呼吸系統(tǒng)常見疾病專家講座

ImagingDiagnosisofRspirotaryDisease

part2

AiPingChen呼吸系統(tǒng)常見疾病第1頁Lungneoplasm肺腫瘤Theincidenceofprimarylungcarcinomaisincreasinginallovertheworld.Mostmalignentlungtumors(over98%)arebronchiogeniccarcinoma支氣管肺癌.呼吸系統(tǒng)常見疾病第2頁Lungneoplasm肺腫瘤Benign:良性harmatoma,adenoma,angioma,fibroma錯(cuò)構(gòu)瘤，腺瘤，血管瘤，纖維瘤malignancy:惡性primary：lungcarcinoma肺癌，sarcoma肉瘤Secondary：metastasis轉(zhuǎn)移瘤呼吸系統(tǒng)常見疾病第3頁harmatomauncommonasymptomatic;symptomstypicallyarepresentwithcentralendobronchiallesions，includehemoptysis,recurrentpneumonia,anddyspnea.呼吸系統(tǒng)常見疾病第4頁harmatomatypicallyround,well-marginatedperipheralmassessmallerthan4cm(range,1to30cm).typicalpattern：‘popcorn’calcification爆米花樣鈣化

Calcification鈣化

probablyispresentinlessthan5%oflesions,Fat脂肪canbedetectedbyCT(attenuation,-40to-120HU)inupto50%ofcasesandisadiagnosticfeature.呼吸系統(tǒng)常見疾病第5頁呼吸系統(tǒng)常見疾病第6頁呼吸系統(tǒng)常見疾病第7頁primarybronchogeniccarcinoma

原發(fā)性支氣管肺癌mostcommonmalignancyriskfactor

：cigarettesmoking

Environmentalandoccupationalexposure

（3%to17%）Interstitialpulmonaryfibrosisandfocalscarringhavebeenreportedtoincreasetheriskforbronchialcarcinoma.呼吸系統(tǒng)常見疾病第8頁Lungcarcinoma(cancer)SCLC(smallcelllungcancer)小細(xì)胞肺癌NSCLC(non-smallcelllungcncer）非小細(xì)胞肺癌squamouscellcarcinoma鱗癌Adenocarcinoma腺癌LargeCellCarcinoma大細(xì)胞癌compoundcarcinoma混合癌bronchioloavelarcarcinomaBAC細(xì)支氣管肺泡癌Lungneoplasm呼吸系統(tǒng)常見疾病第9頁LungneoplasmSCLC(smallcelllungcancer)Smallcellcarcinomaisarapidlygrowingtumorthathasthemostirrefutableassociationwithsmoking.Likesquamouscellcarcinoma,itispredominantlyacentraltumor(90%),butgrowthismainlyalonganatomictissueplanes.metastasizesearly;systemicspreadispresentintwo-thirdsofcasesatpresentation.生長快速，中央型，轉(zhuǎn)移早，全身呼吸系統(tǒng)常見疾病第10頁LungneoplasmNSCLC(non-smallcelllungcncer)squmouscellcarcinomaismostcommonlyacentraltumordevelopingatthelevelofthesegmentalandsubsegmentalbronchiin66%ofcases.Thesetumorsarefrequentlylobulatedandhaveatendencytocavitate.Adenocarcinomaisaperipheraltumorin75%ofcaseswithapredilectionfortheupperlobesandforregionsofparenchymalfibrosis(“scar”carcinomas).bronchioloavelarcarcinomagrowsmainlywithinthealveolirespectinginterstitialboundaries,maybeunifocalormultifocal,whenmultifocal,itmayproducealveolarcellcarcinosis.呼吸系統(tǒng)常見疾病第11頁bronchialcarcinomaasymptomatic，detectedincidentallymostpatients(upto90%)aresymptomatic氣道起源多數(shù)表現(xiàn)為producingcough,hemoptysis,dyspnea,andchestpain約33%會(huì)出現(xiàn)胸外轉(zhuǎn)移癥狀，多見于骨骼系統(tǒng)和神經(jīng)系統(tǒng)。其它，腎上腺，肝臟，淋巴結(jié)。。。呼吸系統(tǒng)常見疾病第12頁AccordingtotypeofgrowthCentraltype:Inter-tuber管內(nèi)Walloftuber管壁Extra-tuber管外Peripheraltype:MassinflammationDiffuseLungneoplasm呼吸系統(tǒng)常見疾病第13頁CentraltumorDirectsignofbronchialcarcinoma

