孤立性肺結(jié)節(jié)的診斷現(xiàn)狀

（優(yōu)選）孤立性(Xing)肺結(jié)節(jié)的診斷現(xiàn)狀第一頁，共九十六頁。概(Gai)況所有胸片0.09%-0.20％150，000/年（預(yù)計(jì)）病因：肉芽腫性疾病、肺癌、錯構(gòu)瘤

惡性結(jié)節(jié)：10－70％占手術(shù)切除肺結(jié)節(jié)的60-80%，IA期肺癌術(shù)后5年生存率61-75％

良性結(jié)節(jié)：感染性肉芽腫80％錯構(gòu)瘤10％Chest2003；123：89-96第二頁，共九十六頁。病(Bing)因第三頁，共九十六頁。Figure1a.

Ribfractureina50-year-oldwomanwithmultiplemyeloma.(a)Close-upposteroanteriorradiographoftherightupperlungshowsapoorlymarginatednodularareaofincreasedopacityoverlyingtheanterioraspectoftherightsecondrib(arrow).(b)CTscanshowsahealedfractureoftherightsecondrib(arrow).Notethelyticlesionsinthevertebralbodysecondarytomultiplemyeloma.第四頁，共九十六頁。Figure2a.

Pseudonoduleina50-year-oldman.(a)Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednodularareaofincreasedopacityprojectingoverthelung(arrow).Notetheadjacentelectrocardiographicleadattachmentpad(arrowhead).Onafollow-upradiographobtainedafterremovaloftheattachmentpad(notshown),nonodulewasobserved.(b)Frontandbackviewsoftheelectrocardiographicleadattachmentpadshowaneccentricallylocatedsilvernitratepad,whichexplainsthecontiguousnodularareaofincreasedopacityonthechestradiograph.第五頁，共九十六頁。Figure3a.

Boneislandina61-year-oldmanwithmelanoma.(a)Close-upposteroanteriorradiographoftheupperchestshowsafocalareaofincreasedopacityoverlyingtherightseventhribposteriorly(arrow).(b)Fluoroscopicimagesshowawell-marginatedintraosseouslesion(arrow).Thisfindingisconsistentwithaboneislandandobviatedfurtherinvestigation.第六頁，共九十六頁。Figure4a.

Osteophyteoftheleftfirstribina60-year-oldwoman.(a)Posteroanteriorchestradiographshowsapoorlydefinednodularareaofincreasedopacityoverlyingtheanterioraspectoftheleftfirstrib(arrow).(b)Posteroanteriorchestradiographobtained2yearsearliershowsthatintervalgrowthhasoccurred(cfa).Thisintervalgrowthraisedsuspicionformalignancy.(c)ContiguouschestCTscans(imageonrightobtainedatalowerlevel)revealthattheareaofincreasedopacityisalargeosteophyteofthefirstrib.Hadfluoroscopybeenperformed,costlyCTcouldhavebeenavoided.第七頁，共九十六頁。Figure5a.

Cutaneousnodulesina51-year-oldmanwithneurofibromatosisandprostaticadenocarcinoma.(a)Posteroanteriorradiographshowsnumerouswell-marginatednodularareasofincreasedopacityprojectingovertheloweraspectofthethoraxandapoorlymarginatednoduleoverlyingtheupperaspectofthelefthemithorax(arrow).Becausethelocationoftheuppernodulewasuncertain,CTwasperformed.(b)CTscanhelpsconfirmtheintraparenchymallocationofthenoduleintheleftupperlobe.(c)CTscandemonstratesmultiplecutaneousnodules.第八頁，共九十六頁。Figure6a.

