肺毛玻璃样病变ppt参考课件

肺部GGO病理解读

及HRCT评价1GGO(ground-glassopacity,GGO)，肺毛玻璃样病变，是周围型肺癌最早期的CT表现容易被我们忽视或者被认为是正常的CT图像随着CT技术的发展及人们健康意识的增强，我们将面临越来越多这种的病人一、GGO的病理解读2这是什么？3456ab7GGO的定义GGO定义

：在高分辨率CT(HRCT)上表现为密度轻度增加,但其内的支气管血管束仍可显示的病变,纵隔窗上病灶往往不能显示或仅能显示磨玻璃样病灶中的实性成分8GGO的病理解读GGO病理：由于肺泡内气体减少、细胞数量相对增多、肺泡上皮细胞增生、肺泡间隔增厚及终末气道部分充填等因素所致的病理变化。Pathology:

Ground-glassopacitymaybecausedbypartialairspacefilling;interstitialthickeningwithinflammation,edema,fibrosis,orneoplasticproliferation;orinterstitialthickeningwithpartialairspacefilling.9a.Transverselung-windowthin-section(1.25-mm-thick)CTscanshows8-mmround,well-definedGGOnodule(arrow)inleftupperlobe.b.Photomicrographshowscolumnartumorcellsgrowingalongthickenedalveolarwalls(lepidicgrowth).ab10AAHin55-year-oldman.

a.Transverselung-windowthin-section(2.5-mm-thick)CTscanshows12-mmround,well-definedGGOnodule(arrow)inleftupperlobe.

b.showsalveolarwallthickeningandincreasednumbersofalveolarliningcellswithminimalwallthickening.ab11

GGO演变为周围型肺癌的过程

肺泡上皮不典型样增生（AAH）

原位癌（AIS）进展期肺癌12肺癌前病变演化成原位癌的病理变化过程

基底细胞增生轻度不典型增生中度不典型增生重度不典型增生原位癌

肺泡上皮不典型样增生（AAH）

原位癌（AIS）13肺腺癌病变病理衍化过程图（腺癌）

侵袭性AISAAH14二、高分辨率CT对GGO的评价15肺良好的自然对比，是CT成像的有利条件；多排螺旋CT，主要是指16排以上螺旋CT，具有高时间、高空间、高密度辨分率以及高信噪比的成像特点；任意层厚重建，能检出1mm的小病灶；高分辨率CT(HRCT)对肺内小病灶细节的显示优于常规CT，能检出0.5mm的小病灶，是评价GGO最佳的无创性方法。16肺多排螺旋CT扫描技术参数层厚(任意层厚重建）0.3-1mm重建算法高分辨率算法矩阵>512×512扫描时间<0.5sPicth<1mm曝光量（尽量低毫安）KV/mAS：120-140/50-80窗宽窗位肺窗：+700—-700Hu纵隔窗：50—300Hu靶重建FOV20-50cm17容积扫描准备各向同性成像图像处理多层、无间隔、连续的图像18薄层，小FOV，多发方位重建19第一种分型第二种分型局限性GGO的CT分型20单纯型GGO(pureGGO，pGGO):

整个病灶密度浅淡,内见血管或支气管壁,完全无实性组织成分,只能在肺窗下看到

混合型GGO(mixedGGO,mGGO):

病灶内部见部分实性组织,相应部分血管被遮盖,实性病变部分可在纵隔窗下看到第一种分型21Ⅰ:单纯磨玻璃样影Ⅱ:密度不均的磨玻璃样影

Ⅲ:中央高密度,外围淡薄模糊磨玻璃样影

Ⅳ:单纯结节影第二种分型22GGO分型和肿瘤发生及CT表现

Ⅰ型：纯磨玻璃样结节,病理改变为肿瘤细胞沿肺泡壁生长,无肺泡塌陷,肿瘤内弹性纤维轻度增生23

Ⅱ型：低密度不均匀结节,病理为肿瘤细胞沿肺泡壁生长,伴有散在肺泡塌陷,肿瘤内弹性纤维、重度增生,但其网状结构仍保存24

Ⅲ型：中心高密度伴周边磨玻璃样结节,病理为肺泡塌陷,瘤体中心弹性纤维增生,伴弹性纤维网状结构断裂,周边区肿瘤细胞伏壁生长25

Ⅳ型：均匀软组织密度结节,病理上肿瘤呈实体生长,无含气肺泡组织,肿瘤内弹性纤维增生,网状结构中断、破坏26Ⅰ型:单纯磨玻璃样阴影GGO发展成肺癌的动态演变过程Ⅱ型:密度不均的磨玻璃样阴影Ⅲ型:中央高密度,外围淡薄模糊的磨玻璃样阴影

