孤立性肺结节的诊断现状

（优选）孤立性肺结节的诊断现状当前第1页\共有96页\编于星期三\3点概况所有胸片0.09%-0.20％150，000/年（预计）病因：肉芽肿性疾病、肺癌、错构瘤

恶性结节：10－70％占手术切除肺结节的60-80%，IA期肺癌术后5年生存率61-75％

良性结节：感染性肉芽肿80％错构瘤10％Chest2003；123：89-96当前第2页\共有96页\编于星期三\3点病因当前第3页\共有96页\编于星期三\3点Figure1a.

Ribfractureina50-year-oldwomanwithmultiplemyeloma.(a)Close-upposteroanteriorradiographoftherightupperlungshowsapoorlymarginatednodularareaofincreasedopacityoverlyingtheanterioraspectoftherightsecondrib(arrow).(b)CTscanshowsahealedfractureoftherightsecondrib(arrow).Notethelyticlesionsinthevertebralbodysecondarytomultiplemyeloma.当前第4页\共有96页\编于星期三\3点Figure2a.

Pseudonoduleina50-year-oldman.(a)Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednodularareaofincreasedopacityprojectingoverthelung(arrow).Notetheadjacentelectrocardiographicleadattachmentpad(arrowhead).Onafollow-upradiographobtainedafterremovaloftheattachmentpad(notshown),nonodulewasobserved.(b)Frontandbackviewsoftheelectrocardiographicleadattachmentpadshowaneccentricallylocatedsilvernitratepad,whichexplainsthecontiguousnodularareaofincreasedopacityonthechestradiograph.当前第5页\共有96页\编于星期三\3点Figure3a.

Boneislandina61-year-oldmanwithmelanoma.(a)Close-upposteroanteriorradiographoftheupperchestshowsafocalareaofincreasedopacityoverlyingtherightseventhribposteriorly(arrow).(b)Fluoroscopicimagesshowawell-marginatedintraosseouslesion(arrow).Thisfindingisconsistentwithaboneislandandobviatedfurtherinvestigation.当前第6页\共有96页\编于星期三\3点Figure4a.

Osteophyteoftheleftfirstribina60-year-oldwoman.(a)Posteroanteriorchestradiographshowsapoorlydefinednodularareaofincreasedopacityoverlyingtheanterioraspectoftheleftfirstrib(arrow).(b)Posteroanteriorchestradiographobtained2yearsearliershowsthatintervalgrowthhasoccurred(cfa).Thisintervalgrowthraisedsuspicionformalignancy.(c)ContiguouschestCTscans(imageonrightobtainedatalowerlevel)revealthattheareaofincreasedopacityisalargeosteophyteofthefirstrib.Hadfluoroscopybeenperformed,costlyCTcouldhavebeenavoided.当前第7页\共有96页\编于星期三\3点Figure5a.

Cutaneousnodulesina51-year-oldmanwithneurofibromatosisandprostaticadenocarcinoma.(a)Posteroanteriorradiographshowsnumerouswell-marginatednodularareasofincreasedopacityprojectingovertheloweraspectofthethoraxandapoorlymarginatednoduleoverlyingtheupperaspectofthelefthemithorax(arrow).Becausethelocationoftheuppernodulewasuncertain,CTwasperformed.(b)CTscanhelpsconfirmtheintraparenchymallocationofthenoduleintheleftupperlobe.(c)CTscandemonstratesmultiplecutaneousnodules.当前第8页\共有96页\编于星期三\3点Figure6a.

Segmentalbronchialatresiaina17-year-oldgirl.(a)Close-upposteroanteriorradiographoftherightlowerlungshowsanodularareaofincreasedopacityinthelowerlobe(arrow).(b)ChestCTscans(imageonleftobtainedatalowerlevel)showabranchingtubularareaofincreasedattenuationintherightlowerlobeaswellaspulmonaryparenchymawithlowerthanexpectedattenuation.Thesefindingsarecharacteristicofsegmentalbronchialatresiaandobviatedfurtherwork-up.当前第9页\共有96页\编于星期三\3点Figure7a.