Segmentalbronchialatresiaina17-year-oldgirl.(a)Close-upposteroanteriorradiographoftherightlowerlungshowsanodularareaofincreasedopacityinthelowerlobe(arrow).(b)ChestCTscans(imageonleftobtainedatalowerlevel)showabranchingtubularareaofincreasedattenuationintherightlowerlobeaswellaspulmonaryparenchymawithlowerthanexpectedattenuation.Thesefindingsarecharacteristicofsegmentalbronchialatresiaandobviatedfurtherwork-up.第九頁，共九十六頁。Figure7a.

Multiplearteriovenousmalformationsina23-year-oldwomanwithhereditaryhemorrhagictelangiectasia.ContiguouschestCTscansrevealmultiplesmallnodularareasofincreasedattenuationbilaterallywithenlargedfeedinganddrainingvessels,findingsthatarediagnosticforarteriovenousmalformations.Achestradiographobtainedearlier(notshown)demonstratedapossiblesmallsolitarypulmonarynoduleintherightlowerlobe.第十頁，共九十六頁。第十一頁，共九十六頁。Figure2a:

(a)Chestradiographshowsanincidentalsmallnodule(arrow)attheleftcostophrenicangle.(b)Thin-sectionCTscanshowscentralfatattenuation(–43HU)inthenodule.Hamartomawasdiagnosed.第十二頁，共九十六頁。Figure4:CTscanina90-year-oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresentacongestedintrapulmonarylymphnode(arrow).Follow-upCTwasnotperformedbecauseofthepatient'sadvancedage.第十三頁，共九十六頁。胸(Xiong)部CT檢測情況病灶敏感性大小≤５mm74％＞5mm82％性質(zhì)毛玻璃樣65％實(shí)性83％部位外周80%中央61%Radiology2003;228:70-75第十四頁，共九十六頁。第十五頁，共九十六頁。SPN惡性危險(xiǎn)因(Yin)素第十六頁，共九十六頁。第十七頁，共九十六頁。第十八頁，共九十六頁。SPN

大(Da)小常規(guī)胸片僅能辨別直徑9mm以上結(jié)節(jié)80％良性結(jié)節(jié)直徑小于2cm42％惡性結(jié)節(jié)直徑小于2cm，15％惡性結(jié)節(jié)直徑小于1cm,直徑8mm左右結(jié)節(jié)經(jīng)隨訪惡性發(fā)生率10-20%,直徑<4mm結(jié)節(jié)惡性發(fā)生率<1%非鈣化直徑小于1cm結(jié)節(jié)，42-92%為良性Radiology2006;239:34-49.Radiographics.2000;20:43-58.Radiology2005;237:395-400.第十九頁，共九十六頁。SPN部(Bu)位良性結(jié)節(jié)分布無規(guī)律性肺癌：右肺/左肺1.5，上葉占70％IPF患者合并肺癌好發(fā)于下葉外周或發(fā)生纖維化部位50％腺癌位于外周，鱗癌多為中央型Radiology2006;239:34-49.第二十頁，共九十六頁。TransverseCTscanina75-year-oldmanwithidiopathicpulmonaryfibrosisshowsasolidleftlowerlobenodule(arrow).FNABofthenodulerevealedsquamouscellcarcinoma.第二十一頁，共九十六頁。SPN邊(Bian)緣光滑：21％惡性結(jié)節(jié)邊界清，多見于轉(zhuǎn)移瘤分葉：25％良性結(jié)節(jié)有分葉，惡性組織生長非均質(zhì)性不規(guī)整：傾向于惡性，可見于肉芽腫性疾病、類脂性肺炎等毛刺：第二十二頁，共九十六頁。Figure8a.

LungnodulecausedbyDirofilaria(canineheartworm)inanasymptomatic70-year-oldman.(a)Close-upCTscanoftherightlungshowsaperipheral,smoothlymarginated,noncalcifiedlungnodule.(b)Photographofaspecimenobtainedwithwedgeresectionshowsawell-circumscribed,2-cmnodulewithyellowareasofgeographicnecrosis.(c)High-powerphotomicrograph(originalmagnification,x175;hematoxylin-eosinstain)showsintravascularDirofilaria.Mostinfectionsmanifestaslungnodulesfromembolicinfarctioncausedbyintravascularworms.光(Guang)滑第二十三頁，共九十六頁。Figure9.

