胸部常见CT征象认读.教程文件

胸部常见CT征象认读.小叶支气管、终末细支气管肺动脉pulmonaryartery

小叶间隔interlobularsepta

肺静脉pulmonaryvein

腺泡pulmonaryacini

正常HRCT.中央肺动脉。支气管与相邻肺动脉直径大致相等。肺动脉常分为两个直径相当的分支。

肺静脉常分成许多细小的分支,这些分支与主支构成直角。

叶间裂（厚度小于1mm，边缘光滑，均一厚度）常见伪影双侧下肺近心脏处，肺血管脉动伪影。低密度区，可以错当作扩大的支气管。常见伪影主叶裂伪影。常见伪影血管双重伪影。正常小叶间隔normalsepta

正常小叶中心动脉正常小叶中心动脉centrilobularartery2肺静脉Pulmonaryveins

肺间质病变发生于：慢性间质性肺炎、弥漫性间质纤维化、结节病、癌性淋巴管炎、结缔组织病（红斑狼疮、类风湿性关节炎、硬皮病、皮肌炎）、尘肺（矽肺、煤矽肺、石棉肺）、组织细胞病Ｘ、淋巴管平滑肌瘤病。ＣＴ：界面征、小叶间隔增厚、小叶中心结构增厚、胸膜下线、长疤痕线（扭曲肺结构）、蜂窝样改变、结节影、牵拉性支扩、磨玻璃样改变。Case1F/60y乳腺癌术后，现呼吸困难。分析：（1）小叶间隔增厚分析：（2）支气管血管周围间质增厚支气管袖口症：分析：(3)斜裂增厚分析：（4）大结节影网状阴影：病理上主要为小叶间隔增厚、小叶内间隔增厚、小叶核心增厚、胸膜下线影、蜂窝肺和支气管血管周围间质增厚等改变。可见于特发性间质性肺炎、结节病、癌性淋巴管炎、特发性含铁血黄素沉积、感染性疾病等。双肺网状阴影多见与特发性间质性肺炎、结缔组织病肺浸润、结节病等。单侧以癌性淋巴管炎和放射性肺炎为主。上病例为癌性淋巴管炎。Case279岁、淋巴瘤病史小叶间隔增厚？(a)Yes(b)No双侧光滑增厚的小叶间隔支气管血管间质是否增厚？(a)Yes(b)No增厚的支气管血管间质胸膜下间质增厚？(a)Yes(b)No斜裂增厚Whatisthemostlikelydiagnosis?最可能的诊断？？？(a)Pulmonaryedema(肺水肿）(b)Interstitialfibrosis（间质纤维化）(c)Lymphangiticspreadoflymphoma（癌性淋巴管炎）Diagnosis:Lymphangiticspreadoflymphoma,withinterlobularseptalthickening。癌性淋巴管炎（小叶间隔增厚）lymphocyticinterstitialpneumonitis(LIP)淋巴间质局限性肺炎Case358-year-oldmanwithheartdisease小叶间隔增厚？？？(a)Yes(b)No双侧小叶间隔增厚支气管血管间质增厚？？？(a)Yes(b)No支气管血管间质增厚Istherethickeningofthesubpleuralinterstitium?(胸膜下间质增厚？)(a)Yes(b)NoNO!!!Whatisthemostlikelydiagnosis?(最可能的诊断？)(a)Pulmonaryedema肺水肿(b)Interstitialfibrosis间质纤维化(c)Lymphangiticspreadofcarcinoma癌性淋巴管炎(a)Pulmonaryedema肺水肿Correct.Becauseofthehistoryofheartdisease心脏病史,characteristicabnormalities典型的异常,ymmetry对称,andthepredominanceofseptalthickeningindependentlung,thisdiagnosismustbeconsidered考虑mostlikely.文献：间质性肺水肿（1）肺血重新分布：左心衰--肺淤血。（2）支气管周围袖口症：正常厚度约1mm—结缔组织内液体存积—增厚。X-肺纹理及肺门血管增粗、模糊.（3）肺透过度下降：液体分布到支气管血管周围、小叶间隔、小叶内支气管血管周围、肺泡间隔—透过度下降。（4）间隔线：KerleyB线—x上与肋膈角处与胸膜垂直。（5）胸膜增厚：液体—入脏层胸膜下薄层结缔组织—胸膜下结缔组织水肿--水肿位于脏层胸膜与结体组织间，不随体位移动。（６）胸腔积液：胸膜腔内液体来自壁层胸膜。不同原因的肺水肿心源性肺水肿：左心衰（见于心梗、二尖瓣病变。肾性肺水肿：急慢性肾功能衰竭，可合并尿毒症－－水钠潴留、左心衰－肺水肿－－上腔静脉、奇静脉增宽。肺微血管损伤性肺水肿：除肺水肿外，还可见出血及细胞渗出–肺血分布正常、无袖口症、间隔线。肺泡实变斑片状，肺野外为分布。毒性气体吸入、胃液吸入、药物、溺水、颅内压升高、高原性肺水肿、复张性肺水肿。Case4a53-year-oldwomanwithandabnormalchestradiographandmildshortness（短缺）ofbreath（异常胸片，气短）

