医学影像学教学课件：肺癌 纵隔病变

ImagingDiagnosisofRspirotaryDisease

part2Lungneoplasm肺肿瘤Theincidenceofprimarylungcarcinomaisincreasinginallovertheworld.Mostlungtumors(over98%)arebronchiogeniccarcinoma支气管肺癌.Lungneoplasm肺肿瘤Benign:良性harmatoma,adenoma,angioma,fibroma错构瘤，腺瘤，血管瘤，纤维瘤malignancy:恶性primary：lungcarcinoma肺癌，sarcoma肉瘤Secondary：metastasis转移瘤Harmatomauncommonasymptomatic;symptomstypicallyarepresentwithcentralendobronchiallesions，includehemoptysis,recurrentpneumonia,anddyspnea.Harmatomatypicallyround,well-marginatedperipheralmassessmallerthan4cm(range,1to30cm).typicalpattern：‘popcorn'calcification

Calcification钙化

probablyispresentinlessthan5%oflesions,Fat脂肪canbedetectedbyCT(attenuation,-40to-120HU)inupto50%ofcasesandisadiagnosticfeature.primarybronchogeniccarcinoma

原发性支气管肺癌mostcommonmalignancyriskfactor：cigarettesmoking

Environmentalandoccupationalexposure

（3%to17%）Interstitialpulmonaryfibrosisandfocalscarringhavebeenreportedtoincreasetheriskforbronchialcarcinoma.Lungcarcinoma(cancer)SCLC(smallcelllungcancer)小细胞肺癌NSCLC(non-smallcelllungcncer）非小细胞肺癌squamouscellcarcinoma鳞癌Adenocarcinoma腺癌LargeCellCarcinoma大细胞癌compoundcarcinoma混合癌bronchioloavelarcarcinomaBAC细支气管肺泡癌LungneoplasmLungneoplasmSCLC(smallcelllungcancer)Smallcellcarcinomaisarapidlygrowingtumorthathasthemostirrefutableassociationwithsmoking.Likesquamouscellcarcinoma,itispredominantlyacentraltumor(90%),butgrowthismainlyalonganatomictissueplanes.metastasizesearly;systemicspreadispresentintwo-thirdsofcasesatpresentation.生长迅速，中央型，转移早，全身LungneoplasmNSCLC(non-smallcelllungcncer)squmouscellcarcinomaismostcommonlyacentraltumordevelopingatthelevelofthesegmentalandsubsegmentalbronchiin66%ofcases.Thesetumorsarefrequentlylobulatedandhaveatendencytocavitate.Adenocarcinomaisaperipheraltumorin75%ofcaseswithapredilectionfortheupperlobesandforregionsofparenchymalfibrosis(“scar”carcinomas).bronchioloavelarcarcinomagrowsmainlywithinthealveolirespectinginterstitialboundaries,maybeunifocalofmultifocal,whenmultifocal,itmayproducealveolarcellcarcinosis.bronchialcarcinomaasymptomatic，detectedincidentallymostpatients(upto90%)aresymptomatic气道起源多数表现为producingcough,hemoptysis,dyspnea,andchestpain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。。。AccordingtotypeofgrowthCentraltype:Inter-tuberWalloftuberExtra-tuberPeripheraltype:MassinflammationDiffuseLungneoplasmCentraltumorDirectsignofbronchialcarcinoma

lungmassBronchiallumen:Bronchialstenosis，endoluminalortransmuralgrowthCentraltumor:massintherightlowloberandrighthilarenlarge,massintherighthilarCentraltumorlungmassinthehilumBronchaillumen支气管改变支气管腔内肿块支气管壁增厚支气管腔狭窄/闭塞MousetailIrregularstenosisFillingdefectCuplikeconeMousetailCentraltumorFillingdefectBronchialstenosisCentraltumorIndirectsign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

Partialorcompleteatelectasis

：Segments,lobes,oranentirelungarenolongeraeratedandundergopartial(dystelectasis)orcompletecollapse(atelectasis).Thisismanifestaspatchyorhomogeneouspulmonaryopacificationoflobarorsegmentaldistribution.Rightupperlobeatelectasis