Solitarymetastasisfrombladdercancerina45-year-oldwoman.ChestCTscanshowsasmoothlymarginated,1-cmperipheralnodule.Metastaticdiseasewasconfirmedatresection.Solitarymetastasesaccountfor3%-5%ofallresectedsolitarypulmonarynodules.第二十四頁，共九十六頁。分(Fen)葉Figure10.

Non-smallcelllungcancerina63-year-oldwoman.Close-upchestCTscanoftherightlungshowsalobulatedandspiculatednoduleinthelowerlobe.第二十五頁，共九十六頁。Figure11a.

Arteriovenousmalformationina34-year-oldmanwithhereditaryhemorrhagictelangiectasia.(a)Close-upposteroanteriorradiographoftherightlungshowsalobulated,well-marginatednoduleinthelowerlobe(arrows).(b)ChestCTscandemonstratesafeedingartery(arrow)andanenlargeddrainingvein(arrowhead).(c)CTscanshowsthenidusofthemalformation.(d)Pulmonaryangiogramhelpsconfirmarteriovenousmalformation.Notetheearlydrainingvein(arrows).第二十六頁，共九十六頁。Figure12.

Intralobarsequestrationina14-year-oldboy.ChestCTscanshowsalobulated,well-marginatednodulewithhomogeneousattenuationintherightlowerlobe.Intrapulmonarysequestrationwasconfirmedatresection.第二十七頁，共九十六頁。邊緣不規(guī)整或細(xì)毛(Mao)刺Figure13.

Bronchioloalveolarcellcarcinomaina65-year-oldman.ChestCTscanshowsanirregularnoduleabuttingthemajorfissure.Notetheindentationoftheadjacentportionofthemajorfissureowingtodesmoplasticreactionaroundthetumor.Figure14.

Non-smallcelllungcancerina61-year-oldwoman.Close-upchestCTscanoftherightlungshowsaspiculatednodulewitheccentriccavitationintheupperlobe.第二十八頁，共九十六頁。SPN內(nèi)部特(Te)征鈣化脂肪密度結(jié)節(jié)衰減空洞空泡征支氣管充氣征第二十九頁，共九十六頁。鈣(Gai)化55％良性結(jié)節(jié)有鈣化結(jié)節(jié)直徑小于3cm，有下列鈣化形式之一考慮良性：中心性，分層，彌漫性，爆米花樣，超過結(jié)節(jié)面積10％13％肺癌有不同程度的鈣化－偏心樣鈣化類癌、轉(zhuǎn)移性骨肉瘤、軟骨肉瘤、結(jié)腸癌、卵巢癌也可表現(xiàn)為良性鈣化第三十頁，共九十六頁。Figure21.

Granulomainanasymptomatic64-year-oldman.Close-upchestCTscanoftheleftlungshowsasoft-tissuenodulewithcentralcalcificationintheupperlobe.Notetheeccentriccavitationwithinthenodule.Figure23.

Pulmonarychondrohamartomaina40-year-oldman.Close-upchestCTscanoftherightlungshowsalobulatednodulewithcentralpopcornlikecalcificationintheupperlobe.第三十一頁，共九十六頁。Figure22a.

Histoplasmomainanasymptomatic50-year-oldman.(a)Close-uptomogramoftheleftlungdemonstratesasmooth,well-marginatednodule.(b)Photographofaresectedspecimenhelpsconfirmcentralcalcificationandlaminatedfibroustissue.第三十二頁，共九十六頁。Figure28a.

