孤立性肺结节的诊断现状课件.ppt

1、精选ppt1定义：（coin leision)任何肺内或胸膜的病灶，在X线上表现直径在2-30mm，边缘清晰或不清晰的圆形或类圆形阴影。Fleischer Society Glossary 肺实质内直径3cm圆形或类圆形的病灶，不伴有淋巴结肿大，阻塞性肺炎或肺不张。Chest 2003；123：89-96 精选ppt20.09%-0.20 所有胸片 150，000/年 （预计）病因：肉芽肿性疾病、肺癌、错构瘤 恶性结节恶性结节：1070 占手术切除肺结节的60-80%IA期肺癌术后5年生存率61-75 良性结节良性结节：感染性肉芽肿 80 错构瘤 10精选ppt3病因病因精选ppt4Figur

2、e 1a.Rib fracture in a 50-year-old woman with multiple myeloma.(a)Close-up posteroanterior radiograph of the right upper lung shows a poorly marginated nodular area of increased opacity overlying the anterior aspect of the right second rib(arrow).(b)CT scan shows a healed fracture of the right secon

3、d rib(arrow).Note the lytic lesions in the vertebral body secondary to multiple myeloma.精选ppt5Figure 2a.Pseudonodule in a 50-year-old man.(a)Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung(arrow).Note the ad

4、jacent electrocardiographic lead attachment pad(arrowhead).On a follow-up radiograph obtained after removal of the attachment pad(not shown),no nodule was observed.(b)Front and back views of the electrocardiographic lead attachment pad show an eccentrically located silver nitrate pad,which explains

5、the contiguous nodular area of increased opacity on the chest radiograph.精选ppt6Figure 4a.Osteophyte of the left first rib in a 60-year-old woman.(a)Posteroanterior chest radiograph shows a poorly defined nodular area of increased opacity overlying the anterior aspect of the left first rib(arrow).(b)

6、Posteroanterior chest radiograph obtained 2 years earlier shows that interval growth has occurred(cf a).This interval growth raised suspicion for malignancy.(c)Contiguous chest CT scans(image on right obtained at a lower level)reveal that the area of increased opacity is a large osteophyte of the fi

7、rst rib.Had fluoroscopy been performed,costly CT could have been avoided.精选ppt7Figure 5a.Cutaneous nodules in a 51-year-old man with neurofibromatosis and prostatic adenocarcinoma.(a)Posteroanterior radiograph shows numerous well-marginated nodular areas of increased opacity projecting over the lowe

8、r aspect of the thorax and a poorly marginated nodule overlying the upper aspect of the left hemithorax(arrow).Because the location of the upper nodule was uncertain,CT was performed.(b)CT scan helps confirm the intraparenchymal location of the nodule in the left upper lobe.(c)CT scan demonstrates m

9、ultiple cutaneous nodules.精选ppt8Figure 6a.Segmental bronchial atresia in a 17-year-old girl.(a)Close-up posteroanterior radiograph of the right lower lung shows a nodular area of increased opacity in the lower lobe(arrow).(b)Chest CT scans(image on left obtained at a lower level)show a branching tub

10、ular area of increased attenuation in the right lower lobe as well as pulmonary parenchyma with lower than expected attenuation.These findings are characteristic of segmental bronchial atresia and obviated further work-up.精选ppt9Figure 7a.Multiple arteriovenous malformations in a 23-year-old woman wi

11、th hereditary hemorrhagic telangiectasia.Contiguous chest CT scans reveal multiple small nodular areas of increased attenuation bilaterally with enlarged feeding and draining vessels,findings that are diagnostic for arteriovenous malformations.A chest radiograph obtained earlier(not shown)demonstrat

12、ed a possible small solitary pulmonary nodule in the right lower lobe.精选ppt10Figure 2a:(a)Chest radiograph shows an incidental small nodule(arrow)at the left costophrenic angle.(b)Thin-section CT scan shows central fat attenuation(43 HU)in the nodule.Hamartoma was diagnosed.精选ppt11Figure 4:CT scan i

