1、Imaging Diagnosis of Rspirotary Diseasepart 2part 2AiPing Chen1Lung neoplasm肺肿瘤肺肿瘤nThe incidence of primary lung carcinoma is increasing in all over the world.nMost malignent lung tumors(over 98%)are bronchiogenic carcinoma 支气管肺癌支气管肺癌.2Lung neoplasm肺肿瘤肺肿瘤nBenign:良性良性qharmatoma,adenoma,angioma,fibrom
2、aq错构瘤，腺瘤，血管瘤，纤维瘤错构瘤，腺瘤，血管瘤，纤维瘤n malignancy:恶性恶性q primary：lung carcinoma 肺癌，肺癌，sarcoma 肉瘤肉瘤qSecondary：metastasis转移瘤转移瘤3harmatomanuncommon nasymptomatic;nsymptoms typically are present with central endobronchial lesions，include hemoptysis,recurrent pneumonia,and dyspnea.4harmatomantypically round,well
3、-marginated peripheral masses smaller than 4cm(range,1 to 30cm).ntypical pattern：popcorn calcification爆米花样的钙化n Calcification钙化 probably is present in less than 5%of lesions,Fat 脂肪can be detected by CT(attenuation,-40 to-120 HU)in up to 50%of cases and is a diagnostic feature.567primary bronchogenic
4、carcinoma原发性支气管肺癌原发性支气管肺癌nmost common malignancy nrisk factor：ncigarette smoking nEnvironmental and occupational exposure（3%to 17%）nInterstitial pulmonary fibrosis and focal scarring have been reported to increase the risk for bronchial carcinoma.8nLung carcinoma(cancer)qSCLC(small cell lung cancer)
5、小细胞肺癌小细胞肺癌qNSCLC(non-small cell lung cncer）非小细胞肺癌）非小细胞肺癌nsquamous cell carcinoma 鳞癌鳞癌nAdenocarcinoma 腺癌腺癌nLarge Cell Carcinoma大细胞癌大细胞癌ncompound carcinoma 混合癌混合癌nbronchioloavelar carcinoma BAC细支气管肺泡癌细支气管肺泡癌Lung neoplasmLung neoplasm9Lung neoplasmqSCLC(small cell lung cancer)qSmall cell carcinoma is a
6、 rapidly growing tumor that has the most irrefutable association with smoking.qLike squamous cell carcinoma,it is predominantly a central tumor(90%),but growth is mainly along anatomic tissue planes.qmetastasizes early;systemic spread is present in two-thirds of cases at presentation.q生长迅速，中央型，转移早，全
7、身生长迅速，中央型，转移早，全身10Lung neoplasmqNSCLC(non-small cell lung cncer)nsqumous cell carcinoma is most commonly a central tumor developing at the level of the segmental and subsegmental bronchi in 66%of cases.These tumors are frequently lobulated and have a tendency to cavitate.nAdenocarcinoma is a periphe
8、ral tumor in 75%of cases with a predilection for the upper lobes and for regions of parenchymal fibrosis(“scar”carcinomas).nbronchioloavelar carcinoma grows mainly within the alveoli respecting interstitial boundaries,may be unifocal or multifocal,when multifocal,it may produce alveolar cell carcino
9、sis.11bronchial carcinoma nasymptomatic，detected incidentallyn most patients(up to 90%)are symptomatic 气道起源多数表现为气道起源多数表现为 producing cough,hemoptysis,dyspnea,and chest painn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。12According to type of According to type of growth growth nCentral type:Central type:qI
10、nter-tuber Inter-tuber 管内管内qWall of tuberWall of tuber管壁管壁qExtra-tuber Extra-tuber 管外管外nPeripheral type:Peripheral type:qMass Mass qinflammationinflammationqDiffuseDiffuseLung neoplasm13Central tumorCentral tumor nBronchial lumen:Bronchial stenosis，endoluminal or transmural growth14Central tumor:mas
11、s in the right low lober and right hilar enlarge,15mass in the right hilar16Central tumornlung mass in the hilumn支气管改变支气管改变q支气管壁增厚支气管壁增厚q支气管腔内肿块支气管腔内肿块q支气管腔狭窄支气管腔狭窄/闭塞闭塞17Mouse tail Irregular stenosisFilling defectCup like 1819Mouse tail Central tumor20Filling defect21Bronchial stenosis22Central tum