Granulomatousdiseaseina48-year-oldwoman.(a)ChestCTscan(10-mmcollimation)showsanodulewithperipheralcalcificationandacalcifiedrighthilarnode.(b)Thin-sectionCTscan(3-mmcollimation)betterdemonstratesthediffusesolidcalcificationinthenodule,afindingthatistypicalofabenigncause第三十三頁，共九十六頁。Figure8:TransverseCTscanshowsa1-cm-diameterleftlowerlobenodulewithcentralniduscalcification.Thisfindingisindicativeofbenigndisease.第三十四頁，共九十六頁。Figure9a:

(a)Chestradiographshowsarightupperlobenodulewithcentralcalcification.Themarginsareirregular.(b)CTscanshowsarightupperlobenodulewithirregularmarginsthatrepresentspulmonarycarcinoma(blackarrow).Thecalcificationseenontheradiographiscausedbyacalcifiedgranulomaanteriortothetumor(whitearrow).第三十五頁，共九十六頁。Figure10:CTscaninan80-year-oldmanshowsa2.2-cm-diameternoduleintheleftupperlobewitheccentriccalcification.FNABofthenodulerevealedadenocarcinoma.Figure11:CTscanshowseccentricdensecalcificationinarightlowerlobecarcinoidtumor第三十六頁，共九十六頁。Figure12:CTscanshowscalcifiedrightlowerlobenodulethatresemblesabenigngranuloma(arrow).Thepatienthadahistoryofosteosarcoma.Openlungbiopsyrevealedmetastaticdisease.第三十七頁，共九十六頁。Figure24.

Typicalpulmonarycarcinoidtumorina68-year-oldwoman.ChestCTscanshowsalobulatedlesionwithscatteredpunctatecalcificationsintheleftlowerlobe.第三十八頁，共九十六頁。Figure25a.

Non-smallcelllungcancerina45-year-oldwoman.(a)Close-upchestradiographoftherightlungshowsalobulated,sharplymarginatednoduleintheupperlobe.Notethepresenceofemphysemaandupperlobebullae.(b)Close-upchestCTscanoftherightlungrevealsamorphouscalcificationinthenodule,apatternthatistypicalofmalignancy.Adenocarcinomawasconfirmedatresection.第三十九頁，共九十六頁。Figure26.

Lungcancerina72-year-oldman.Close-upchestCTscanoftherightlungshowsalobularlesionwithperipheralpunctatecalcificationintheupperlobe,afindingthatisconsistentwith"engulfed"granuloma.Unlikethatincalcifiedgranulomas,calcificationinengulfedgranulomaistypicallyperipheralandconstitutesonlyasmallpartofthenodule.第四十頁，共九十六頁。Figure27a.

Metastaticosteosarcomaina21-year-oldman.(a)Close-upchestCTscanoftheleftlungshowsasmall,high-attenuationnoduleinthelowerlobe(arrow).Thisfindingwassuggestiveofabenigncause.(b)ChestCTscanobtained8monthslaterrevealsintervalgrowthofthenodule,whichhashighattenuationandalobulatedcontour.Resectionrevealedmetastaticosteosarcoma.第四十一頁，共九十六頁。脂(Zhi)肪密度良性：錯構(gòu)瘤、脂肪瘤惡性：脂肉瘤、腎透明細(xì)胞癌第四十二頁，共九十六頁。Figure19a.

Hamartomainanasymptomaticman.(a)ChestCTscanshowsaheterogeneous,sharplymarginatedlesionwithsmallfocalareasofcalcificationandfat.Thesefindingsaretypicalfeaturesofhamartoma.(b)Photographofaresectedspecimendemonstratesayellowish,glistening,lobularcutsurface,afindingthatisconsistentwithfat.(c)Photomicrograph(originalmagnification,x100;hematoxylin-eosinstain)helpsconfirmthepresenceofadiposetissue(arrow)andshowsepithelialtissuecontaininganislandofbasophiliccartilage(arrowhead).Thismixtureofepithelialandmesenchymaltissueisdiagnosticforhamartoma.第四十三頁，共九十六頁。Figure20a.