Isseptalthickeningpresent?(a)Yes(b)No小叶间隔增厚吗？增厚的小叶间隔Aretheseptasmoothornodularinappearance?(a)Smooth(b)Nodular

小叶间隔增厚是结节状还是光滑增厚？小叶间隔结节状增厚胸膜下间质结节影支气管袖口症Possiblediagnosesinclude:(a)pulmonaryedema肺水肿(b)interstitialfibrosis间质纤维化(c)sarcoidosis结节病最可能的诊断？sarcoidosis结节病Correct.Nodularthickeningofinterlobularseptaandfissurescanbeseeninthisdiseaseandlymphangiticspreadofcarcinoma.（小叶间隔结节状改变可见于结节病、癌性淋巴管炎、尘肺）。支气管血管间质、胸膜下间质结节状改变—对结节病有特征性的诊断。Case5

a42-year-oldmanwithmildshortnessofbreathforanumberofyears（气促多年）Isseptalthickeningvisible?(a)Yes(b)No

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小叶间隔增厚吗？增厚的小叶间隔扭曲的肺结构叶间裂的扭曲Diagnosis:End-stagesarcoidosiswithfibrosisandinterlobularseptalthickening.结节病伴随征象：肺结构扭曲、小叶间隔结节状增厚、牵拉性支扩、蜂窝肺等。文献：肺间质病变界面征：支气管血管间质增厚—支气管血管束增粗、支气管袖口症；液体—边缘光滑、肿瘤或肉芽组织—结节状界面。胸膜下线：近胸膜面1cm内弧线状影—为肺纤维化征象。长疤痕线：蜂窝肺：结节影：小结节—2-5mm，肉芽、肿瘤、纤维组织。肺结构扭曲变形及牵拉支扩：磨玻璃样改变：Case6a68-year-oldwomanwithrheumatoidarthritis（风湿性关节炎）andprogressive累计shortness短缺ofbreathovera2-yearperiodThepredominantabnormalfindingonthesescansis?(a)interlobularseptalthickening小叶间隔增厚。(b)honeycombing蜂窝肺主要的异常表现？蜂窝肺部分层面小叶间隔增厚Whatdoeshoneycombingreflecthistologically?(a)Interstitialedema肺间质水肿(b)Interstitialinfiltration渗透bycells(c)Interstitialfibrosis蜂窝肺的组织学—肺间质纤维化的后期表现。Diagnosis:Rheumatoidlungdisease,withfibrosisandhoneycombing.风湿性肺疾病，肺纤维化、蜂窝肺。壁厚0.8-1MM，胸膜下3-4cm范围内或近叶裂处；早期囊腔小而少；囊壁为折叠破坏的肺泡壁及气道壁。Case7a74-year-oldwomanwithprogressiveshortnessofbreathover6months

Themostsignificantabnormalfindinginthisstudyis:(a)interlobularseptalthickening小叶间隔增厚(b)honeycombing蜂窝肺(c)subpleuralemphysema胸膜下肺气肿主要的异常表现？蜂窝肺Whatisthemostlikelydiagnosis?(a)Idiopathicpulmonaryfibrosis(IPF)特发性肺间质纤维化(b)Autoimmunedisease(e.g.,rheumatoidlungdisease)自身免疫性疾病(c)End-stagehypersensitivitypneumonitis过敏性肺炎(d)Asbestosis石棉肺(e)Drug-relatedlunginjury麻醉药物肺损害(f)Sarcoidosis结节病最可能的诊断？IPF:特发性肺间质纤维化磨玻璃密度：肺野周围—活动性肺泡炎症。网状改变：小叶间隔、小叶中心结构增厚—蜂窝状改变的前期。蜂窝状改变：胸膜下间质纤维化：胸膜下弧线状影、脏层胸膜及叶间胸膜增厚。肺气肿：小叶中心型肺气肿。肺实变：支扩：蜂窝肺牵拉性支扩小叶间隔增厚Case8

