT is the imaging method of choice for evaluating the possibility of thymic disease. Differen

30、tiation 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

31、 thymoma.97胸腺瘤X線表現(xiàn)：單側或雙側縱隔增寬突出，邊緣一般較清晰。CT表現(xiàn)：前縱隔內類圓形腫塊，惡性表現(xiàn)為包膜不完整，累及周圍組織，胸膜和肺，淋巴結增大98Thymoma99Thymoma100Thymoma101102胸腺瘤，可疑包膜侵潤 男性，47歲，查體發(fā)現(xiàn)103ThymomaThymomas have intermediate signal intensity (equal to that of skeletal muscle) in T1W1 and increased signal intensity (approaching that of fat) on T2W1.

32、 Cystic regions are areas of hemorrhage have low signal intensity on T1W1 and high signal intensity on T2W1.104胸腺瘤MRI105畸胎瘤 teratoma先天性腫瘤，屬生殖細胞瘤好發(fā)于2040歲，絕大多數(shù)屬良性病理來源于原始胚胎組織的殘留物皮樣囊腫：主要含有外胚層衍生物實質性畸胎瘤：含有內、中、外三個胚層衍生物，可為良性或惡性106畸胎瘤 teratomaX線表現(xiàn)及CT表現(xiàn)含有多種組織而密度不均鈣化和囊變是特征性表現(xiàn)囊變部分CT值近似水惡性畸胎瘤常較大，邊緣不規(guī)則107Teratoma

33、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

34、 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.108teratoma109teratoma110teratoma111112113精原細胞瘤男，16歲，面部浮腫1月，咳嗽20天惡性生殖細胞腫瘤 114Mediasti

35、nal tumorAnterior mediastinal tumor：Middle mediastinal tumor：Malignant lymphomaBronchogenic cystPosterior mediastinal tumor115Malignant lymphomaThe thorax is frequently involved in patients with Hodgkins and non-Hodgkins lymphomas. It has been estimate that lymphoma constitutes about 20% of all medi

36、astinal 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. 116惡性淋巴瘤淋巴組織惡性腫瘤發(fā)熱，周圍淋巴結增大及全身衰弱上腔靜脈阻塞綜合征縱隔淋巴結增大，常見于血管前、氣管旁、主肺動脈窗、肺門等部位117惡性淋巴瘤X線表現(xiàn)腫塊向縱隔兩側突出，氣管受壓CT表現(xiàn)縱隔內多組淋巴結增大，可融合成塊侵及鄰近結構118Malignant lymphoma119Malignant lymphoma120Malignant lymphomaCT and MRI are more sensitive than radiograph. The enlarged lymph nodes or mass mostly