lungmassBronchiallumen:Bronchialstenosis，endoluminalortransmuralgrowth呼吸系統(tǒng)常見疾病第14頁Centraltumor:massintherightlowloberandrighthilarenlarge,呼吸系統(tǒng)常見疾病第15頁massintherighthilar呼吸系統(tǒng)常見疾病第16頁CentraltumorlungmassinthehilumBronchiallumen支氣管改變支氣管壁增厚支氣管腔內(nèi)腫塊支氣管腔狹窄/閉塞呼吸系統(tǒng)常見疾病第17頁MousetailIrregularstenosisFillingdefectCuplike呼吸系統(tǒng)常見疾病第18頁呼吸系統(tǒng)常見疾病第19頁MousetailCentraltumor呼吸系統(tǒng)常見疾病第20頁Fillingdefect呼吸系統(tǒng)常見疾病第21頁Bronchialstenosis呼吸系統(tǒng)常見疾病第22頁CentraltumorIndirectsign間接征象：支氣管阻塞所致改變阻塞性肺肺氣腫阻塞性肺炎：不易吸收，同一部位重復(fù)發(fā)作阻塞性肺不張：肺不張合并腫塊，肺不張合并轉(zhuǎn)移是其特點(diǎn)

呼吸系統(tǒng)常見疾病第23頁P(yáng)artialorcompleteatelectasis

：Segments,lobes,oranentirelungarenolongeraeratedandundergopartial(dystelectasis)orcompletecollapse(atelectasis).Thisismanifestaspatchyorhomogeneouspulmonaryopacificationoflobarorsegmentaldistribution.呼吸系統(tǒng)常見疾病第24頁Rightupperlobeatelectasis

呼吸系統(tǒng)常見疾病第25頁Rightupperlobeatelectasis呼吸系統(tǒng)常見疾病第26頁leftupperlobeatelectasis呼吸系統(tǒng)常見疾病第27頁Leftlowlobeatelectasis呼吸系統(tǒng)常見疾病第28頁LeftlowlobeatelectasisBronchialstenosis呼吸系統(tǒng)常見疾病第29頁Leftlowlobeatelectasis呼吸系統(tǒng)常見疾病第30頁CentraltumorIndirectsignofbronchialcarcinoma:Distalpneumoniapresentsaslobarorsegmentalconsolidation,whichmaypartiallyresolvewithantibiotictherapy.Inpatientswithappropriateriskfactorsandrecurrentorpersistentpneumonia,furtherevaluationtoexcludeacentralendobronchialtumorismerited.呼吸系統(tǒng)常見疾病第31頁Distalpneumonia呼吸系統(tǒng)常見疾病第32頁pneumoniamassPleuraleffusion呼吸系統(tǒng)常見疾病第33頁CentraltumorIndirectsignofbronchialcarcinoma:Intrathoracicspreadofbronchialcarcinoma.呼吸系統(tǒng)常見疾病第34頁RightsideCentraltumor呼吸系統(tǒng)常見疾病第35頁CentraltumorIndirectsignofbronchialcarcinoma:Mediastinallymphnodeenlargement.Mediastinalwideningmaybethefirstradiographicsignoflungcancer,especiallyincasesofsmallcellcarcinoma.呼吸系統(tǒng)常見疾病第36頁呼吸系統(tǒng)常見疾病第37頁CentraltumorHematogenousspreadofbronchialcarcinoma.Osteolyticbonelesionsandpathologicfractures溶骨性破壞和病理性骨折signifyhematogenousspreadofdisease.血行播散呼吸系統(tǒng)常見疾病第38頁Costalbonedamage呼吸系統(tǒng)常見疾病第39頁Rightlungmetastasis呼吸系統(tǒng)常見疾病第40頁呼吸系統(tǒng)常見疾病第41頁呼吸系統(tǒng)常見疾病第42頁CentraltumorMRImanifestationBronchiwallthickenBronchiwallstenosisMassinthehilumEmphysema;pneumonia;atlectasisofobstructionAffectmediastinum，enlargementoflymphnode(diameter>15mm)呼吸系統(tǒng)常見疾病第43頁呼吸系統(tǒng)常見疾病第44頁呼吸系統(tǒng)常見疾病第45頁plainfilm、CT、MRICentraltumor呼吸系統(tǒng)常見疾病第46頁P(yáng)lainfilm呼吸系統(tǒng)常見疾病第47頁CT平掃CTscannocontrast呼吸系統(tǒng)常見疾病第48頁CT增強(qiáng)CTscancontrast呼吸系統(tǒng)常見疾病第49頁MRI呼吸系統(tǒng)常見疾病第50頁呼吸系統(tǒng)常見疾病第51頁呼吸系統(tǒng)常見疾病第52頁P(yáng)eripheraltumor