13、n a 90-year-old woman with chronic congestive heart failure shows a tiny nodule adjacent to the right major fissure that is likely to represent a congested intrapulmonary lymph node(arrow).Follow-up CT was not performed because of the patients advanced age.精选ppt12病灶敏感性 大小mm74 5mm82性质 毛玻璃样65 实性83部位 外

14、周80%中央61%Radiology 2003;228:70-75精选ppt13精选ppt14精选ppt15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Radiology 2006;239:34-49.Radiographics.2000;20:43-58.Radiology 2005;237:395-400.精选ppt16良性结节分布无规律性肺癌：右肺/左肺 1.5，上叶占70IPF患者合并肺癌好发于下

15、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Radiology 2006;239:34-49.精选ppt17Transverse CT scan in a 75-year-old man with idiopathic pulmonary fibrosis shows a solid left lower lobe nodule(arrow).FNAB of the nodule revealed squamous cell carcinoma.精选ppt18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

16、脂性肺炎等毛刺：精选ppt19Figure 8a.Lung nodule caused by Dirofilaria(canine heartworm)in an asymptomatic 70-year-old man.(a)Close-up CT scan of the right lung shows a peripheral,smoothly marginated,noncalcified lung nodule.(b)Photograph of a specimen obtained with wedge resection shows a well-circumscribed,2-

17、cm nodule with yellow areas of geographic necrosis.(c)High-power photomicrograph(original magnification,x175;hematoxylin-eosin stain)shows intravascular Dirofilaria.Most infections manifest as lung nodules from embolic infarction caused by intravascular worms.光滑精选ppt20Figure 9.Solitary metastasis fr

18、om bladder cancer in a 45-year-old woman.Chest CT scan shows a smoothly marginated,1-cm peripheral nodule.Metastatic disease was confirmed at resection.Solitary metastases account for 3%-5%of all resected solitary pulmonary nodules.精选ppt21分叶Figure 10.Non-small cell lung cancer in a 63-year-old woman

19、.Close-up chest CT scan of the right lung shows a lobulated and spiculated nodule in the lower lobe.精选ppt22Figure 11a.Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia.(a)Close-up posteroanterior radiograph of the right lung shows a lobulated,well-marginated

20、nodule in the lower lobe(arrows).(b)Chest CT scan demonstrates a feeding artery(arrow)and an enlarged draining vein(arrowhead).(c)CT scan shows the nidus of the malformation.(d)Pulmonary angiogram helps confirm arteriovenous malformation.Note the early draining vein(arrows).精选ppt23Figure 12.Intralob

21、ar sequestration in a 14-year-old boy.Chest CT scan shows a lobulated,well-marginated nodule with homogeneous attenuation in the right lower lobe.Intrapulmonary sequestration was confirmed at resection.精选ppt24边缘不规整或细毛刺边缘不规整或细毛刺Figure 13.Bronchioloalveolar cell carcinoma in a 65-year-old man.Chest CT

22、 scan shows an irregular nodule abutting the major fissure.Note the indentation of the adjacent portion of the major fissure owing to desmoplastic reaction around the tumor.Figure 14.Non-small cell lung cancer in a 61-year-old woman.Close-up chest CT scan of the right lung shows a spiculated nodule

23、with eccentric cavitation in the upper lobe.精选ppt25钙化脂肪密度结节衰减空洞空泡征支气管充气征精选ppt2655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1013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 精选ppt27Figure 21.Granuloma in an asymptomatic 64-year-old man.Close-up chest CT scan of the left lung shows a soft

24、-tissue nodule with central calcification in the upper lobe.Note the eccentric cavitation within the nodule.Figure 23.Pulmonary chondrohamartoma in a 40-year-old man.Close-up chest CT scan of the right lung shows a lobulated nodule with central popcornlike calcification in the upper lobe.精选ppt28Figu

25、re 22a.Histoplasmoma in an asymptomatic 50-year-old man.(a)Close-up tomogram of the left lung demonstrates a smooth,well-marginated nodule.(b)Photograph of a resected specimen helps confirm central calcification and laminated fibrous tissue.精选ppt29Figure 28a.Granulomatous disease in a 48-year-old wo