Multiplearteriovenousmalformationsina23-year-oldwomanwithhereditaryhemorrhagictelangiectasia.ContiguouschestCTscansrevealmultiplesmallnodularareasofincreasedattenuationbilaterallywithenlargedfeedinganddrainingvessels,findingsthatarediagnosticforarteriovenousmalformations.Achestradiographobtainedearlier(notshown)demonstratedapossiblesmallsolitarypulmonarynoduleintherightlowerlobe.当前第10页\共有96页\编于星期三\3点当前第11页\共有96页\编于星期三\3点Figure2a:

(a)Chestradiographshowsanincidentalsmallnodule(arrow)attheleftcostophrenicangle.(b)Thin-sectionCTscanshowscentralfatattenuation(–43HU)inthenodule.Hamartomawasdiagnosed.当前第12页\共有96页\编于星期三\3点Figure4:CTscanina90-year-oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresentacongestedintrapulmonarylymphnode(arrow).Follow-upCTwasnotperformedbecauseofthepatient'sadvancedage.当前第13页\共有96页\编于星期三\3点胸部CT检测情况病灶敏感性大小≤５mm74％＞5mm82％性质毛玻璃样65％实性83％部位外周80%中央61%Radiology2003;228:70-75当前第14页\共有96页\编于星期三\3点当前第15页\共有96页\编于星期三\3点SPN恶性危险因素当前第16页\共有96页\编于星期三\3点当前第17页\共有96页\编于星期三\3点当前第18页\共有96页\编于星期三\3点SPN

大小常规胸片仅能辨别直径9mm以上结节80％良性结节直径小于2cm42％恶性结节直径小于2cm，15％恶性结节直径小于1cm,直径8mm左右结节经随访恶性发生率10-20%,直径<4mm结节恶性发生率<1%非钙化直径小于1cm结节，42-92%为良性Radiology2006;239:34-49.Radiographics.2000;20:43-58.Radiology2005;237:395-400.当前第19页\共有96页\编于星期三\3点SPN部位良性结节分布无规律性肺癌：右肺/左肺1.5，上叶占70％IPF患者合并肺癌好发于下叶外周或发生纤维化部位50％腺癌位于外周，鳞癌多为中央型Radiology2006;239:34-49.当前第20页\共有96页\编于星期三\3点TransverseCTscanina75-year-oldmanwithidiopathicpulmonaryfibrosisshowsasolidleftlowerlobenodule(arrow).FNABofthenodulerevealedsquamouscellcarcinoma.当前第21页\共有96页\编于星期三\3点SPN边缘光滑：21％恶性结节边界清，多见于转移瘤分叶：25％良性结节有分叶，恶性组织生长非均质性不规整：倾向于恶性，可见于肉芽肿性疾病、类脂性肺炎等毛刺：当前第22页\共有96页\编于星期三\3点Figure8a.

LungnodulecausedbyDirofilaria(canineheartworm)inanasymptomatic70-year-oldman.(a)Close-upCTscanoftherightlungshowsaperipheral,smoothlymarginated,noncalcifiedlungnodule.(b)Photographofaspecimenobtainedwithwedgeresectionshowsawell-circumscribed,2-cmnodulewithyellowareasofgeographicnecrosis.(c)High-powerphotomicrograph(originalmagnification,x175;hematoxylin-eosinstain)showsintravascularDirofilaria.Mostinfectionsmanifestaslungnodulesfromembolicinfarctioncausedbyintravascularworms.光滑当前第23页\共有96页\编于星期三\3点Figure9.

Solitarymetastasisfrombladdercancerina45-year-oldwoman.ChestCTscanshowsasmoothlymarginated,1-cmperipheralnodule.Metastaticdiseasewasconfirmedatresection.Solitarymetastasesaccountfor3%-5%ofallresectedsolitarypulmonarynodules.当前第24页\共有96页\编于星期三\3点分叶Figure10.

Non-smallcelllungcancerina63-year-oldwoman.Close-upchestCTscanoftherightlungshowsalobulatedandspiculatednoduleinthelowerlobe.当前第25页\共有96页\编于星期三\3点Figure11a.