86-year-oldmanwithchronicmyelogenousleukemia骨髓性的白血病,treatedusingmethotrexate化疗,nowcomplainsofshortnessofbreath气短.DoesthismanshowevidenceoffibrosisandUIP?(a)Yes(b)No显示明显的纤维化和普通间质性肺炎？？屑性间质性肺炎（DIP）、普通性间质性肺炎（UIP）。(a)Yes

Correct.Findingsindicativeofusualinterstitialpneumonitis(UIP)visibleinthispatientinclude:honeycombing;蜂窝肺irregularfissures;叶裂扭曲irregularinterlobularseptalthickening;小叶间隔不规则增厚。tractionbronchiectasis.牵拉性支扩蜂窝肺叶裂扭曲不规则小叶间隔增厚牵拉性支扩Themostlikelydiagnosisis:可能的诊断？(a)idiopathicpulmonaryfibrosis(IPF)(b)lunginvolvementbyleukemia白血病肺浸润。(c)drug-relatedlunginjury化疗药物肺损害。(c)drug-relatedlunginjury

Correct.Thepatternoffibrosisseeninthispatientisnonspecific,andcouldbecausedbyIPF.Therecenthistoryoftreatmentwithmethotrexatemakesdrug-relatedfibrosismostlikely.Lunginvolvementbyleukemiawouldlikelyresultinanappearancesimilartothatoflymphangiticspreadofcarcinomawithseptalthickeningbeingthepredominantfinding.IPF一可有同种表现，但患者有最近化疗史，白血病肺浸润小叶间隔增厚明显。Case9

ina63-year-oldmanwithahistoryofscleroderma硬皮病andprogressiveshortnessofbreath进行性喘憋

Findingsinclude:

interlobularseptalthickening;小叶间隔增厚。tractionbronchiectasis;牵拉性支扩subpleuralhoneycombing;胸膜下蜂窝肺irregularfissures.叶裂扭曲小叶间隔增厚牵拉性支扩胸膜下蜂窝肺斜裂扭曲Canyoubeconfidentthatlungfibrosisispresent?(a)Yes(b)No你能确定肺纤维化存在？YesCorrect.Thepresenceofhoneycombingisdiagnosticoffibrosis.Tractionbronchiectasisisalsostronglysuggestiveoffibrosis.Interlobularseptalthickeningandirregularfissuresarenonspecific,andcannotbereliedupontodiagnosefibrosis.蜂窝肺、牵拉性支扩—肺纤维化存在。小叶间隔增厚、斜裂扭曲对肺纤维化的诊断意义不大。Diagnosis:Scleroderma,withlungfibrosis,honeycombing,andtractionbronchiectasis硬皮病—肺纤维化：蜂窝肺、牵拉性支扩。结缔组织病及肺血管炎—主要为肺间质病变。肺内实变—肺泡内渗出、肉芽肿形成、肺泡内出血、水肿。肺内多发结节—肺内血管炎、肉芽肿、肺栓塞所形成。常见于：wengner\类风湿性关节炎。肺间质病变—肺间质性肺炎、肺泡炎—间质纤维化、蜂窝肺。Case10

ina61-year-oldwomanwithprogressiveshortnessofbreath进行性喘憋.Whichofthefollowingfindingsareshownonthisscan?上图包含症像:(a)Honeycombing蜂窝肺(b)Asubpleuralline胸膜下线(c)Aperipheralandsubpleuraldistribution外围胸膜下分布(d)Alloftheabove以上全包括Alloftheabove

Correct.Smallsubpleuralcystsarepresenttypicalofmildhoneycombing.轻度的蜂窝肺Anirregularlineparallelsthepleuralsurface,termedasubpleuralline.胸膜下线Whichofthefollowingismostlikelyinthiscase?最符合的诊断？(a)Idiopathicpulmonaryfibrosis(IPF)特发性间质纤维化(b)Autoimmunedisease(e.g.,rheumatoidlungdisease)自身免疫性疾病(c)End-stagehypersensitivityPneumonitis过敏性肺炎(d)Asbestosis石棉肺(e)Drug-relatedlunginjury药物肺损害(f)Sarcoidosis结节病Idiopathicpulmonaryfibrosis(IPF)

Correct.Idiopathicpulmonaryfibrosis(IPF).Intheabsenceahistorytosuggestoneofthespecificdiagnosesonthislist,IPFismostlikely.Itaccountsfor60%ofcaseshavingthisappearance.IPF在该病例无特异性，60%有该表现。Case11a34-year-oldmanwithprogressiveshortnessofbreath喘憋Thepredominantabnormalityinthiscaseis:明显的异常表现(a)honeycombing蜂窝肺(b)intralobularinterstitialthickening小叶间质增厚intralobularinterstitialthickening