Pulmonaryhamartomaina74-year-oldwoman.(a)ChestCTscanobtainedwith10-mmcollimationdemonstratesanodule(arrow),butitsinternalmorphologicfeaturesarepoorlyvisualized.(b)Thin-sectionCTscanobtainedwith1-mmcollimationbetterdemonstratesapunctateareaoffatwithinthenodule(arrow),afindingthatisdiagnosticforhamartoma.第四十四頁，共九十六頁。結(jié)節(jié)(Jie)衰減非實(shí)性（毛玻璃樣）：34％為惡性，直徑大于1.5cm圓形惡性風(fēng)險(xiǎn)度增加（多見于BAC、腺癌有BAC特征）良性：炎癥性病變，癌前病變（不典型腺瘤樣增生，支氣管肺泡過度增生）部分實(shí)性：40-50%直徑小于1.5cm結(jié)節(jié)為惡性，實(shí)性成分位于中央?yún)^(qū)提示侵襲性腺癌實(shí)性：15％直徑小于1cm病灶為惡性，轉(zhuǎn)移性病灶多為實(shí)性第四十五頁，共九十六頁。Figure14:CTscaninan81-year-oldmanshowsa2.8-cmirregular,partlysolidleftupperlobenodulewithpleuraltags.FNABrevealedbronchioloalveolarcellcarcinoma.Figure13:CTscanina64-year-oldmanshowsanoval2.1-cmleftlowerlobenonsolidnodule(arrow).FNABrevealedadenocarcinoma.第四十六頁，共九十六頁?？?Kong)洞(>5mm)良性空洞：壁光滑、薄(<4mm)惡性空洞：偏心、壁不規(guī)整、厚(>16mm)15%肺癌有空洞（病灶直徑>3cm）第四十七頁，共九十六頁。Figure16.

Aspergillusinfectionina48-year-oldmanwithleukemia.Close-upchestCTscanoftherightlungshowsathin-walledcavitarynodule.Figure17.

Squamouscelllungcancerina60-year-oldwoman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednoduleinthelowerlobe.Notetheeccentriccavitationandthickwalls.第四十八頁，共九十六頁。Figure18:CTscaninan83-year-oldmanshowsa2.3-cmleftupperlobecavitarynodule.Thewallisvariableandthecavitywallisasthickas8mm.FNABrevealedsquamouscellcarcinoma.Figure19:CTscaninan80-year-oldmanshowsarightupperlobe2.9-cmcavitarynodulewithasmooth,uniform2.5-mm-thickcavitywall.FNABrevealednon–smallcelllungcancer.第四十九頁，共九十六頁。Figure18.

Bullettrackfromagunshotwoundina20-year-oldman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginated,thick-wallednodulewitheccentriclucencyinthemidlung.Notethebulletfragmentsoverlyingtherightlung.Thesefindingsareconsistentwithparenchymalhematomaandabullettrack.第五十頁，共九十六頁?？张?Pao)征：空泡征為腫瘤內(nèi)小的低密度影，多為2～3mm大小，1個或多個，CT掃描僅限于1～2個層面見到?？张菡魇俏撮]塞的小支氣管或肺泡，主要原因同支氣管空氣征一樣，為癌細(xì)胞呈伏壁生長，部分肺泡腔和細(xì)支氣管未被腫瘤組織填充，腫瘤內(nèi)的纖維組織或瘢痕組織的牽拉而擴(kuò)張。多見于BAC或腺癌第五十一頁，共九十六頁。支氣管充(Chong)氣征是指結(jié)節(jié)內(nèi)見到充氣的支氣管，CT表現(xiàn)為氣體密度小管影。此征多見于中高分化的腺癌，癌細(xì)胞沿著支氣管呈伏壁生長，肺的支架結(jié)構(gòu)未被破壞，腫瘤內(nèi)的支氣管結(jié)構(gòu)仍保存。有此征象的腫瘤與無此征象的腫瘤相比，具有相對低度惡性的生物學(xué)行為。在惡性SPN的發(fā)生率為26．9％～65．0％而在良性SPN，其發(fā)生率僅為0．0％～5．9％

