No七年制臨床呼吸常見病課件

1、Imaging Diagnosis of Rspirotary Diseasepart 2AiPing Chen1Imaging Diagnosis of RspirotaLung 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The incidence Lung neoplasm肺腫瘤Be

2、nign:良性harmatoma, adenoma, angioma, fibroma錯構(gòu)瘤，腺瘤，血管瘤，纖維瘤 malignancy:惡性 primary：lung carcinoma 肺癌，sarcoma 肉瘤Secondary：metastasis轉(zhuǎn)移瘤3Lung neoplasm肺腫瘤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

4、 to 50% of cases and is a diagnostic feature. 5harmatomatypically round, well6677primary bronchogenic carcinoma原發(fā)性支氣管肺癌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) 小細胞肺癌NSCLC(non-small cell lung cncer）非小細胞肺癌squamous 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 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. 生長迅速，中央型，轉(zhuǎn)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 氣道起源多數(shù)表現(xiàn)為 producing cough, hemoptysis,

10、dyspnea, and chest pain約33% 會出現(xiàn)胸外轉(zhuǎn)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(jié)。12bronchial carcinoma asymptomatAccording to type of growth Central type:Inter-tuber 管內(nèi)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支氣管改變支氣管壁增厚支氣管腔內(nèi)腫塊支氣管腔狹窄/閉塞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(zhuǎn)移是其特點 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 溶骨性的破壞和病理性的骨折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平掃CT scan no contrast48CT平掃CT scan no contrast48CT增強CT scan contrast49CT增強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(zhì)浸潤有關(guān)空洞形成: 偏心性，內(nèi)壁不規(guī)則或呈結(jié)節(jié)狀55Peripheral tumor分葉征象: 生長不均衡，周圍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絨毛膜癌, g

28、erminal 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carcinoma of the breast乳腺癌, and rhabdomyosarcoma橫紋肌肉瘤. 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縱隔腫瘤主要診斷依據(jù)：position, shape， density.83Mediastinal tumor縱隔腫瘤主要診斷依據(jù)：8Tumor of the anterior mediastinumThymoma TeratomaIntrathoracic thyroid Malignant lymphomaBronchogenic cystNeurogenic tumors 84Tumor of the anterior mediastiMediastinal tumorAnter

31、ior mediastinal tumor前縱隔Intra-thoracia thyroid mass胸內(nèi)甲狀腺腫: upper of mediastinumThymoma胸腺瘤: anteriorTeratoma畸胎瘤：calcification; fatMiddle mediastinal tumor中縱隔Posterior mediastinal tumor后縱隔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胸內(nèi)甲狀腺腫intrathora

33、cic goiter病理：多數(shù)為結(jié)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87胸內(nèi)甲狀腺腫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結(jié)甲伴腺瘤樣增生女，62歲腫物與甲狀腺相連90結(jié)甲伴腺瘤樣增生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(zhuǎn)移95胸腺瘤thymoma占前縱隔腫瘤50%多見于中年人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線表現(xiàn)：單側(cè)或雙側(cè)縱隔增寬突出，邊緣一般較清晰。CT表現(xiàn)：前縱隔內(nèi)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(jié)增大98胸腺瘤X線表現(xiàn)：單側(cè)或雙側(cè)縱隔增寬突出，邊緣一般較清晰。98Thymoma99Thymoma99Thymoma100Thymoma100Thymoma101Thymoma101102102胸腺瘤，可疑包膜侵潤 男性，47歲，查體發(fā)現(xiàn)103胸腺瘤，可疑包膜侵潤 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(zhì)性畸胎瘤：含有內(nèi)、中、外三個胚層衍生物，可為良性或惡性106畸胎瘤 teratoma先天性腫瘤，屬生殖細胞瘤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107畸胎瘤 teratomaX線表現(xiàn)及CT表現(xiàn)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精原細胞瘤男，16歲，面部浮腫1月，咳嗽20天惡性

43、生殖細胞腫瘤 114精原細胞瘤惡性生殖細胞腫瘤 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惡性淋巴瘤淋巴組織惡性腫瘤發(fā)熱，周圍淋巴結(jié)增大及全身衰弱上腔靜脈阻塞綜合征縱隔淋巴結(jié)增大，常見于血管前、氣管旁、主肺動脈窗、肺門等部位117惡性淋巴瘤淋巴組織惡性腫瘤117惡性淋巴瘤X線表現(xiàn)腫塊向縱隔兩側(cè)突出，氣管受壓CT表現(xiàn)縱隔內(nèi)多組淋巴結(jié)增大，可融合成塊侵及鄰近結(jié)構(gòu)118惡性淋巴瘤X線表現(xiàn)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