Correct.Honeycombingisnotvisibleinthispatient.Afineirregularreticular不规则的网状改变patternispresentinthelungperiphery,representingintralobularinterstitialthickening.小叶间质增厚Insomepatientswithpulmonaryfibrosis,thisfindingwillpredominate.Otherfindingsoffibrosisinthispatientincludetractionbronchiectasis.牵拉性支扩Thedifferentialdiagnosisofthisappearanceisidenticalasthatforhoneycombing.小叶间质增厚牵拉性支扩Diagnosis:Idiopathicpulmonaryfibrosis特发性间质纤维化,withintralobularinterstitialthickening.Case12a71-year-oldmanwithprogressiveshortnessofbreathThepredominantabnormalityinthiscaseis:突出的表现(a)honeycombing蜂窝肺(b)intralobularinterstitialthickening小叶间质增厚intralobularinterstitialthickening

Correct.Honeycombingisnotclearlyseeninthispatient.Afinebutirregularreticularpattern不规则的网状改变ispresentinthelungperiphery外围,representingintralobularinterstitialthickening小叶间质增厚.Insomepatientswithpulmonaryfibrosis,thisfindingwillpredominate.Otherfindings其他征象offibrosisinthispatientincludetractionbronchiectasis牵拉性支扩,andirregularinterlobularseptalthickening不规则小叶间隔增厚.Thedifferentialdiagnosisofthisappearanceisidenticaltothatforhoneycombing.小叶间质增厚牵拉性支扩不规则小叶间隔增厚Diagnosis:Idiopathicpulmonaryfibrosis特发性间质纤维化,withintralobularinterstitialthickening.Case1334-year-oldwomanwithlupuserytematosus狼疮红斑Canyoudiagnosefibrosis?能诊断纤维化？(a)Yes(b)No

Yes

Correct.HRCTobtainedinthesupineandpronepositions仰卧和俯卧位showsanumberoffindingsindicatingfibrosis指示,including:honeycombingwhichismildindegree;轻度蜂窝肺tractionbronchiectasis;牵拉性支扩intralobularinterstitialthickening;小叶间质增厚interlobularseptalthickening小叶间隔增厚;andasubpleuraldistribution.胸膜下分布轻度蜂窝肺牵拉性支扩小叶间质增厚小叶间隔增厚Diagnosis:Systemiclupuserythematosus（SLE系统性红斑狼疮肺部表现—肺结缔组织病,withfibrosisandhoneycombing.Case14

a65-year-oldwomanwithrheumatoidarthritis风湿性关节炎andmilddyspnea

轻度呼吸困难Canyoudiagnosefibrosis?能诊断纤维化？(a)Yes(b)NoCorrectincluding:tractionbronchiectasis;牵拉性支扩intralobularinterstitialthickening;小叶间质增厚asubpleuralline.胸膜下线牵拉性支扩小叶间质增厚胸膜下线Diagnosis:Rheumatoidlungdisease肺结缔组织病,withmildpulmonaryfibrosis轻度肺纤维化andintralobularinterstitialthickening小叶间质增厚.Case15a26-year-oldwomanwithmixedconnectivetissuedisease混合结缔组织病,basilarcracklesonphysicalexamination双肺底水泡音,andrestrictivediseaseonpulmonaryfunctiontests

肺功能受限Canyoudiagnosefibrosis?能诊断纤维化？(a)Yes(b)NoYes

Correct.Including:tractionbronchiectasis;牵拉性支扩intralobularinterstitialthickening小叶间质增厚;asubpleuraldistribution胸膜下分布牵拉性支扩小叶间质增厚Diagnosis:Mixedconnectivetissuedisease混合结缔组织病,withpulmonaryfibrosis,andintralobularinterstitialthickeningCase16a81-year-oldmanwithsignificantoccupationalexposuretoasbestos石棉职业史Ispulmonaryfibrosispresent?肺纤维化存在？(a)Yes(b)NoYes

Correct.Findingsoffibrosisinclude:tractionbronchiectasis;牵拉性支扩intralobularinterstitialthickening;小叶间质增厚asubpleuraldistribution.胸膜下分布irregularinterlobularseptalthickening不规则的小叶间隔增厚牵拉性支扩小叶间质增厚胸膜下分布小叶间隔增厚Diagnosis:石棉肺Asbestosiswithtractionbronchiectasis牵拉性支扩andintralobularinterstitialthickening小叶间质纤维化.纵隔窗pleuralthickeningandcalcification胸膜增厚、钙化椎旁区域横膈胸膜肥厚钙化Case17a58-year-oldmanwithahistoryofasbestosexposure石棉史