Arteriovenousmalformationina34-year-oldmanwithhereditaryhemorrhagictelangiectasia.(a)Close-upposteroanteriorradiographoftherightlungshowsalobulated,well-marginatednoduleinthelowerlobe(arrows).(b)ChestCTscandemonstratesafeedingartery(arrow)andanenlargeddrainingvein(arrowhead).(c)CTscanshowsthenidusofthemalformation.(d)Pulmonaryangiogramhelpsconfirmarteriovenousmalformation.Notetheearlydrainingvein(arrows).当前第26页\共有96页\编于星期三\3点Figure12.

Intralobarsequestrationina14-year-oldboy.ChestCTscanshowsalobulated,well-marginatednodulewithhomogeneousattenuationintherightlowerlobe.Intrapulmonarysequestrationwasconfirmedatresection.当前第27页\共有96页\编于星期三\3点边缘不规整或细毛刺Figure13.

Bronchioloalveolarcellcarcinomaina65-year-oldman.ChestCTscanshowsanirregularnoduleabuttingthemajorfissure.Notetheindentationoftheadjacentportionofthemajorfissureowingtodesmoplasticreactionaroundthetumor.Figure14.

Non-smallcelllungcancerina61-year-oldwoman.Close-upchestCTscanoftherightlungshowsaspiculatednodulewitheccentriccavitationintheupperlobe.当前第28页\共有96页\编于星期三\3点SPN内部特征钙化脂肪密度结节衰减空洞空泡征支气管充气征当前第29页\共有96页\编于星期三\3点钙化55％良性结节有钙化结节直径小于3cm，有下列钙化形式之一考虑良性：中心性，分层，弥漫性，爆米花样，超过结节面积10％13％肺癌有不同程度的钙化－偏心样钙化类癌、转移性骨肉瘤、软骨肉瘤、结肠癌、卵巢癌也可表现为良性钙化当前第30页\共有96页\编于星期三\3点Figure21.

Granulomainanasymptomatic64-year-oldman.Close-upchestCTscanoftheleftlungshowsasoft-tissuenodulewithcentralcalcificationintheupperlobe.Notetheeccentriccavitationwithinthenodule.Figure23.

Pulmonarychondrohamartomaina40-year-oldman.Close-upchestCTscanoftherightlungshowsalobulatednodulewithcentralpopcornlikecalcificationintheupperlobe.当前第31页\共有96页\编于星期三\3点Figure22a.

Histoplasmomainanasymptomatic50-year-oldman.(a)Close-uptomogramoftheleftlungdemonstratesasmooth,well-marginatednodule.(b)Photographofaresectedspecimenhelpsconfirmcentralcalcificationandlaminatedfibroustissue.当前第32页\共有96页\编于星期三\3点Figure28a.

Granulomatousdiseaseina48-year-oldwoman.(a)ChestCTscan(10-mmcollimation)showsanodulewithperipheralcalcificationandacalcifiedrighthilarnode.(b)Thin-sectionCTscan(3-mmcollimation)betterdemonstratesthediffusesolidcalcificationinthenodule,afindingthatistypicalofabenigncause当前第33页\共有96页\编于星期三\3点Figure8:TransverseCTscanshowsa1-cm-diameterleftlowerlobenodulewithcentralniduscalcification.Thisfindingisindicativeofbenigndisease.当前第34页\共有96页\编于星期三\3点Figure9a:

(a)Chestradiographshowsarightupperlobenodulewithcentralcalcification.Themarginsareirregular.(b)CTscanshowsarightupperlobenodulewithirregularmarginsthatrepresentspulmonarycarcinoma(blackarrow).Thecalcificationseenontheradiographiscausedbyacalcifiedgranulomaanteriortothetumor(whitearrow).当前第35页\共有96页\编于星期三\3点Figure10:CTscaninan80-year-oldmanshowsa2.2-cm-diameternoduleintheleftupperlobewitheccentriccalcification.FNABofthenodulerevealedadenocarcinoma.Figure11:CTscanshowseccentricdensecalcificationinarightlowerlobecarcinoidtumor当前第36页\共有96页\编于星期三\3点Figure12:CTscanshowscalcifiedrightlowerlobenodulethatresemblesabenigngranuloma(arrow).Thepatienthadahistoryofosteosarcoma.Openlungbiopsyrevealedmetastaticdisease.当前第37页\共有96页\编于星期三\3点Figure24.

