No七年制临床呼吸常见病

1、Imaging Diagnosis of Rspirotary Diseasepart 2AiPing Chen1Lung 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Benign:良性harmatoma, adenoma, angioma, fibroma错构瘤，腺瘤，血管瘤，纤维瘤 m

2、alignancy:恶性 primary：lung carcinoma 肺癌，sarcoma 肉瘤Secondary：metastasis转移瘤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 to 50% of cases and is a diagnostic feature. 567primary bronchogenic carcinoma原发性支气管肺癌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) 小细胞肺癌NSCLC(non-small cell lung cncer）非小细胞肺癌s

5、quamous 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 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. 生长迅速，中央型，转移早，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 气道起源多数表现为 producing cough, hemoptysis, 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。12According to type of growth Central type:Inter-tuber 管内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17Mouse tail Irregular stenosisFilling defectCup li

11、ke 1819Mouse tail Central tumor20Filling defect21Bronchial stenosis22Central 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 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 溶骨性的破坏和病理性的骨折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平扫CT scan no contrast48CT增

17、强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绒毛膜癌, germinal 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carcin

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

24、umor纵隔肿瘤主要诊断依据：position, shape， density.83Tumor of the anterior mediastinumThymoma TeratomaIntrathoracic thyroid Malignant lymphomaBronchogenic cystNeurogenic tumors 84Mediastinal tumorAnterior 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

25、：calcification; fatMiddle mediastinal tumor中纵隔Posterior mediastinal tumor后纵隔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胸内甲状腺肿intrathoracic 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结甲伴腺瘤样增生女，62岁肿物与甲状腺相连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98Thymoma99Thymoma100Thymoma101102胸腺瘤，可疑包膜侵润 男性，47岁，查体发现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 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精原细胞瘤男，16岁，面部浮肿1月，咳嗽20天恶性生殖细胞肿瘤 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118Malignant lymphoma119Malignant lymphoma120Malignant lymphomaCT and MRI are more sensitive than radiograph. The enlarged lymph nodes or mass mostly