Peripheralpulmonarynodule.round，usuallylessthan5cmindiameter.Thefollowingfeaturessuggestadiagnosisofbronchialcarcinoma:ill-definedmarginin85%ofmalignanttumors;radialstriatedmarkingsattheinterfacewithlungparenchymarepresentingtumorspreadalongthelymphatics;notchingofthecontour;acavitatinglesiontypicalofsquamouscellcarcinoma.呼吸系統(tǒng)常見疾病第53頁P(yáng)eripheraltumorPulmonarynoduleintheearlystage.Lobulation，Spiculatedmargin.Airbronchogram.Cavitary.Bubble-likelucencieswithinthenodule.空泡征Retractionofpleura-pleuralindentationsign胸膜凹陷征

呼吸系統(tǒng)常見疾病第54頁P(yáng)eripheraltumor分葉征象:生長不均衡，周圍血管和支氣管限制毛刺征象:腫瘤沿血管及間質(zhì)浸潤相關(guān)空洞形成:偏心性，內(nèi)壁不規(guī)則或呈結(jié)節(jié)狀呼吸系統(tǒng)常見疾病第55頁notchingofthecontour呼吸系統(tǒng)常見疾病第56頁notchingofthecontour呼吸系統(tǒng)常見疾病第57頁Cavitary.呼吸系統(tǒng)常見疾病第58頁Retractionofpleura.Spiculatemargin.notchingofthecontour呼吸系統(tǒng)常見疾病第59頁Retractionofpleura.Spiculatemargin.notchingofthecontour呼吸系統(tǒng)常見疾病第60頁Retractionofpleura.Spiculatemargin.notchingofthecontour呼吸系統(tǒng)常見疾病第61頁

Spiculatemargin.notchingofthecontour呼吸系統(tǒng)常見疾病第62頁Spiculatemargin.notchingofthecontour呼吸系統(tǒng)常見疾病第63頁Bonemetastasis呼吸系統(tǒng)常見疾病第64頁呼吸系統(tǒng)常見疾病第65頁Bronchiolo-alveolarcarcinomaIsolatedmasstypePneumoniatypeDiffusenoduletype呼吸系統(tǒng)常見疾病第66頁IsolatedmasstypeBronchiolo-alveolarcarcinoma

呼吸系統(tǒng)常見疾病第67頁Bronchiolo-alveolarcarcinoma

Pneumoniatype

呼吸系統(tǒng)常見疾病第68頁呼吸系統(tǒng)常見疾病第69頁呼吸系統(tǒng)常見疾病第70頁ill-definedmarginpulmonarynoduleBronchiolo-alveolarcarcinoma呼吸系統(tǒng)常見疾病第71頁Bronchiolo-alveolarcarcinoma呼吸系統(tǒng)常見疾病第72頁Bronchiolo-alveolarcarcinoma呼吸系統(tǒng)常見疾病第73頁LungmestastasisThemostcommonprimarytumorsitewaslung,followedbylargebowel,prostate,breast,uterus,

andesophagus.Between20%and40%ofprimarycarcinomasofthelungproducedpulmonarymetastases.Tumorswiththegreatestrateofmetastasestothelungincludechoriocarcinoma絨毛膜癌,germinaltumorsofthetestis睪丸生殖細(xì)胞瘤,melanoma黑色素瘤,Ewing’ssarcoma尤文氏肉瘤,osteosarcoma,骨肉瘤carcinomaofthethyroid,甲狀腺癌carcinomaofthebreast乳腺癌,andrhabdomyosarcoma橫紋肌肉瘤.呼吸系統(tǒng)常見疾病第74頁LungmestastasisHematogenousmestastasisLymphaticvesselmestastasis