Typicalpulmonarycarcinoidtumorina68-year-oldwoman.ChestCTscanshowsalobulatedlesionwithscatteredpunctatecalcificationsintheleftlowerlobe.当前第38页\共有96页\编于星期三\3点Figure25a.

Non-smallcelllungcancerina45-year-oldwoman.(a)Close-upchestradiographoftherightlungshowsalobulated,sharplymarginatednoduleintheupperlobe.Notethepresenceofemphysemaandupperlobebullae.(b)Close-upchestCTscanoftherightlungrevealsamorphouscalcificationinthenodule,apatternthatistypicalofmalignancy.Adenocarcinomawasconfirmedatresection.当前第39页\共有96页\编于星期三\3点Figure26.

Lungcancerina72-year-oldman.Close-upchestCTscanoftherightlungshowsalobularlesionwithperipheralpunctatecalcificationintheupperlobe,afindingthatisconsistentwith"engulfed"granuloma.Unlikethatincalcifiedgranulomas,calcificationinengulfedgranulomaistypicallyperipheralandconstitutesonlyasmallpartofthenodule.当前第40页\共有96页\编于星期三\3点Figure27a.

Metastaticosteosarcomaina21-year-oldman.(a)Close-upchestCTscanoftheleftlungshowsasmall,high-attenuationnoduleinthelowerlobe(arrow).Thisfindingwassuggestiveofabenigncause.(b)ChestCTscanobtained8monthslaterrevealsintervalgrowthofthenodule,whichhashighattenuationandalobulatedcontour.Resectionrevealedmetastaticosteosarcoma.当前第41页\共有96页\编于星期三\3点脂肪密度良性：错构瘤、脂肪瘤恶性：脂肉瘤、肾透明细胞癌当前第42页\共有96页\编于星期三\3点Figure19a.

Hamartomainanasymptomaticman.(a)ChestCTscanshowsaheterogeneous,sharplymarginatedlesionwithsmallfocalareasofcalcificationandfat.Thesefindingsaretypicalfeaturesofhamartoma.(b)Photographofaresectedspecimendemonstratesayellowish,glistening,lobularcutsurface,afindingthatisconsistentwithfat.(c)Photomicrograph(originalmagnification,x100;hematoxylin-eosinstain)helpsconfirmthepresenceofadiposetissue(arrow)andshowsepithelialtissuecontaininganislandofbasophiliccartilage(arrowhead).Thismixtureofepithelialandmesenchymaltissueisdiagnosticforhamartoma.当前第43页\共有96页\编于星期三\3点Figure20a.

Pulmonaryhamartomaina74-year-oldwoman.(a)ChestCTscanobtainedwith10-mmcollimationdemonstratesanodule(arrow),butitsinternalmorphologicfeaturesarepoorlyvisualized.(b)Thin-sectionCTscanobtainedwith1-mmcollimationbetterdemonstratesapunctateareaoffatwithinthenodule(arrow),afindingthatisdiagnosticforhamartoma.当前第44页\共有96页\编于星期三\3点结节衰减非实性（毛玻璃样）：34％为恶性，直径大于1.5cm圆形恶性风险度增加（多见于BAC、腺癌有BAC特征）良性：炎症性病变，癌前病变（不典型腺瘤样增生，支气管肺泡过度增生）部分实性：40-50%直径小于1.5cm结节为恶性，实性成分位于中央区提示侵袭性腺癌实性：15％直径小于1cm病灶为恶性，转移性病灶多为实性当前第45页\共有96页\编于星期三\3点Figure14:CTscaninan81-year-oldmanshowsa2.8-cmirregular,partlysolidleftupperlobenodulewithpleuraltags.FNABrevealedbronchioloalveolarcellcarcinoma.Figure13:CTscanina64-year-oldmanshowsanoval2.1-cmleftlowerlobenonsolidnodule(arrow).FNABrevealedadenocarcinoma.当前第46页\共有96页\编于星期三\3点空洞(>5mm)良性空洞：壁光滑、薄(<4mm)恶性空洞：偏心、壁不规整、厚(>16mm)15%肺癌有空洞（病灶直径>3cm）当前第47页\共有96页\编于星期三\3点Figure16.