12、orCentral tumornIndirect signn间接征象间接征象：q阻塞性肺肺气肿阻塞性肺肺气肿q阻塞性肺炎：不易吸收，同一部位反复发作阻塞性肺炎：不易吸收，同一部位反复发作q阻塞性肺不张：阻塞性肺不张：肺不张合并肿块，肺不张合并肺不张合并肿块，肺不张合并转移转移是其特点是其特点n 23nPartial or complete atelectasis：Segments,lobes,or an entire lung are no longer aerated and undergo partial(dystelectasis)or complete collapse(atelect
13、asis).This is manifest as patchy or homogeneous pulmonary opacification of lobar or segmental distribution.24Right upper lobe atelectasis 25Right upper lobe atelectasis26left upper lobe atelectasis27Left low lobe atelectasis28Left low lobe atelectasisBronchial stenosis29Left low lobe atelectasis30Ce
14、ntral tumornIndirect sign of bronchial carcinoma:nDistal pneumonia presents as lobar or segmental consolidation,which may partially resolve with antibiotic therapy.In patients with appropriate risk factors and recurrent or persistent pneumonia,further evaluation to exclude a central endobronchial tu
15、mor is merited.31Distal pneumonia32pneumoniamassPleural effusion33Central tumornIndirect sign of bronchial carcinoma:nIntrathoracic spread of bronchial carcinoma.34Right side Central tumor35Central tumornIndirect sign of bronchial carcinoma:nMediastinal lymph node enlargement.Mediastinal widening ma
16、y be the first radiographic sign of lung cancer,especially in cases of small cell carcinoma.3637Central tumornHematogenous spread of bronchial carcinoma.nOsteolytic bone lesions and pathologic fractures 溶骨性的破坏和病理性的骨折signify hematogenous spread of disease.血行播散38Costal bone damage 39Right lung metasta
17、sis404142Central tumornMRI manifestationqBronchi wall thickenqBronchi wall stenosisqMass in the hilumqEmphysema;pneumonia;atlectasis of obstructionqAffect mediastinum，enlargement of lymph node(diameter15mm)434445nplain film、CT、MRICentral tumor46Plain film47CT scan no contrast48CT scan contrast495051
18、52Peripheral tumorPeripheral tumorn Peripheral pulmonary nodule.n round，usually less than 5cm in diameter.n The following features suggest a diagnosis of bronchial carcinoma:ill-defined margin in 85%of malignant tumors;radial striated markings at the interface with lung parenchyma representing tumor
19、 spread along the lymphatics;notching of the contour;a cavitating lesion typical of squamous cell carcinoma.53Peripheral tumorPulmonary nodule in the early stage.nLobulationLobulation，SpiculatedSpiculated margin.margin.nAir Air bronchogrambronchogram.nCavitaryCavitary.nBubble-like Bubble-like lucenc
20、ieslucencies within the within the nodule.nodule.空泡征空泡征nRetraction of pleura-Retraction of pleura-pleural indentation sign胸膜凹陷征胸膜凹陷征 54Peripheral tumorn分叶征象分叶征象:生长不均衡，周围血管和支气生长不均衡，周围血管和支气管的限制管的限制n毛刺征象毛刺征象:肿瘤沿血管及间质浸润有关肿瘤沿血管及间质浸润有关n空洞形成空洞形成:偏心性，内壁不规则或呈结节偏心性，内壁不规则或呈结节状状55notching of the contour56notchi
21、ng of the contour57Cavitary.58Retraction of pleura.Spiculate margin.notching of the contour59Retraction of pleura.Spiculate margin.notching of the contour60Retraction of pleura.Spiculate margin.notching of the contour61 Spiculate margin.notching of the contour62Spiculate margin.notching of the conto
22、ur63Bone metastasis6465BronchioloBronchiolo-alveolar carcinoma-alveolar carcinomanIsolated mass typeIsolated mass typenPneumonia typePneumonia typenDiffuse nodule typeDiffuse nodule type66Isolated mass type Isolated mass type BronchioloBronchiolo-alveolar carcinomaalveolar carcinoma 67Bronchiolo-alv