RightupperlobeatelectasisleftupperlobeatelectasisCentraltumorIndirectsignofbronchialcarcinoma:Distalpneumoniapresentsaslobarorsegmentalconsolidation,whichmaypartiallyresolvewithantibiotictherapy.Inpatientswithappropriateriskfactorsandrecurrentorpersistentpneumonia,furtherevaluationtoexcludeacentralendobronchialtumorismerited.DistalpneumoniapneumoniamassPleuraleffusionCentraltumorIndirectsignofbronchialcarcinoma:Intrathoracicspreadofbronchialcarcinoma.CentraltumorIndirectsignofbronchialcarcinoma:Mediastinallymphnodeenlargement.Mediastinalwideningmaybethefirstradiographicsignoflungcancer,especiallyincasesofsmallcellcarcinoma.CentraltumorHematogenousspreadofbronchialcarcinoma.Osteolyticbonelesionsandpathologicfractures溶骨性的破坏和病理性的骨折signifyhematogenousspreadofdisease.血行播散CostalbonedamageRightlungmetastasis2023/4/4M-57Y，右肺上叶中央型肺癌，肺门肿块+上叶支气管截断+上叶不张，纵隔淋巴结肿大2023/4/4伴淋巴结、肝脏多发转移；做化疗2023/4/4M-71Y，因“咳嗽咳痰，痰中带血2月”入院2023/4/4穿刺活检病理：低分化腺癌

胸水：腺癌CentraltumorMRImanifestationBronchiwallthickenBronchiwallstenosisMassinthehilumEmphysema;pneumonia;atlectasisofobstructionAffectmediastinum，enlargementoflymphnode(diameter>15mm)plainfilm、CT、MRICentraltumorPlainfilmCT平扫CTscannocontrastCT增强CTscancontrastMRIPeripheraltumor

Peripheralpulmonarynodule/mass.round，usuallylessthan5cmindiameter.Thefollowingfeaturessuggestadiagnosisofbronchialcarcinoma:apulmonarymassgreaterthan6cmindiameter;ill-definedmarginin85%ofmalignanttumors;radialstriatedmarkingsattheinterfacewithlungparenchymarepresentingtumorspreadalongthelymphatics;notchingofthecontour;acavitatinglesiontypicalofsquamouscellcarcinoma.PeripheraltumorPulmonarynoduleintheearlystage.Lobulation，Spiculatedmargin.Airbronchogram.Cavitary.PseudocavitationBubble-likelucencieswithinthenodule.空泡征Retractionofpleura-pleuralindentationsign胸膜凹陷征

Peripheraltumor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notchingofthecontournotchingofthecontourCavitary.BonemetastasisRetractionofpleura.Spiculatemargin.notchingofthecontourRetractionofpleura.Spiculatemargin.notchingofthecontourRetractionofpleura.Spiculatemargin.notchingofthecontour

Spiculatemargin.notchingofthecontourSpiculatemargin.notchingofthecontour2023/4/4F-65（左下肺）浸润性腺癌，

（肺门）淋巴结见癌转移（1/2）。2023/4/4M-50Y，因“胸部不适一周”入院。2023/4/4病理：（左上肺）腺癌，Ⅱ-Ⅲ级，周围型Bronchiolo-alveolarcarcinomaIsolatedmasstypePneumoniatypeDiffusenoduletypeIsolatedmasstypeBronchiolo-alveolarcarcinomaBronchiolo-alveolarcarcinoma

Pneumoniatype

ill-definedmarginpulmonarynoduleBronchiolo-alveolarcarcinomaBronchiolo-alveolarcarcinomaBronchiolo-alveolarcarcinomaLungmetastasisThemostcommonprimarytumorsitewaslung,followedbylargebowel,prostate,breast,uterus,

andesophagus.Between20%and40%ofprimarycarcinomasofthelungproducedpulmonarymetastases.Tumorswiththegreatestrateofmetastasestothelungincludechoriocarcinoma绒毛膜癌,germinaltumorsofthetestis睾丸的生殖细胞瘤,melanoma黑色素瘤,Ewing’ssarcoma尤文氏肉瘤,osteosarcoma,骨肉瘤carcinomaofthethyroid,甲状腺癌carcinomaofthebreast乳腺癌,andrhabdomyosarcoma横纹肌肉瘤.LungmetastasisHematogenousmetastasisLymphaticvesselmetastasis