Aspergillusinfectionina48-year-oldmanwithleukemia.Close-upchestCTscanoftherightlungshowsathin-walledcavitarynodule.Figure17.

Squamouscelllungcancerina60-year-oldwoman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednoduleinthelowerlobe.Notetheeccentriccavitationandthickwalls.当前第48页\共有96页\编于星期三\3点Figure18:CTscaninan83-year-oldmanshowsa2.3-cmleftupperlobecavitarynodule.Thewallisvariableandthecavitywallisasthickas8mm.FNABrevealedsquamouscellcarcinoma.Figure19:CTscaninan80-year-oldmanshowsarightupperlobe2.9-cmcavitarynodulewithasmooth,uniform2.5-mm-thickcavitywall.FNABrevealednon–smallcelllungcancer.当前第49页\共有96页\编于星期三\3点Figure18.

Bullettrackfromagunshotwoundina20-year-oldman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginated,thick-wallednodulewitheccentriclucencyinthemidlung.Notethebulletfragmentsoverlyingtherightlung.Thesefindingsareconsistentwithparenchymalhematomaandabullettrack.当前第50页\共有96页\编于星期三\3点空泡征：空泡征为肿瘤内小的低密度影，多为2～3mm大小，1个或多个，CT扫描仅限于1～2个层面见到。空泡征是未闭塞的小支气管或肺泡，主要原因同支气管空气征一样，为癌细胞呈伏壁生长，部分肺泡腔和细支气管未被肿瘤组织填充，肿瘤内的纤维组织或瘢痕组织的牵拉而扩张。多见于BAC或腺癌当前第51页\共有96页\编于星期三\3点支气管充气征是指结节内见到充气的支气管，CT表现为气体密度小管影。此征多见于中高分化的腺癌，癌细胞沿着支气管呈伏壁生长，肺的支架结构未被破坏，肿瘤内的支气管结构仍保存。有此征象的肿瘤与无此征象的肿瘤相比，具有相对低度恶性的生物学行为。在恶性SPN的发生率为26．9％～65．0％而在良性SPN，其发生率仅为0．0％～5．9％

当前第52页\共有96页\编于星期三\3点SPN与支气管的关系I型：支气管被SPN截断II型：支气管进入SPN呈锥状中断Ⅲ型：支气管在SPN内呈长段开放状，并可进一步分叉Ⅳ型：支气管紧贴SPN边缘走行，管腔形态正常V型：支气管紧贴SPN边缘走行，管腔受压变扁ClinicalRadiology(2004)59,1121–1127当前第53页\共有96页\编于星期三\3点当前第54页\共有96页\编于星期三\3点当前第55页\共有96页\编于星期三\3点当前第56页\共有96页\编于星期三\3点当前第57页\共有96页\编于星期三\3点当前第58页\共有96页\编于星期三\3点当前第59页\共有96页\编于星期三\3点恶性结节最常见的肿瘤一支气管关系是I型，其次为Ⅳ型，V型最少见；良性结节最常见的是V型，其次为I型，未见到Ⅱ型。就肿瘤一支气管关系类型而言，I型恶性SPN多于良性SPN，后者主要见于结核球；Ⅱ型仅见于恶性SPN；Ⅲ型可见于恶性和良性SPN，但前者的支气管形态僵硬，管腔保持通畅甚或轻度扩张；后者支气管形态柔软，走向自然，管腔扩张度不如恶性肿瘤，并常见支气管有多个树枝状分又及支气管呈断续状表现；IV型以恶性SPN占绝大多数V型则以良性SPN多见。当前第60页\共有96页\编于星期三\3点SPN一支气管关系类型的病理基础膨胀性生长：瘤细胞增殖、堆积，呈实性压迫、推移邻近肺组织，由于肿瘤为支气管源性，故导致支气管在肿瘤边缘截断。伏壁性生长：以肺结构为支架，瘤细胞沿肺泡壁和肺泡隔爬行，经肺泡孔扩展，同时可经淋巴道、小气道或以直接浸润的方式从1个肺小叶扩展到另1个肺小叶，而支气管仍保持通畅，形成支气管充气征。当前第61页\共有96页\编于星期三\3点支气管管壁由外向内的肿瘤浸润、管壁产生的纤维性增殖性反应使支气管管壁增厚、僵硬，加上瘤内成纤维化反应的牵拉，使瘤内的支气管不仅未被肿瘤压扁，反而保持高度的通畅，甚至有所扩张，形成恶性肿瘤的含气支气管征特有的表现。良性结节边缘的支气管未受肿瘤侵犯和成纤维化反应的影响，管壁仍很柔软，易受膨胀性生长的结节压迫，导致管腔变扁甚至闭塞。结核球引起支气管截断是由于后者参与形成包膜。炎性假瘤的含气支气管征由肺实质的渗出、实变、机化衬托引起，支气管形态自然，常见树枝状分叉，管腔内可有分泌物、出血或血栓，使支气管表现为断续状。当前第62页\共有96页\编于星期三\3点SPN血管特征恶性结节增强超过良性结节CT增强值低于15HU倾向于良性CT净增值超过25HU，清除值5-31HU倾向恶性当前第63页\共有96页\编于星期三\3点AJR2007;188:57-68当前第64页\共有96页\编于星期三\3点Graphoffourdifferenttypesoftime-attenuationcurveofnodulehemodynamicsinconsiderationofbothwash-inandwashoutphasesofdynamicCT.Radiology2005;237:675-683当前第65页\共有96页\编于星期三\3点PatternsofNoduleEnhancementatEarlyandDelayedEnhancementCT