23、eolar carcinomaPneumonia type686970ill-defined margin pulmonary nodule Bronchiolo-alveolar carcinoma71Bronchiolo-alveolar carcinoma72Bronchiolo-alveolar carcinoma73Lung mestastasisnThe most common primary tumor site was lung,followed by large bowel,prostate,breast,uterus,and esophagus.nBetween 20%an
24、d 40%of primary carcinomas of the lung produced pulmonary metastases.Tumors with the greatest rate of metastases to the lung include choriocarcinoma绒毛膜癌,germinal tumors of the testis睾丸的生殖细胞瘤,melanoma黑色素瘤,Ewings sarcoma尤文氏肉瘤,osteosarcoma,骨肉瘤carcinoma of the thyroid,甲状腺癌carcinoma of the breast乳腺癌,and
25、rhabdomyosarcoma横纹肌肉瘤.74Lung mestastasisnHematogenous mestastasisnLymphatic vessel mestastasis 75Hematogeneous mestastasis76Hematogeneous mestastasis77Hematogeneous mestastasis78Hematogeneous mestastasis79Lymphatic vessel mestastasis80Pleural carcinomatosis 8182MediastinalMediastinal tumor tumor纵隔肿瘤
26、纵隔肿瘤主要诊断依据：position,shape，density.83Tumor of the anterior mediastinumThymoma TeratomaIntrathoracic thyroid Malignant lymphomaBronchogenic cystNeurogenic tumors 84MediastinalMediastinal tumor tumorqIntra-thoracia thyroid mass胸内甲状腺肿:upper of mediastinumqThymoma胸腺瘤:anteriorqTeratoma畸胎瘤：calcification;fa
27、tnMiddle mediastinal tumornPosterior mediastinal tumor85Intrathoracic thyroidnIntrathoracic thyroid is usually a downward prolongation or outgrowth of a cervical thyroid enlargement.On radiolograph most cases show widening of one or other side of the anterior superior mediastinum and displacement of
28、 the trachea to the opposite side and compression of the trachea on the side of the tumor.86胸内甲状腺肿intrathoracic goitern病理：多数为结节性甲状腺肿nX线表现q前纵隔上部q边缘光滑，与颈部肿物相连q气管受肿块推压87Intrathoracic thyroid88Intrathoracic thyroidnThe CT appearances of thyroid goiters are specific.Anatomical continuity usually can be d
29、emonstrated with the cervical thyroid.Focal calcifications and inhomogeneity are frequent features.After injecting contrast material,there is a definite prolonged rise in the CT Hounsfield number.89l结甲伴腺瘤样增生结甲伴腺瘤样增生l女，女，6262岁岁l肿物与甲状腺相连肿物与甲状腺相连90Intrathoracic thyroidnMR imaging particularly in the co
30、ronal and sagittal planes,can show the extent of intrathoracic thyroid tissue and its relationship to adjacent structures.Multinodular goiters have heterogeneous signal characteristics on T1W1 and T2W1.919293Thymoma胸腺瘤胸腺瘤nanterior superior mediastinum.nround,lobulated or plaque-like,and produce unil
31、ateral widening of the mediastinum.nCalcification or cystic degeneration may be seen in a small percentage of cases.94胸腺瘤thymoman占前纵隔肿瘤50%多见于中年人n多数无症状，少数有压迫或侵犯表现n三分之一伴有重症肌无力n良性：包膜完整，无周围浸润n恶性：包膜不完整，向周围侵犯转移9596ThymomanCT is the imaging method of choice for evaluating the possibility of thymic disease.
32、Differentiation between thymoma and thymic hyperplasia is difficult in patients less than 40 years of age.Thymic hyperplasia tends to enlarge but preserve the normal shape of the gland.However,exceptions to this are encountered in which hyperplasia is found in nodular glands,simulating the presence
33、of a thymoma.97胸腺瘤nX线表现：单侧或双侧纵隔增宽突出，边缘一般较清晰。nCT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98Thymoma99Thymoma100Thymoma101102l胸腺瘤，可疑包膜侵润胸腺瘤，可疑包膜侵润 l男性，男性，4747岁，查体发现岁，查体发现103ThymomanThymomas have intermediate signal intensity(equal to that of skeletal muscle)in T1W1 and increased signal intensity(approa