26、man.(a)Chest CT scan(10-mm collimation)shows a nodule with peripheral calcification and a calcified right hilar node.(b)Thin-section CT scan(3-mm collimation)better demonstrates the diffuse solid calcification in the nodule,a finding that is typical of a benign cause 精选ppt30Figure 8:Transverse CT sc

27、an shows a 1-cm-diameter left lower lobe nodule with central nidus calcification.This finding is indicative of benign disease.精选ppt31Figure 9a:(a)Chest radiograph shows a right upper lobe nodule with central calcification.The margins are irregular.(b)CT scan shows a right upper lobe nodule with irre

28、gular margins that represents pulmonary carcinoma(black arrow).The calcification seen on the radiograph is caused by a calcified granuloma anterior to the tumor(white arrow).精选ppt32Figure 10:CT scan in an 80-year-old man shows a 2.2-cm-diameter nodule in the left upper lobe with eccentric calcificat

29、ion.FNAB of the nodule revealed adenocarcinoma.Figure 11:CT scan shows eccentric dense calcification in a right lower lobe carcinoid tumor 精选ppt33Figure 12:CT scan shows calcified right lower lobe nodule that resembles a benign granuloma(arrow).The patient had a history of osteosarcoma.Open lung bio

30、psy revealed metastatic disease.精选ppt34Figure 24.Typical pulmonary carcinoid tumor in a 68-year-old woman.Chest CT scan shows a lobulated lesion with scattered punctate calcifications in the left lower lobe.精选ppt35Figure 25a.Non-small cell lung cancer in a 45-year-old woman.(a)Close-up chest radiogr

31、aph of the right lung shows a lobulated,sharply marginated nodule in the upper lobe.Note the presence of emphysema and upper lobe bullae.(b)Close-up chest CT scan of the right lung reveals amorphous calcification in the nodule,a pattern that is typical of malignancy.Adenocarcinoma was confirmed at r

32、esection.精选ppt36Figure 26.Lung cancer in a 72-year-old man.Close-up chest CT scan of the right lung shows a lobular lesion with peripheral punctate calcification in the upper lobe,a finding that is consistent with engulfed granuloma.Unlike that in calcified granulomas,calcification in engulfed granu

33、loma is typically peripheral and constitutes only a small part of the nodule.精选ppt37Figure 27a.Metastatic osteosarcoma in a 21-year-old man.(a)Close-up chest CT scan of the left lung shows a small,high-attenuation nodule in the lower lobe(arrow).This finding was suggestive of a benign cause.(b)Chest

34、 CT scan obtained 8 months later reveals interval growth of the nodule,which has high attenuation and a lobulated contour.Resection revealed metastatic osteosarcoma.精选ppt38良性：错构瘤、脂肪瘤恶性：脂肉瘤、肾透明细胞癌精选ppt39Figure 19a.Hamartoma in an asymptomatic man.(a)Chest CT scan shows a heterogeneous,sharply margina

35、ted lesion with small focal areas of calcification and fat.These findings are typical features of hamartoma.(b)Photograph of a resected specimen demonstrates a yellowish,glistening,lobular cut surface,a finding that is consistent with fat.(c)Photomicrograph(original magnification,x100;hematoxylin-eo

36、sin stain)helps confirm the presence of adipose tissue(arrow)and shows epithelial tissue containing an island of basophilic cartilage(arrowhead).This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma.精选ppt40Figure 20a.Pulmonary hamartoma in a 74-year-old woman.(a)Chest CT scan

37、 obtained with 10-mm collimation demonstrates a nodule(arrow),but its internal morphologic features are poorly visualized.(b)Thin-section CT scan obtained with 1-mm collimation better demonstrates a punctate area of fat within the nodule(arrow),a finding that is diagnostic for hamartoma.精选ppt41非实性（毛