呼吸系統(tǒng)常見疾病第75頁Hematogeneousmestastasis呼吸系統(tǒng)常見疾病第76頁Hematogeneousmestastasis呼吸系統(tǒng)常見疾病第77頁Hematogeneousmestastasis呼吸系統(tǒng)常見疾病第78頁Hematogeneousmestastasis呼吸系統(tǒng)常見疾病第79頁Lymphaticvesselmestastasis呼吸系統(tǒng)常見疾病第80頁P(yáng)leuralcarcinomatosis

呼吸系統(tǒng)常見疾病第81頁呼吸系統(tǒng)常見疾病第82頁

Mediastinaltumor縱隔腫瘤主要診療依據(jù)：position,shape，density.呼吸系統(tǒng)常見疾病第83頁TumoroftheanteriormediastinumThymoma

TeratomaIntrathoracicthyroid

MalignantlymphomaBronchogeniccystNeurogenictumors呼吸系統(tǒng)常見疾病第84頁Mediastinaltumor

Anteriormediastinaltumor前縱隔Intra-thoraciathyroidmass胸內(nèi)甲狀腺腫:upperofmediastinumThymoma胸腺瘤:anteriorTeratoma畸胎瘤：calcification;fatMiddlemediastinaltumor中縱隔Posteriormediastinaltumor后縱隔呼吸系統(tǒng)常見疾病第85頁IntrathoracicthyroidIntrathoracicthyroidisusuallyadownwardprolongationoroutgrowthofacervicalthyroidenlargement.Onradiolographmostcasesshowwideningofoneorothersideoftheanteriorsuperiormediastinumanddisplacementofthetracheatotheoppositesideandcompressionofthetracheaonthesideofthetumor.呼吸系統(tǒng)常見疾病第86頁胸內(nèi)甲狀腺腫