Ⅳ型:单纯结节影27GGO发展成肺癌CT表现的四步曲pGGO：pureGGO（纯毛玻璃样病变）mGGO:

mixedGGO（混合型毛玻璃样病变）SOLIDSPN(<3cm)MASS

(>3cm，肿块，实体瘤，进展期肺癌)肺腺癌的演变过程是和CT的表现相对应的28pGGO：AAHmGGO：AISMASS:腺癌从病理学角度看肺癌的CT图像的演变过程29IllustrationoftherelationshipbetweentheNoguchihistologicclassificationofadenocarcinomaofthelung(NoguchitypesAthoughF)andcorrespondingCTappearancesoftheselesions.30Persistentnodularground-glassopacityinan80-year-oldmanwithadenocarcinoma.Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen.a.Initialthick-sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule(arrow)inthemiddlelobeoftherightlung.b.Follow-upCTimageobtained

12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent(arrow).c.Follow-upthin-sectionCTimageobtainedat

16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion(arrow).abc31BAC.Sequentialmagnified1-mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGOovera3-yearperiod.Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent,whichwasbettercharacterizedonsequentialimages.3233（一）肺恶性GGO的CT评价

34GGO和AAHAtypicaladenomatoushyperplasiaina53-year-oldwoman.a.Thin-sectionCTimageoftherightlungshowsan11-mmwell-definednodularground-glassopacitywithoutasolidcomponentinthelowerlobe.b.photomicrographshowsthickenedalveolarwallslinedbyanintermittentsinglelayerofatypicalcuboidalpneumocytes.ab35

Concurrentatypicaladenomatous

hyperplasiaandadenocarcinoma

ina71-year-oldwoman.Thin-sectionCTimageatthelevelofthecarinashowsan18-mm-diametermixednodularground-glassopacitywithasolid

componentintheupperlobeoftherightlunganda10-mmpurenodularground-glassopacity

inthelowerlobeoftheleftlung.AAHcarcinomaofthebronchioloalveolar36

MultipleAAHsina42-year-oldwoman.CTscansshowroundwell-defined,pureGGOnodules(arrow).PhotomicrographofthenoduleintheleftupperlobeshowAAH.abc37bronchioloalveolarcarcinomaina63-year-oldwoman.a.therightupperanteriorsegmentalbronchusshowsa10-mmwell-definednodularground-glassopacitywithoutasolidcomponentinthelowerlobeoftherightlung.Notethepresenceofpulmonaryvesselsinthelesion.b.Photomicrographspecimenshowsreplacementofthealveolarliningbyneoplasticcolumnarepithelium,withoutevidenceofstromalinvasion.GGO和BAC(AIS)ab38bronchioloalveolarcarcinomaina49-year-oldwoman.a.Theleveloftherightbronchusintermediusshowsa14-mmwell-definednodularground-glassopacitywithasolidcomponent(arrow)inthelowerlobeoftherightlung,abuttingthevertebralbody.b.PhotomicrographshowsBAC(AIS)ab39Adenocarcinomawithmixedacinarand

bronchioloalveolarcarcinomaina50-year-oldwoman.a.

Thin-sectionCTimageshowsa28-mmwell-definedmixedground-glassopacitylesionwithperipheralground-glassopacityintheupperlobeoftheleftlung.Themassabutsthepleura.b.

PhotomicrographofahistologicspecimenshowsBAC(AIS).ab40BACandAAH

ina63-year-oldwoman.a.lung-windowCTscanshowsa19-mmovoid,well-defined,pureGGOnoduleinthe

leftlowerlobe.Thislesionwasconfirmedas

BAC

afterbasalsegmentectomy.b.

lung-windowthin-sectionCTscanshowsa9-mmround,well-defined,pureGGOnodule(arrow)

intheleftupperlobe.

Thislesionwasconfirmed

asAAHafterwedgeresection.c.

Noduleintheleftlowerlobeshowscolumnarorcuboidalcellliningthickenedalveolarwallswithoutevidenceofstromal,vascular,orpleuralinvasion.abc41a.Transverselung-windowthin-section(1-mm-thick)CTscanshowsa22-mmirregularGGOnodulewithbubble-lucencyintheleftlowerlobe.

Thislesionwasconfirmedas

adenocarcinoma

withapredominantBACcomponentafterlobectomy.b.Transverselung-windowthin-section(1-mm)CTscanshowsa12-mmround,well-definedpureGGOnoduleintherightupperlobe.Thislesionwasconfirmedas

BAC.