HematogeneousmetastasisHematogeneousmetastasisHematogeneousmetastasisHematogeneousmetastasisLymphaticvesselmetastasisPleuralcarcinomatosis

Mediastinaltumor纵隔肿瘤绝大多数为良性benign.主要诊断依据：position,shape，density.TumoroftheanteriormediastinumThymoma

TeratomaIntrathoracicthyroid

MalignantlymphomaBronchogeniccystNeurogenictumorsMediastinaltumor

Anteriormediastinaltumor前纵隔Intra-thoraciathyroidmass胸内甲状腺肿:upperofmediastinumThymoma胸腺瘤:anteriorTeratoma畸胎瘤：calcification;fatMiddlemediastinaltumor中纵隔Posteriormediastinaltumor后纵隔IntrathoracicthyroidIntrathoracicthyroidisusuallyadownwardprolongationoroutgrowthofacervicalthyroidenlargement.Onradiolographmostcasesshowwideningofoneorothersideoftheanteriorsuperiormediastinumanddisplacementofthetracheatotheoppositesideandcompressionofthetracheaonthesideofthetumor.胸内甲状腺肿

intrathoracicgoiter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IntrathoracicthyroidIntrathoracicthyroidTheCTappearancesofthyroidgoitersarespecific.Anatomicalcontinuityusuallycanbedemonstratedwiththecervicalthyroid.Focalcalcificationsandinhomogeneityarefrequentfeatures.Afterinjectingcontrastmaterial,thereisadefiniteprolongedriseintheCTHounsfieldnumber.结甲伴腺瘤样增生女，62岁肿物与甲状腺相连IntrathoracicthyroidMRimagingparticularlyinthecoronalandsagittalplanes,canshowtheextentofintrathoracicthyroidtissueanditsrelationshiptoadjacentstructures.MultinodulargoitershaveheterogeneoussignalcharacteristicsonT1W1andT2W1.Thymoma胸腺瘤anteriorsuperiormediastinum.round,lobulatedorplaque-like,andproduceunilateralwideningofthemediastinum.Calcificationorcysticdegenerationmaybeseeninasmallpercentageofcases.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ThymomaDifferentiationbetweenthymomaandthymichyperplasiaisdifficultinpatientslessthan40yearsofage.Thymichyperplasiatendstoenlargebutpreservethenormalshapeofthegland.However,exceptionstothisareencounteredinwhichhyperplasiaisfoundinnodularglands,simulatingthepresenceofathymoma.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ThymomaThymomaThymoma胸腺瘤，可疑包膜侵润男性，47岁，查体发现2023/4/4M-61，胸腺癌，肝脏多发转移ThymomaThymomashaveintermediatesignalintensity(equaltothatofskeletalmuscle)inT1W1andincreasedsignalintensity(approachingthatoffat)onT2W1.CysticregionsareareasofhemorrhagehavelowsignalintensityonT1W1andhighsignalintensityonT2W1.胸腺瘤MRI畸胎瘤teratoma先天性肿瘤，属生殖细胞瘤好发于20~40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TeratomaMostmediastinalteratomasareseenonradiographasalocalizedmassintheanteriorcompartmentclosetotheoriginofthemajorvesselsfromtheheart.Calcificationisevidentonradiographinmatureteratomas.OnCT,mosttumorshavewell-definedmarginsthatweresmoothorlobulatedwithroundorovalinshapeandhaveheterogeneousattenuationwithsofttissue,fluidandfat.teratomateratomateratoma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

MediastinaltumorAnteriormediastinaltumor：Middlemediastinaltumor：MalignantlymphomaBronchogeniccystPosteriormediastinaltumorMalignantlymphomaThethoraxisfrequentlyinvolvedinpatientswithHodgkin’sandnon-Hodgkin’slymphomas.Ithasbeenestimatethatlymphomaconstitutesabout20%ofallmediastinalneoplasmsinadultsand50%inchildren.Lymphnodeenlargementisevidentontheinitialradiographofapproximately50%ofpatients,especiallybilateralenlargementofhilarandparatracheallymphnodes.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Malignant

lymphomaMalignantlymphomaMalignantlymphoma

CTandMRIaremoresensitivethanradiograph.Theenlargedlymphnodesor