孤立性肺结节：良性与恶性对比

Solitarypulmonarynodule:benignversusmalignant

孤立性肺结节：良性(liánɡxìnɡ)与恶性对比第一页，共三十一页。编辑课件Thedifferentialdiagnosisofasolitarypulmonarynoduleisbroadandmanagementdependsonwhetherthelesionisbenignormalignant.孤立性肺结节的鉴别诊断是很多的，处理方法依赖于该病变是良性还是恶性

InthisoverviewwewilldiscusssomeofthenewfeaturesthatcanhelptodifferentiatebetweenbenignandmalignantnodulesbaseduponCTandPET-CTfindings.在此篇文章，我们着重讨论(tǎolùn)下一些有助于鉴别良恶性结节的新特征，此特征是基于CT与PET-CT的检查结果第二页，共三十一页。编辑课件CT:benignversusmalignantCalcification

SizeGrowth

Shape

Margin

AirBronchogramsign

SolidandGround-glasscomponents

Contrastenhancement

第三页，共三十一页。编辑课件CT:良性(liánɡxìnɡ)与恶性钙化大小生长速度形状(xíngzhuàn)边缘支气管含气征实性或磨玻璃样增强特征第四页，共三十一页。编辑课件Calcification钙化(gàihuà)Diffuse,central,laminatedorpopcorncalcificationsarebenignpatternsofcalcification.弥漫性，中心(zhōngxīn)性，分层，爆米花钙化是良性钙化，第五页，共三十一页。编辑课件Thesetypesofcalcificationareseeningranulomatousdiseaseandhamartomas这些(zhèxiē)形式的钙化最常见于错构瘤、肉芽肿性病变第六页，共三十一页。编辑课件Theexceptiontotheruleaboveiswhenpatientsareknowntohaveaprimarytumor.

Forinstancethediffusecalcificationpatterncanbeseeninpatientswithosteosarcomaorchondrosarcoma.

SimilarlythecentralandpopcornpatterncanbeseeninpatientswithGI-tumorsandpatientswhopreviouslyhadchemotherapy.一些病人(bìngrén)有原发肿瘤病史，可以表现为良性钙化例如骨肉瘤、软骨肉瘤可以表现弥漫性钙化。胃肠间质瘤的病人化疗后可以表现为中心性或苞米花钙化。第七页，共三十一页。编辑课件Size大小(dàxiǎo)Asolitarypulmonarynodule(SPN)isdefinedasasingleintraparenchymallesionlessthan3cminsizeandnotassociatedwithatelectasisorlymphadenopathy.

Alesiongreaterthan3cmindiameteriscalledamass.

孤立性结节定义(dìngyì)为小于3cm，不伴有肺不张、淋巴结转移，大于3cm的为肿块Thisdistinctionismade,becauselesionsgreaterthan3cmareusuallymalignant,whilesmallerlesionscanbeeitherbenignormalignant.以3cm为界，因为大于3cm的通常是恶性的，而小于3cm的可能是良性或恶性。第八页，共三十一页。编辑课件RelationshipbetweenSPN-sizeandchanceofmalignancyinpatientswithhighriskforlungcancer

结节(jiéjié)大小与恶性度具有密切相关性第九页，共三十一页。编辑课件Growth生长(shēngzhǎng)速度ComparisonwithpriorimagingstudiesisoftenthemostusefulproceduretodeterminetheimportanceofthefindingofaSPN,sincestabilityover2yearsishighlyassociatedwithbenignity.与前次影像结果相比是鉴别孤立性结节良恶性的一个非常有用(yǒuyònɡ)的方法。如果超过2年以上保持不变，这个结节就是良性结节第十页，共三十一页。编辑课件Shape形态(xíngtài)Japanesescreeningstudiesshowedthatapolygonalshapeandathree-dimensionalratio>1.78wasasignofbenignity(2,3).

日本(rìběn)的一项研究表明，多变形和三维立体比率大于1.78是良性结节的标志Apolygonalshapemeansthatthelesionhasmultiplefacets(multi-sided).

多边形意味这个病灶具有多个面Aperipheralsubpleurallocationwasalsoasignofbenignityinthisstudy在这项研究中，周围的胸膜下的病变也是良性结节的一个标志第十一页，共三十一页。编辑课件Thethree-dimensionalratioismeasuredbyobtainingthemaximaltransversedimensionanddividingitbythemaximalverticaldimension.

Alargethree-dimensionalratioindicatesthatthelesionisrelativelyflat,whichisabenignsign.第十二页，共三十一页。编辑课件Margin边缘(biānyuán)Coronaradiatasign-highlyassociatedwithmalignancy(figure)放射(fàngshè)冠征Lobulatedorscallopedmargins-intermediateprobability分叶征和锯齿征第十三页，共三十一页。编辑课件Smoothmargins-morelikelybenignunlessmetastaticinorigin边缘光滑见于良性(liánɡxìnɡ)结节，除外转移瘤第十四页，共三十一页。编辑课件AirBronchogramsign

空气(kōngqì)支气管征Recentstudieshaveshowedthatanairbronchogramismorecommonlyseeninmalignantpulmonarynodules.