34、ching that of fat)on T2W1.Cystic regions are areas of hemorrhage have low signal intensity on T1W1 and high signal intensity on T2W1.104胸腺瘤MRI105畸胎瘤畸胎瘤 teratoman先天性肿瘤，属生殖细胞瘤n好发于2040岁，绝大多数属良性n病理q来源于原始胚胎组织的残留物q皮样囊肿：主要含有外胚层衍生物q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106畸胎瘤畸胎瘤 teratomaX线表现线表现及及CT表现表现n含有多种组织而密度不均含有
35、多种组织而密度不均n钙化和囊变钙化和囊变是特征性表现是特征性表现q囊变部分囊变部分CT值值近似水近似水n恶性畸胎瘤恶性畸胎瘤常较大，边缘不规则常较大，边缘不规则107TeratomanMost mediastinal teratomas are seen on radiograph as a localized mass in the anterior compartment close to the origin of the major vessels from the heart.Calcification is evident on radiograph in mature terat
36、omas.On CT,most tumors have well-defined margins that were smooth or lobulated with round or oval in shape and have heterogeneous attenuation with soft tissue,fluid and fat.Fat-depressed MRI sequences can demonstrate fat better than CT.occasionally a fat-fluid level is seen on radiograph and CT scan
37、.108teratoma109teratoma110teratoma111112113l精原细胞瘤精原细胞瘤l男，男，1616岁，面部浮肿岁，面部浮肿1 1月，咳嗽月，咳嗽2020天天恶性生殖细胞肿瘤 114MediastinalMediastinal tumor tumornAnterior Anterior mediastinalmediastinal tumor tumor：nMiddle Middle mediastinalmediastinal tumor tumor：qMalignant lymphomaMalignant lymphomaqBronchogenicBronchog
38、enic cyst cystnPosterior Posterior mediastinalmediastinal tumor tumor115Malignant lymphomanThe thorax is frequently involved in patients with Hodgkins and non-Hodgkins lymphomas.nIt has been estimate that lymphoma constitutes about 20%of all mediastinal neoplasms in adults and 50%in children.nLymph
39、node enlargement is evident on the initial radiograph of approximately 50%of patients,especially bilateral enlargement of hilar and paratracheal lymph nodes.116恶性淋巴瘤n淋巴组织恶性肿瘤n发热，周围淋巴结增大及全身衰弱n上腔静脉阻塞综合征n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117恶性淋巴瘤nX线表现线表现q肿块向纵隔两侧突出，气管受压肿块向纵隔两侧突出，气管受压nCT表现表现q纵隔内多组淋巴结增大，可融合成块
40、纵隔内多组淋巴结增大，可融合成块q侵及邻近结构侵及邻近结构118Malignant lymphoma119Malignant lymphoma120Malignant lymphomanCT and MRI are more sensitive than radiograph.The enlarged lymph nodes or mass mostly show soft tissue density or signal intensity.121Malignant lymphoma122淋巴瘤MRI123lHLHL，探查术证实，探查术证实 l女性，女性，3939岁岁124支气管囊肿 bro
41、nchial cystn胚胎期原始前肠的支气管芽突脱落演变而成n位于气管旁或气管分叉处，内含液体125支气管囊肿n位于中纵隔n与支气管相邻，呈圆形或椭圆形n边缘清楚，内含液体nCT扫描无强化nMRI表现：T1WI低信号，T2WI为高信号126127128129l淋巴管瘤淋巴管瘤l女性，女性，4343岁，咳嗽半月岁，咳嗽半月l多房，张力低多房，张力低130l食管囊肿食管囊肿l男性，男性，4747岁，进食不顺岁，进食不顺1 1周周131MediastinalMediastinal tumor tumornAnterior mediastinal tumor：nMiddle mediastinal
42、tumor：nPosterior Posterior mediastinalmediastinal tumor:tumor:qNeurogenicNeurogenic tumor tumor132Posterior mediastinal tumor nNeurogenic tumors are the most common tumors of the posterior mediastinum.They may arise from peripheral nerves(i.e.,neurofibromas and neurilemomas),from sympathetic ganglia
43、,they are the neurofibroma and neurilemoma(schwannoma),most of which are benign.133Posterior mediastinal tumornThe tumors are well defined,oval or occasionally round in shape.Few are lobulated.All the tumors lie posteriorly in the paravertebral sulcus,growing close to the spine and the posterior par
44、t of the ribs.A dumb-bell neurofibroma may have its intraspinal part compressing the cord.134神经源性肿瘤neurogenic tumourn好发于后纵隔脊柱旁沟，与脊柱关系密切n良性为主n最常见类型：神经鞘瘤，神经纤维瘤nMRI检查较CT好q伪影少，软组织分辨力高q冠状位很好显示肿瘤形态及与周围关系135神经源性肿瘤n圆形或哑铃状肿块n边界清楚，信号均匀nCT可清晰显示椎间孔变大nMRI表现：T1WI稍低信号，T2WI稍高信号n较大肿瘤可发生囊变、坏死，呈混杂信号136Neurogenic tumors137神经源性肿瘤MRI138139