AAdenocarcinomawithapredominantBACcomponentandBACina48-yearoldwoman.

ab42

65-year-old-womanwithmultiplepureground-glassopacities(PGGOs)a.MultiplesmallPGGOswerefoundinalllobesoflung.ComputedtomographicslicerevealsthreePGGOs(arrows)intherightupperlobe.Thelobe,includingthemaximalPGGO(10mmindiameter),wasremoved.b.Comprehensivehistologicexaminationofresectedspecimensdemonstratedexistenceofmanysmallerlesionsrevealing

bronchioloalveolarcarcinomaoratypicaladenomatoushyperplasia.During37monthsofpostoperativefollow-up,onlyaslightincreaseinsizeordensitywasrecognizedinsomeresidualPGGOsscatteredinalllobes.ab43Adenocarcinomaina56-year-oldman.a.Thin-sectionCTimageobtainedshowsa14-mmnodularground-glassopacitywithnosolidcomponentintheupperlobeoftherightlung.b.Photomicrographofahistologicspecimenshows

adenocarcinoma

withdensesclerosis.GGO与腺癌ab44CTscan(1-mmsection)ofmixedsubtypeadenocarcinomawithBACcomponent(NoguchitypeClesion)showsanodulewithpureGGO,demonstratingthatalthoughnonsolidnodulesarelikelyto

representAAHorBAC,aninvasivecomponentmayrarelybepresentasinthiscase.45CTscanina64-year-oldmanshowsanoval2.1-cmleftlowerlobenonsolidnodule(arrow).FNABrevealed

adenocarcinoma.46支气管充气造影征轴位示：左上肺毛玻璃阴影47分叶征冠状位48毛刺征矢状位BAC49CT:左上肺毛玻璃阴影短毛刺征50冠状位重建51矢状位重建典型胸膜凹陷征BAC52左上肺尖段纯毛玻璃结节:1.0×0.9cm53冠状位重建：局灶性纯磨玻璃密度影(Focalpureground—glassopacity，pGGO54矢状位局部放大BAC55峰值时间后移F，68，腺鳞癌,HRCT动态增强特征56（二）肺良性GGO的CT评价57肺局灶性间质纤维化与GGO

Focalinterstitialfibrosisina40-year-oldwomana.Thin-sectionCTimageshowsa25-mmwell-definednodularground-glassopacitywithnosolidcomponentinthelowerlobeoftheleftlung.b.Photomicrographofahistologicshowsthelesion(arrow)withalveolarseptalthickeningandfibrosisandwithintraalveolarinfiltrationbyinflammatorycells.ab58A36-year-oldwomanwithtwonodularGGOsa.Transversethin-sectionCTscanshowsa5.1-mmwelldefinedroundpureGGOnoduleintherightmiddlelobe.

focalinterstitialfibrosis.b.Theother9-mmmixedGGOnodulecontainingacentralsolidportionisshownintherightlowerlobe.

bronchioloalveolarcarcinoma

ab59Focalnonspecificinterstitialpneumonia.a,b.Thin-sectionCTscansattheleveloftheleftpulmonaryarteryandaorticarch,respectively,showthreefociofpersistentGGO.c.Histologicspecimenshowsthickeningofthealveolarwallwithchronicinflammatoryinfiltrates.Notumorwasidentified.abc60A34-year-oldwomanwith

focalinterstitialfibrosis

showingaroundpureGGOlesiona.Transversethin-sectionCTscanshowsan8.5-mmwell-definedroundnodulewithpureGGO.Therewasnoevidenceofspiculationorvascularconvergencearoundthelesion.

b.Photomicrographofresectionspecimenshowsalveolarinterstitialthickeningwith

fibrosis

andtypeIIpneumocyteproliferationab61

A50-year-oldwomanwith

focalinterstitialfibrosisappearingasmixedGGOwithaspiculatedmarginandpleuraltraction.a.Transversethin-sectionCTscanshowsamixedGGOnoduleintheleftupperlobe.Notethespiculatedmarginandpleuralretraction.b.Thisfollow-upthin-sectionCTtaken2monthslatershowsasimilarappearance.Thelesionwasresectedundertheimpressionofprimarylungcancer.Thepathologicdiagnosiswasoffocalinterstitialfibrosiswithoutevidenceofmalignancyab62A66-year-oldmanwith

focalinterstitialfibrosiswithapolygonalshapeandperi-lobularlineardensity.TransversethinsectionCTscanshowsanodularGGOlesionwithperi-lobularlinearopacities(arrow)aroundthelesionintherightupperlobe.Notethepleuraltractionaroundthelesion63Nodular