ItismostcommonlyseeninBAC(bronchoalveolarcellcarcinoma)andadenocarcinoma.最近一项研究表明，在恶性结节中经常看见(kànjiàn)空气支气管征，主要见于支气管肺泡癌或腺癌第十五页，共三十一页。编辑课件Thecaseontheleftshowsanairbronchogramseenasalinearlucency(broadarrow)andasamorecysticlucency(smallarrow)duetothefactthatthebronchusisseenenface.第十六页，共三十一页。编辑课件Onthelefttwosolitarypulmonarynodules.

Baseduponthemorphology,whichlesionhasthemostmalignantfeatures?下列两个结节有哪些恶性(èxìng)特征呢第十七页，共三十一页。编辑课件Thelesiononthefarlefthasaspicuatedmarginandhaslucencieswithinit.

Thelesionnexttoitislobulatedincontourandhassomespiculesradiatingtothepleura.

Itishoweverhomogeneousinattenuation.

Basedonthesefindingsweshouldbemostconcernedthatthelesiononthefarleftismalignant.

Itprovedtobeanadenocarninoma,whiletheotheronewasafungalinfection.

Thelucenciesandfrankairbronchogramsshouldnotmisleadyouinthinkingthatitprobablyisinfection.第十八页，共三十一页。编辑课件SolidandGround-glasscomponents

实性与磨玻璃(bōlí)样Anotherresultfromscreeningstudiesisthatnodulescontainingaground-glasscomponentaremorelikelytobemalignant(5).

另一项研究表明，含有磨玻璃样密度的结节很可能是恶性结节。Partlysolidlesionswithground-glasscomponentshadamalignancyrateof63%.部分(bùfen)实性和磨玻璃样密度是恶性结节的可能性事63%Nonsolid-onlyground-glasslesionshadamalignancyrateof18%.完全磨玻璃样密度结节16%是恶性结节Onlysolidlesionshadamalignancyrateofonly7%.完全实性结节是仅7%是恶性结节第十九页，共三十一页。编辑课件Partlysolidnodulecontainingground-glasscomponentmostlikelytobemalignant第二十页，共三十一页。编辑课件Onthefarleftalesionthatonlyhasaground-glassappearanceandnexttoitalesionthathasbothground-glassandsolidcomponents.

Thelikelihoodofmalignancyis1:5forthelesiononthefarleftand2:3forthelesionwithbothground-glassandsolidcomponents.第二十一页，共三十一页。编辑课件LEFT:1in5malignant

左边(zuǒbian)图是5个病灶1个为恶性结节RIGHT:2in3malignant右边图是3个病灶2个为恶性结节第二十二页，共三十一页。编辑课件Contrastenhancement

对比(duìbǐ)增强Contrastenhancementlessthan15HUhasaveryhighpredictivevalueforbenignity(99%).

Afterabaselinescan,4consecutivescansat1minuteintervalareperformed.

对比增强(zēngqiáng)小于15HU是良性病变的可能性（99%）

第二十三页，共三十一页。编辑课件Thisappliesonlyfornoduleswiththefollowingselectioncriteria:Nodule>5mm结节大于5mmRelativelyspherical相对圆形Homogeneous,nonecrosis,fatorcalcification均匀，无坏死(huàisǐ)、钙化Nomotionorbeamhardeningartifacts没有运动、硬射线伪影第二十四页，共三十一页。编辑课件PET-CT:benignversusmalignantPET-CTplaysanincreasinglyimportantroleintheevaluationofsolitarynodules.PET-CT在肺结节的评价(píngjià)中起着很重要作用第二十五页，共三十一页。编辑课件PEThasaveryhighsensitivity95%,butalesserspecificityofonly81%PET有很高的敏感性95%，但特异性仅为81%PETisfalsepositiveingranulomatousdiseasePET是假阳性在炎症性疾病中国PETisusuallyfalsenegativeinsize<10mmandlow-grademalignancyincludingbronchoalveolarcarcinomaandcarcinoid当病变小于19mm时或低度恶性时，PET表现为假阴性(yīnxìng)，包括支气管肺泡癌和类癌第二十六页，共三十一页。编辑课件FalsenegativePETinapatientwithadenocarcinoma.

Activityisnotsufficientforthediagnosismalignancy.

第二十七页，共三十一页。编辑课件Conclusion

结论(jiélùn)Inthedifferentiationofbenignversusmalignantsolitarypulmonarynodulesnowadaysnewimagingfeatureshavetobeadded.

Weespeciallyhavetolookforthepresenceofareasofground-glassopacity,airbronchogramsorcavitiesandthethree-dimensionalratiosofalesion.在肺结节的鉴别(jiànbié)诊断中，一些征象将被增加，包括磨玻璃密度、空气支气管征、空洞及三维立体比率第二十八页，共三十一页。编辑课件WiththeincreasinglyimportantroleofPET-CT,wehavetobeawareoftheaccuracyofPET-CTandweshouldhaveanideaabouttheprevalenceofinfectiousandnon-infectiousgranulomatousdiseaseintheareathatwepractice.我们应该充分意识到PET-CT的重要性，在实践诊断(zhěnduàn)中应该注意感染性与非感染性疾病的流行情况第二十九页，共三十一页。编辑课件ReferencesCTScreeningforLungCancer:Five-yearProspectiveExperi