当前第66页\共有96页\编于星期三\3点PatternsofNoduleEnhancementaccordingtoHistologicDiagnosis当前第67页\共有96页\编于星期三\3点Fig.4A

—Metastaticadenocarcinomain57-year-oldmanwithrectalcancershowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTandpositiveuptakeonintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows9-mmnodule(arrow)inleftupperlobe.当前第68页\共有96页\编于星期三\3点Fig.3A

—Adenocarcinomain67-year-oldmanshowsnetenhancementof25Handwashoutof5-31HatdynamichelicalCTandpositiveuptakeatintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows16-mmnodule(arrow)inleftupperlobehaslobulatedandspiculatedmargin.当前第69页\共有96页\编于星期三\3点Figure3a.CTscansoftuberculomawithtypeIIenhancement(<25HUwash-in)ina58-year-oldman.(a)Transversethin-section(2.5-mmcollimation)scanobtainedwithlungwindowattheleveloftherightmainbronchusshows21-mmnodulewithlobulatedandspiculatedmarginintherightupperlobe.(b)Serialimageswithdynamicenhancementcurveforthenodule.Peakenhancementis49HU;netenhancement,3HU;andabsolutelossofenhancement(washout),1HU.当前第70页\共有96页\编于星期三\3点Figure4a.CTscansoforganizingpneumonia(focalpneumoniawithoutspecificmicroorganism)withtypeIIIenhancement(25HUwash-inwithpersistentenhancement)ina58-year-oldwoman.(a)Transversethin-section(2.5-mmcollimation)scanobtainedwithlungwindowatthelevelofthehepaticdomeshows14-mmnodule(arrow)inrightlowerlobe.Bronchiectasisisalsoseeninbothlowerlobes.(b)Serialimageswithdynamicenhancementcurveforthenodule.Peakenhancementis118HU;netenhancement,69HU.Thisnoduleshowedpersistentenhancementwithoutabsolutelossofenhancement.当前第71页\共有96页\编于星期三\3点Figure5.CTscansofleiomyomawithtypeIVenhancement(25HUwash-in,>31HUwashout)ina45-year-oldwoman.Serialimageswithdynamicenhancementcurvefortheleftlowerlobenoduleshowpeakenhancementis165HU;netenhancement,133HU;absolutelossofenhancement(washout),90HU;andtimetopeakenhancement,1minute.当前第72页\共有96页\编于星期三\3点当前第73页\共有96页\编于星期三\3点Figure1a.