38、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精选ppt42Figure 14:CT scan in an 81-year-old man shows a 2.8-cm irregular,partly solid left upper lobe nodule with pleural tags.FNAB revealed bronchioloal

39、veolar cell carcinoma.Figure 13:CT scan in a 64-year-old man shows an oval 2.1-cm left lower lobe nonsolid nodule(arrow).FNAB revealed adenocarcinoma.精选ppt43良性空洞：壁光滑、薄(16mm)15%肺癌有空洞（病灶直径3cm）精选ppt44Figure 16.Aspergillus infection in a 48-year-old man with leukemia.Close-up chest CT scan of the right

40、lung shows a thin-walled cavitary nodule.Figure 17.Squamous cell lung cancer in a 60-year-old woman.Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodule in the lower lobe.Note the eccentric cavitation and thick walls.精选ppt45Figure 18:CT scan in an 83-year-old man

41、shows a 2.3-cm left upper lobe cavitary nodule.The wall is variable and the cavity wall is as thick as 8 mm.FNAB revealed squamous cell carcinoma.Figure 19:CT scan in an 80-year-old man shows a right upper lobe 2.9-cm cavitary nodule with a smooth,uniform 2.5-mm-thick cavity wall.FNAB revealed nonsm

42、all cell lung cancer.精选ppt46Figure 18.Bullet track from a gunshot wound in a 20-year-old man.Close-up posteroanterior radiograph of the right lung shows a smoothly marginated,thick-walled nodule with eccentric lucency in the midlung.Note the bullet fragments overlying the right lung.These findings a

43、re consistent with parenchymal hematoma and a bullet track.精选ppt47空泡征为肿瘤内小的低密度影，多为23 mm大小，1个或多个，CT扫描仅限于12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或腺癌精选ppt48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

44、比，具有相对低度恶性的生物学行为。在恶性SPN的发生率为269 650 而在良性SPN，其发生率仅为00 59 精选ppt49I型：支气管被SPN截断II型：支气管进入SPN呈锥状中断型：支气管在SPN内呈长段开放状，并可进一步分叉型：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Clinical Radiology(2004)59,11211127精选ppt50I型：支气管被SPN截断精选ppt51II型：支气管进入SPN呈锥状中断精选ppt52型：支气管在SPN内呈长段开放状，并可进一步分叉精选ppt53型：支气管在SPN内呈长段开放状，并可进一步分叉精

45、选ppt54型：支气管紧贴SPN边缘走行，管腔形态正常精选ppt55V型：支气管紧贴SPN边缘走行，管腔受压变扁精选ppt56I型：支气管被SPN截断II型：支气管进入SPN呈锥状中断型：支气管在SPN内呈长段开放状，并可进一步分叉型：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Clinical Radiology(2004)59,11211127精选ppt57恶性结节最常见的肿瘤一支气管关系是I型，其次为型，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；型仅见于恶性

46、SPN；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。精选ppt58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。精选ppt59支气管管壁由外向内的肿瘤浸润、管壁产生的纤维

47、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。精选ppt60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倾向恶性精选ppt

48、61AJR 2007;188:57-68 精选ppt62Graph of four different types of time-attenuation curve of nodule hemodynamics in consideration of both wash-in and washout phases of dynamic CT.Radiology 2005;237:675-683 精选ppt63Patterns of Nodule Enhancement at Early and Delayed Enhancement CT 精选ppt64Patterns of Nodule

49、Enhancement according to Histologic Diagnosis精选ppt65Fig.4A Metastatic adenocarcinoma in 57-year-old man with rectal cancer shows net enhancement of 25 H and washout of 5-31 H on dynamic helical CT and positive uptake on integrated PET/CT.Lung window of transverse thin-section(2.5-mm collimation)CT s

50、can shows 9-mm nodule(arrow)in left upper lobe.精选ppt66Fig.3A Adenocarcinoma in 67-year-old man shows net enhancement of 25 H and washout of 5-31 H at dynamic helical CT and positive uptake at integrated PET/CT.Lung window of transverse thin-section(2.5-mm collimation)CT scan shows 16-mm nodule(arrow