fibrosis

withconcavemarginsin67-year-oldman.Bothreviewersinterpretedlesionashavingconcavemargins(arrow),airbronchograms(arrowheads),andpredominantlyground-glassappearanceontransversehigh-resolutionCTimages.Lesionsizewasmeasured8mmbyreviewer1and8.5mmbyreviewer2.Pathologicdiagnosiswas

nodularfibrosis.64Nodularfibrosiswithpolygonalshapein72-year-oldman.Bothreviewersinterpretedlesion(arrow)ashavingcoarsespiculation,pleuraltag,andpolygonalshape,andasbeingpredominantlysolidontransversehighresolutionCTimages.Lesionsizewasmeasuredas8mmbyreviewer1and9mmbyreviewer2.Pathologicdiagnosiswas

nodularfibrosis.65Intrapulmonarylymphnodethatshowedperipheralsubpleurallesionin53-year-oldwoman.Bothreviewersregardedlesion(arrow)aspredominantlysolidlesionattachedtomajorfissureontransversehigh-resolutionCTimages.Lesionsizewasmeasured9mmbybothreviewers.Pathologicdiagnosiswasintrapulmonarylymphnode.肺内淋巴结与GGO66CTscanina90-year-oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresent

acongestedintrapulmonarylymphnode

(arrow).

67GGO与霉菌灶Thin-sectionCTimageatthelevelofthemainpulmonaryarteryshowsa23-mmpoorlydefinednodularground-glassopacityintheupperlobeoftheleftlung.Thelesionincludesseveralperipheralsolidportions(arrows)andasubtlegroundglassopacity(arrowhead).68Eosinophilicpneumoniaina36-year-oldmanwithperipheralbloodeosinophilia.a.Thin-sectionCTimageattheleveloftheaorticarchshowsanill-definedareaofnodularground-glassopacityintheupperlobeoftherightlung.

b.Thin-sectionCTimageattheleveloftheupperlobarbronchusintheleftlungshowsasimilarnodularground-glassopacity.ab69GGO与结核灶FalsepositivePETinpatientwith

tuberculosis.a.Thin-sectionaxialCTscanthroughtheupperlobesatlungwindowsshowsaleftupperlobenodulewithirregularmargins.b.FusedimagefromPET-CTshowsincreasedmetabolicactivitywithinthenodule.SurgicalresectionrevealedagranulomawithculturespositiveforMycobacteriumtuberculosis.ab70（三）GGO的CT处理原则和步骤CT随访GGO变化的重要性体积不变体积变大体积变小密度变实代谢较低711、体积不变72Persistentnodularground-glassopacityina69-year-oldman.a.Thin-sectionCTimageobtainedattheleveloftheleftbrachiocephalicveinshowsa14-mmpoorlydefinedroundnodularground-glassopacityintheupperlobeoftheleftlung.b.Follow-upthin-sectionCTimageobtained4monthslatershowsthepersistenceandstableappearanceofthelesion.Thepathologicdiagnosis,obtainedafterawedgeresection,wasfocal

interstitialfibrosis.ab73Purenodularground-glassopacityconfirmedasfocalinterstitialfibrosis

A.Thin-sectionCTshows30mmpurenodularground-glassopacityintherightupperlobe.

B.Onfollow-upCTscanaftersevenmonths,anintervalchangewasnotnoted.

ab74Purenodularground-glassopacityconfirmedasatypicaladenomatoushyperplasiaina58-year-oldman.

A.Initialthin-sectionCTshowsa15mmpurenodularground-glassopacity

B.Onthin-sectionCTafter2months,anintervalchangewasnotnoted.Alllesionswerepathologicallyconfirmedasatypicaladenomatoushyperplasiabymultifocalwedgeresection.ab75Purenodularground-glassopacityconfirmedas

atypicaladenomatoushyperplasiaa.

InitialCTshows8mmpurenodularground-glassopacityintherightupperlobe.b.

Thin-sectionCTafter10monthsshowspersistentpurenodulargroundglassopacitywiththesamesize.ab762、体积变大体积变大一般为恶性病变77

SmalladenocarcinomadetectedonscreeningCT.ａ.InitialaxialthinsectionCTattheleveloftherightupperlobebronchusshowsa4mmnoduleintherightupperlobe.ｂ.RepeatCTscan3monthslateratthesamelevelshowsslightenlargementofthenodule.Biopsyrevealedadenocarcinoma.ab78GrowthofsmallnoduleonfollowupCT.

(adenocarcinoma)ａ.Initialthin-sectionaxialCTconedtotheleftlungshowsasmallleftupperlobenodulemeasuringapproximately4mmindiameter.ｂ.Repeatscan6monthslatershowsintervalgrowthofthelesion.Aninvasive

adenocarcinoma

wasfoundatsurgery.ab79

BAC.