(a)Transverse,nonenhancedspiralCTimage(3-mmcollimation)througharelativelyhomogeneous15-mmrightupperlobelungadenocarcinomarecurrenceina71-year-oldwoman.Notethemanuallyplacedregionofinterest(1)onanodule.Theregionofinterestispositionedcentrally,anditsshapeapproximatesthatofthenoduleonthecross-sectionalimage.Itsnetenhancementvaluewas14HU.(b)Photomicrographofthisadenocarcinomashowsanappearanceconsistentwithlymphangiticmetastasis.Notethecentralzoneofnecrosis(arrows).Thereislittlevascularstroma,whichmayhavebeenafactorinitsrelativelylowenhancementvalue.(AntibodytofactorVIII-associatedantigen;originalmagnification,x50.)当前第74页\共有96页\编于星期三\3点周围型肺癌的血供源于支气管动脉，肿瘤间质内血管丰富，且分化不成熟，血管分布紊乱，基底膜不完整，管壁通透性高，有利于大分子造影剂渗入细胞间隙，部分肺癌微血管扩张，利于造影剂在血管内停留。炎性结节形成过程中，肺动脉水平上发生弥漫性血栓，血供直接源于支气管动脉，造影剂通过相对较直的、结构正常的血管进入间质，进入血管周围间质的造影剂因淋巴管的通畅加快了引流。部分恶性及良性病灶持续强化无清除可能与局部组织纤维化的程度数量相关。病理学基础：当前第75页\共有96页\编于星期三\3点SPN生长速度评价大部分恶性结节倍增时间30-400天2年随访病灶稳定，倍增时间至少730天倾向良性疾病倍增时间小于7天，超过465天倾向良性直径小于1cm病灶较难评价Radiographics.2000;20:59-66当前第76页\共有96页\编于星期三\3点计算公式

Td=Ti·log2/3·log(Di/Do)

Ti=intervaltimeDi=initialdiameterDo=finaldiameter当前第77页\共有96页\编于星期三\3点Figure1.

Effectofinitialnodulesizeonperceptionofgrowth.Schematicillustratestwovolumedoublingsofa4-mmnoduleanda3-cmnodule.Becausetheeyeperceivesthearithmeticincreaseindiameterratherthanthechangeinvolume,thesmallernoduleappearstobegrowingmoreslowlythanthelargerone,eventhoughbotharedoublinginvolumeatthesamerate.当前第78页\共有96页\编于星期三\3点Figure21a:

(a)CTscaninan80-year-oldmanshowsa2.5-cmrightupperlobenoduleattheposteriorsegment.(b)RepeatCTscanobtainedpriortotreatmentperformed2monthslatershowsrapidintervalenlargement.Thevolumetricdoublingtimewas26days.FNABrevealedmixedsmallcellandnon–smallcellcarcinoma.当前第79页\共有96页\编于星期三\3点Bayesian

Analysis

根据临床资料和影像学特征计算pCapCa<0.12影像学随访pCa0.12-0.69行CT、PET检查pCa0.70-0.90行活检、手术pCa>0.90手术NEnglJMed2003Jun19;348(25):2535-42当前第80页\共有96页\编于星期三\3点EffectofageandsmokinghistoryonpCainanindeterminatepulmonarynodule.Close-upchestCTscanoftherightlungshowsa7-mm,smoothlymarginated,noncalcifiednoduleinthemiddlelobe.Onthebasisofdecisionanalysis,observationwouldbethemostcost-effectivemanagementstrategyina35-year-oldnonsmoker(pCa=0.01)orcurrentsmoker(pCa=0.05),andbiopsywouldbethemostcost-effectivemanagementstrategyina70-year-oldnonsmoker(pCa=0.07)orcurrentsmoker(pCa=0.50)当前第81页\共有96页\编于星期三\3点其他辅助检查对于SPN诊断价值PET胸部低剂量螺旋CTFNABVATS当前第82页\共有96页\编于星期三\3点PET直径1-3cm实性结节，敏感性94％特异性83％SUV值超过2.5即为阳性假阳性：局部感染，炎症，肉芽肿性疾病假阴性：病灶直径小于1cm，类癌，BAC当前第83页\共有96页\编于星期三\3点Figure7a.

Non-smallcelllungcancerina65-year-oldman.(a)ChestCTscanshowsasmallnoduleintheleftlowerlobe.(b)AxialFDGPETscanshowsmarkedFDGaccumulationinthenodule,afindingthatissuspicious