第五十二頁，共九十六頁。SPN與支(Zhi)氣管的關(guān)系I型：支氣管被SPN截?cái)郔I型：支氣管進(jìn)入SPN呈錐狀中斷Ⅲ型：支氣管在SPN內(nèi)呈長段開放狀，并可進(jìn)一步分叉Ⅳ型：支氣管緊貼SPN邊緣走行，管腔形態(tài)正常V型：支氣管緊貼SPN邊緣走行，管腔受壓變扁ClinicalRadiology(2004)59,1121–1127第五十三頁，共九十六頁。第五十四頁，共九十六頁。第五十五頁，共九十六頁。第五十六頁，共九十六頁。第五十七頁，共九十六頁。第五十八頁，共九十六頁。第五十九頁，共九十六頁。惡性結(jié)節(jié)最常見的腫瘤一支氣管關(guān)系是I型，其次為Ⅳ型，V型最少見；良性結(jié)節(jié)最常見的是V型，其次為I型，未見到Ⅱ型。就腫瘤一支氣管關(guān)系類型而言，I型惡性SPN多于良性SPN，后者主要見于結(jié)核球；Ⅱ型僅見于惡性SPN；Ⅲ型可見于惡性和良性SPN，但前者的支氣管形態(tài)僵硬，管腔保持通暢甚或輕度擴(kuò)張；后者支氣管形態(tài)柔軟，走向自然，管腔擴(kuò)張度不如惡性腫瘤，并常見支氣管有多個樹枝狀分又及支氣管呈斷續(xù)狀表現(xiàn)；IV型以惡性SPN占絕大(Da)多數(shù)V型則以良性SPN多見。第六十頁，共九十六頁。SPN一支氣管關(guān)系(Xi)類型的病理基礎(chǔ)膨脹性生長：瘤細(xì)胞增殖、堆積，呈實(shí)性壓迫、推移鄰近肺組織，由于腫瘤為支氣管源性，故導(dǎo)致支氣管在腫瘤邊緣截?cái)唷７谛陨L：以肺結(jié)構(gòu)為支架，瘤細(xì)胞沿肺泡壁和肺泡隔爬行，經(jīng)肺泡孔擴(kuò)展，同時可經(jīng)淋巴道、小氣道或以直接浸潤的方式從1個肺小葉擴(kuò)展到另1個肺小葉，而支氣管仍保持通暢，形成支氣管充氣征。第六十一頁，共九十六頁。支氣管管壁由外向內(nèi)的腫瘤浸潤、管壁產(chǎn)生的纖維性增殖性反應(yīng)使支氣管管壁增厚、僵硬，加上瘤內(nèi)成纖維化反應(yīng)的牽拉，使瘤內(nèi)的支氣管不僅未被腫瘤壓扁，反而保持高度的通暢，甚至有所擴(kuò)張，形成惡性腫瘤的含氣支氣管征特有的表現(xiàn)。良性結(jié)節(jié)邊緣的支氣管未受腫瘤侵犯和成纖維化反應(yīng)的影響，管壁仍很柔軟，易受膨脹性生長的結(jié)節(jié)壓迫，導(dǎo)致管腔變扁甚至閉塞。結(jié)核球引起支氣管截?cái)嗍怯捎诤笳邊⑴c形成包膜。炎性假瘤的含氣支氣管征由肺實(shí)質(zhì)的滲出、實(shí)變、機(jī)(Ji)化襯托引起，支氣管形態(tài)自然，常見樹枝狀分叉，管腔內(nèi)可有分泌物、出血或血栓，使支氣管表現(xiàn)為斷續(xù)狀。第六十二頁，共九十六頁。SPN血管(Guan)特征惡性結(jié)節(jié)增強(qiáng)超過良性結(jié)節(jié)CT增強(qiáng)值低于15HU傾向于良性CT凈增值超過25HU，清除值5-31HU傾向惡性第六十三頁，共九十六頁。AJR2007;188:57-68第六十四頁，共九十六頁。Graphoffourdifferenttypesoftime-attenuationcurveofnodulehemodynamicsinconsiderationofbothwash-inandwashoutphasesofdynamicCT.Radiology2005;237:675-683第六十五頁，共九十六頁。PatternsofNoduleEnhancementatEarlyandDelayedEnhancementCT