Sequentialmagnified1-mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGO

overa3-yearperiod.

Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent,whichwasbettercharacterizedonsequentialimages.80Sequentialmagnified5-mmCTsectionsthroughtheleftupperlobeshowGGO．initiallymeasuring8mminsizeovera3-yearperiod.Histologicanalysisshowedmixedsubtype

adenocarcinomacomposedofacinaradenocarcinoma(40%)andBAC(60%).81Computedtomogramfrom57-year-oldman(patient1)withlong-termfollow-upofpureground-glassopacity(PGGO)formorethan10years.Patienthadundergoneoperationfor

adenocarcinomaoriginatinginrightupperlobe

10yearspreviously.ａ.SmallPGGOinleftupperlobe(arrow)waspointedoutasafunctionoftheretrospectivereviewofconventionalCTtakenatthatoperation.ｂ.Onfollow-up124monthslater,high-resolutioncomputedtomographyshows

enlargementofPGGOfrom8mm(A)to25mmindiameter.ｃ.Mostoftheresectedspecimenreveals

bronchioloalveolarcarcinomaabc82

Mixedsubtype

adenocarcinoma,

progressionofGGOtoanodulewithmixedsolidcomponentandGGO.

a.Magnified1-mmCTsectionshowsadiscreteGGO(arrows).

b.Follow-upCTscanobtained1yearlatershowsclearprogressionofthedisease,withthedevelopmentofacentralsolidcomponent,althoughthereisnoappreciableenlargementofthelesion(arrows).ab83Mixedsubtype

adenocarcinoma.aMagnified1-mmCTsectionthroughtheleftlowerlobeshowsanodulewithmixedsolidcomponentandGGO.bFollow-upCTscanobtained6monthslatershowsincreaseintheextentofthesolidcomponentwithinthenodule.ab84Persistentnodularground-glassopacityinan80-year-oldmanwith

adenocarcinoma.

ａ．Initialthick-sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule(arrow)inthemiddlelobeoftherightlung.ｂ．Follow-upCTimageobtained12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent(arrow).ｃ．Follow-upthin-sectionCTimageobtainedat16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion(arrow).Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen.abc85

a.TransverseCTscanina75-year-oldmanshowsa2.0-cm-diameternonsolidleftupperlobenodule.FNABrevealednomalignantcells.

b.ThelesionwasfollowedupwithserialCT;25monthslater,thenodulewasslightlyincreasedinsizeandhadconvertedtoapartlysolidattenuationlesionwithairbronchograms.Volumetricmeasurementshowedthedoublingtimeoftheopacitytobe

1375days.RepeatFNABshowedbronchioloalveolarcellcarcinoma.ab86３、体积变小体积变小一般为良性病变87Resolutionofnodularground-glassopacityovertimehelpsdeterminethebenignityofalesionina50-year-oldman.Initialthin-sectionCTimageattheleveloftheinferiorpulmonaryveinshowsa12-mmpoorlydefinednodularground-glassopacityintherightlowerlobe.Follow-upCTimageobtainedapproximately2monthslatershowsthatthelesioninahasresolved.ab88Focalinflammationmimickingadenocarcinoma.

a.Magnified1-mmCTsectionthroughtherightupperlobeshowsnoduleswithGGOinitiallydiagnosedasprobableBAC.b.Follow-upCTscanobtained3monthslatershowsnearcompleteresolutionofthelesion(arrow),(focalnonspecificinflammation).ab89Transversethin-sectionCTscansshowtransientPSNwithmultiplicityina43-year-oldman.a.Scanshowsa16-mmPSN(arrow)intheleftupperlobe.Thispatienthadeosinophilia(eosinophilcount,574permicroliter).b.Follow-upscanobtained1monthlatershowsdisappearanceofthePSN.ab90Transversethin-sectionCTscansshowtransientPSNwithill-definedborderin37-year-oldman.a.Scanshowsa27-mmPSN(arrow)withanill-definedborderintherightupperlobe.Thispatienthadbloodeosinophilia(eosinophilcount,1577permicroliter).b.Atfollow-upCTperformed3weekslater,thePSNhasdisappeared.ab91ResolutionofspiculatedSPNcausedbyinfection.a.AxialCTscanatleveloftrachealcarinaina52-year-oldsmokerwhohasfever,cough,andhemoptysisshowsaspiculatednoduleintheleftupperlobe.b.RepeataxialCT5weekslatershowsmarkeddecreaseinthesizeofthenodule.Thepatienthadbeentreatedintheintervalwithbroadspectrumantibioticsforapresumedinfec