可见椎旁胸膜增厚、不规则线状影Thepleuralthickeningistypicalofasbestosexposure胸膜增厚是典型的石棉肺表现.Wouldyoudiagnoseasbestosis诊断石棉肺吗?(a)Yes(b)NoNo

Correct.Linearopacities线状影asseeninthiscase(termedparenchymalbands肺实质带)arecommoninpatientswithpleuralthickening胸膜增厚,butarenotnecessarilyassociated不必须考虑withlungfibrosis肺纤维化.肺实质带parenchymalbands位于下肺部，肺内条状影；肺实质内的纤维化。尽管如此，结合病史，考虑Asbestosexposurewithpleuraldiseaseandparenchymalbands石棉至椎旁胸膜增厚、肺实质带。Case18a67-year-oldmanwithahistoryofasbestosexposure石棉史No

Correct.HRCTatlungwindowsshowsirregularlinearopacities不规则的线状影(“crow‘sfeet”乌鸦脚),withoutevidenceofhoneycombing无蜂窝肺,intralobularinterstitialthickening小叶间质增厚,ortractionbronchiectasis牵拉性支扩.Thisappearancedoesnotindicateasbestosis无石棉特征.Linearopacities,asseeninthiscase(parenchymalbands肺实质带)arecommoninpatientswithpleuralthickeningrelatedtoasbestosexposure,butarenotnecessarilyassociatedwithlungfibrosis不必须考虑肺纤维化.Theyrepresentfocalareasofatelectasis焦点为肺膨胀不全,associated联系withthepleuralthickening,orfocalareasofscarring焦点区疤痕.乌鸦脚（"crow'sfeet"),即尽管如此，结合病史考虑Asbestosexposurewithpleuraldiseaseandparenchymalbands。另一病例：胸膜下线椎旁胸膜增厚Case19a56-year-oldmanwithsignificantoccupationalexposuretoasbestos石棉史Istherepleuralthickening胸膜增厚youwouldconsider考虑likely可能duetoasbestosexposure石棉?(a)Yes(b)NoYes

correct.Afocal焦点,calcifiedpleuralplaque胸膜钙斑isvisibleanteriorly,typicalofasbestosexposure石棉肺典型表现.Althoughplaquesaremorelikelyposteriorinlocation常见后胸膜,thisappearanceishighlysuggestive高度提示.Canadefinitediagnosisofpulmonaryfibrosisonthepronelungwindowscansbemade?肺窗能明确诊断肺纤维化吗？(a)Yes(b)NoNo

Correct.Thereismildseptalthickening轻度间隔增厚andreticulation

网状intheposteriorsubpleuralregion后胸膜下ontheright.Thisisunassociated无联系withadjacent临近pleuralthickening.Thisisaverysubtleabnormality轻微的异常whichcouldrepresenttheearlieststageofasbestosis石棉肺早期表现.However,intheabsenceofamoredefiniteabnormality明确的异常orsimilar类似findingsontheleft,itwouldbedifficult困难tomakeadefinitediagnosisoffibrosis石棉肺或肺纤维化的诊断orasbestosis.小叶间质增厚—轻度网状改变Diagnosis:Asbestosisexposure石棉肺.Possiblefibrosis可能纤维化.文献：石棉肺[1]胸膜改变：胸膜斑、弥漫性胸膜增厚、胸腔积液。[2]肺改变：弥漫性肺间质纤维化—HRCT胸膜下弧线、胸膜下点状致密影、肺实质带、蜂窝状改变、胸膜下磨玻璃表现（肺泡壁小叶间隔增厚）；圆形肺不张（支气管血管结构进入-彗星尾征）。Case20a57-year-oldwomanwithyearsofprogressivedyspnea多年呼吸困难Ispulmonaryfibrosispresent?肺纤维化存在吗？(a)Yes(b)NoYes

Correct.Thispatientshowsanumberof许多findingsindicativeofpulmonaryfibrosis肺纤维化征象.Theseinclude:Extensive广泛的tractionbronchiectasis

牵拉性支扩involvingbothupperlobes双上叶;Irregularreticularopacities不规则的网状anddistortionoflungarchitecture肺结构扭曲associatedwithtractionbronchiectasis;andHoneycombingatthelungbas