第六十六頁，共九十六頁。PatternsofNoduleEnhancementaccordingtoHistologicDiagnosis第六十七頁，共九十六頁。Fig.4A

—Metastaticadenocarcinomain57-year-oldmanwithrectalcancershowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTandpositiveuptakeonintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows9-mmnodule(arrow)inleftupperlobe.第六十八頁，共九十六頁。Fig.3A

—Adenocarcinomain67-year-oldmanshowsnetenhancementof25Handwashoutof5-31HatdynamichelicalCTandpositiveuptakeatintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows16-mmnodule(arrow)inleftupperlobehaslobulatedandspiculatedmargin.第六十九頁，共九十六頁。Figure3a.CTscansoftuberculomawithtypeIIenhancement(<25HUwash-in)ina58-year-oldman.(a)Transversethin-section(2.5-mmcollimation)scanobtainedwithlungwindowattheleveloftherightmainbronchusshows21-mmnodulewithlobulatedandspiculatedmarginintherightupperlobe.(b)Serialimageswithdynamicenhancementcurveforthenodule.Peakenhancementis49HU;netenhancement,3HU;andabsolutelossofenhancement(washout),1HU.第七十頁，共九十六頁。Figure4a.CTscansoforganizingpneumonia(focalpneumoniawithoutspecificmicroorganism)withtypeIIIenhancement(25HUwash-inwithpersistentenhancement)ina58-year-oldwoman.(a)Transversethin-section(2.5-mmcollimation)scanobtainedwithlungwindowatthelevelofthehepaticdomeshows14-mmnodule(arrow)inrightlowerlobe.Bronchiectasisisalsoseeninbothlowerlobes.(b)Serialimageswithdynamicenhancementcurveforthenodule.Peakenhancementis118HU;netenhancement,69HU.Thisnoduleshowedpersistentenhancementwithoutabsolutelossofenhancement.第七十一頁，共九十六頁。Figure5.CTscansofleiomyomawithtypeIVenhancement(25HUwash-in,>31HUwashout)ina45-year-oldwoman.Serialimageswithdynamicenhancementcurvefortheleftlowerlobenoduleshowpeakenhancementis165HU;netenhancement,133HU;absolutelossofenhancement(washout),90HU;andtimetopeakenhancement,1minute.第七十二頁，共九十六頁。第七十三頁，共九十六頁。Figure1a.

(a)Transverse,nonenhancedspiralCTimage(3-mmcollimation)througharelativelyhomogeneous15-mmrightupperlobelungadenocarcinomarecurrenceina71-year-oldwoman.Notethemanuallyplacedregionofinterest(1)onanodule.Theregionofinterestispositionedcentrally,anditsshapeapproximatesthatofthenoduleonthecross-sectionalimage.Itsnetenhancementvaluewas14HU.(b)Photomicrographofthisadenocarcinomashowsanappearanceconsistentwithlymphangiticmetastasis.Notethecentralzoneofnecrosis(arrows).Thereislittlevascularstroma,whichmayhavebeenafactorinitsrelativelylowenhancementvalue.(AntibodytofactorVIII-associatedantigen;originalmagnification,x50.)第七十四頁，共九十六頁。周圍型肺癌的血供源于支氣管動脈，腫瘤間質(zhì)內(nèi)血管豐富，且分化不成熟，血管分布紊亂，基底膜不完整，管壁通透性高，有利于大分子造影劑滲入細(xì)胞間隙，部分肺癌微血管擴(kuò)張，利于造影劑在血管內(nèi)停留。炎性結(jié)節(jié)形成過程中，肺動脈水平上發(fā)生彌漫性血栓，血供直接源于支氣管動脈，造影劑通過相對較直的、結(jié)構(gòu)正常的血管進(jìn)入間質(zhì)，進(jìn)入血管周圍間質(zhì)的造影劑因淋巴管的通暢加快了引(Yin)流。部分惡性及良性病灶持續(xù)強(qiáng)化無清除可能與局部組織纖維化的程度數(shù)量相關(guān)。病理學(xué)基礎(chǔ)：第七十五頁，共九十六頁。SPN生長(Chang)速度評價大部分惡性結(jié)節(jié)倍增時間30-400天2年隨訪病灶穩(wěn)定，倍增時間至少730天傾向良性疾病倍增時間小于7天，超過465天傾向良性直徑小于1cm病灶較難評價Radiographics.2000;20:59-66第七十六頁，共九十六頁。計(jì)算公(Gong)式

Td=Ti·log2/3·log(Di/Do)

Ti=intervaltimeDi=initialdiameterDo=finaldiameter第七十七頁，共九十六頁。Figure1.

Effectofinitialnodulesizeonperceptionofgrowth.Schematicillustratestwovolumedoublingsofa4-mmnoduleanda3-cmnodule.Becausetheeyeperceivesthearithmeticincreaseindiameterratherthanthechangeinvolume,thesmallernoduleappearstobegrowingmoreslowlythanthelargerone,eventhoughbotharedoublinginvolumeatthesamerate.第七十八頁，共九十六頁。Figure21a:

(a)CTscaninan80-year-oldmanshowsa2.5-cmrightupperlobenoduleattheposteriorsegment.(b)RepeatCTscanobtainedpriortotreatmentperformed2monthslatershowsrapidintervalenlargement.Thevolumetricdoublingtimewas26days.FNABrevealedmixedsmallcellandnon–smallcellcarcinoma.第七十九頁，共九十六頁。Bayesian

Analysis

根據(jù)臨床資料和影像學(xué)特征計(jì)算pCapCa<0.12影像學(xué)隨訪pCa0.12-0.69行CT、PET檢(Jian)查pCa0.70-0.90行活檢、手術(shù)pCa>0.90手術(shù)NEnglJMed2003Jun19;348(25):2535-42第八十頁，共九十六頁。EffectofageandsmokinghistoryonpCainanindeterminatepulmonarynodule.Close-upchestCTscanoftherightlungshowsa7-mm,smoothlymarginated,noncalcifiednoduleinthemiddlelobe.Onthebasisofdecisionanalysis,observationwouldbethemostcost-effectivemanagementstrategyina35-year-oldnonsmoker(pCa=0.01)orcurrentsmoker(pCa=0.05),andbiopsywouldbethemostcost-effectivemanagementstrategyina70-year-oldnonsmoker(pCa=0.07)orcurrentsmoker(pCa=0.50)第八十一頁，共九十六頁。其(Qi)他輔助檢查對于SPN診斷價值PET胸部低劑量螺旋CTFNABVATS第八十二頁，共九十六頁。PET直徑1-3cm實(shí)性結(jié)節(jié)，敏感性94％特異性83％SUV值超(Chao)過2.5即為陽性假陽性：局部感染，炎癥，肉芽腫性疾病假陰性：病灶直徑小于1cm，類癌，BAC第八十三頁，共九十六頁。Figure7a.

Non-smallcelllungcancerina65-year-oldman.(a)ChestCTscanshowsasmallnoduleintheleftlowerlobe.(b)AxialFDGPETscanshowsmarkedFDGaccumulationinthenodule,