intrathoracicgoiter病理：多數(shù)為結(jié)節(jié)性甲狀腺腫X線表現(xiàn)前縱隔上部邊緣光滑，與頸部腫物相連氣管受腫塊推壓呼吸系統(tǒng)常見疾病第87頁Intrathoracicthyroid呼吸系統(tǒng)常見疾病第88頁IntrathoracicthyroidTheCTappearancesofthyroidgoitersarespecific.Anatomicalcontinuityusuallycanbedemonstratedwiththecervicalthyroid.Focalcalcificationsandinhomogeneityarefrequentfeatures.Afterinjectingcontrastmaterial,thereisadefiniteprolongedriseintheCTHounsfieldnumber.呼吸系統(tǒng)常見疾病第89頁結(jié)甲伴腺瘤樣增生女，62歲腫物與甲狀腺相連呼吸系統(tǒng)常見疾病第90頁IntrathoracicthyroidMRimagingparticularlyinthecoronalandsagittalplanes,canshowtheextentofintrathoracicthyroidtissueanditsrelationshiptoadjacentstructures.MultinodulargoitershaveheterogeneoussignalcharacteristicsonT1W1andT2W1.呼吸系統(tǒng)常見疾病第91頁呼吸系統(tǒng)常見疾病第92頁呼吸系統(tǒng)常見疾病第93頁Thymoma胸腺瘤anteriorsuperiormediastinum.round,lobulatedorplaque-like,andproduceunilateralwideningofthemediastinum.Calcificationorcysticdegenerationmaybeseeninasmallpercentageofcases.呼吸系統(tǒng)常見疾病第94頁胸腺瘤thymoma占前縱隔腫瘤50%多見于中年人多數(shù)無癥狀，少數(shù)有壓迫或侵犯表現(xiàn)三分之一伴有重癥肌無力良性：包膜完整，無周圍浸潤惡性：包膜不完整，向周圍侵犯轉(zhuǎn)移呼吸系統(tǒng)常見疾病第95頁呼吸系統(tǒng)常見疾病第96頁ThymomaCTistheimagingmethodofchoiceforevaluatingthepossibilityofthymicdisease.Differentiationbetweenthymomaandthymichyperplasiaisdifficultinpatientslessthan40yearsofage.Thymichyperplasiatendstoenlargebutpreservethenormalshapeofthegland.However,exceptionstothisareencounteredinwhichhyperplasiaisfoundinnodularglands,simulatingthepresenceofathymoma.呼吸系統(tǒng)常見疾病第97頁胸腺瘤X線表現(xiàn)：單側(cè)或雙側(cè)縱隔增寬突出，邊緣普通較清楚。CT表現(xiàn)：前縱隔內(nèi)類圓形腫塊，惡性表現(xiàn)為包膜不完整，累及周圍組織，胸膜和肺，淋巴結(jié)增大呼吸系統(tǒng)常見疾病第98頁Thymoma呼吸系統(tǒng)常見疾病第99頁Thymoma呼吸系統(tǒng)常見疾病第100頁Thymoma呼吸系統(tǒng)常見疾病第101頁呼吸系統(tǒng)常見疾病第102頁胸腺瘤，可疑包膜侵潤男性，47歲，查體發(fā)覺呼吸系統(tǒng)常見疾病第103頁ThymomaThymomashaveintermediatesignalintensity(equaltothatofskeletalmuscle)inT1W1andincreasedsignalintensity(approachingthatoffat)onT2W1.CysticregionsareareasofhemorrhagehavelowsignalintensityonT1W1andhighsignalintensityonT2W1.呼吸系統(tǒng)常見疾病第104頁胸腺瘤MRI呼吸系統(tǒng)常見疾病第105頁畸胎瘤teratoma先天性腫瘤，屬生殖細(xì)胞瘤好發(fā)于20~40歲，絕大多數(shù)屬良性病理起源于原始胚胎組織殘留物皮樣囊腫：主要含有外胚層衍生物實(shí)質(zhì)性畸胎瘤：含有內(nèi)、中、外三個(gè)胚層衍生物，可為良性或惡性呼吸系統(tǒng)常見疾病第106頁畸胎瘤teratomaX線表現(xiàn)及CT表現(xiàn)含有各種組織而密度不均鈣化和囊變是特征性表現(xiàn)囊變部分CT值近似水惡性畸胎瘤常較大，邊緣不規(guī)則呼吸系統(tǒng)常見疾病第107頁TeratomaMostmediastinalteratomasareseenonradiographasalocalizedmassintheanteriorcompartmentclosetotheoriginofthemajorvesselsfromtheheart.Calcificationisevidentonradiographinmatureteratomas.OnCT,mosttumorshavewell-definedmarginsthatweresmoothorlobulatedwithroundorovalinshapeandhaveheterogeneousattenuationwithsofttissue,fluidandfat.Fat-depressedMRIsequencescandemonstratefatbetterthanCT.occasionallyafat-fluidlevelisseenonradiographandCTscan.呼吸系統(tǒng)常見疾病第108頁teratoma呼吸系統(tǒng)常見疾病第109頁teratoma呼吸系統(tǒng)常見疾病第110頁teratoma呼吸系統(tǒng)常見疾病第111頁呼吸系統(tǒng)常見疾病第112頁呼吸系統(tǒng)常見疾病第113頁精原細(xì)胞瘤男，16歲，面部浮腫1月，咳嗽20天惡性生殖細(xì)胞腫瘤

呼吸系統(tǒng)常見疾病第114頁MediastinaltumorAnteriormediastinaltumor：Middlemediastinaltumor：MalignantlymphomaBronchogeniccystPosteriormediastinaltumor呼吸系統(tǒng)常見疾病第115頁MalignantlymphomaThethoraxisfrequentlyinvolvedinpatientswithHodgkin’sandnon-Hodgkin’slymphomas.Ithasbeenestimatethatlymphomaconstitutesabout20%ofallmediastinalneoplasmsinadultsand50%inchildren.Lymphnodeenlargementisevidentontheinitialradiographofapproximately50%ofpatients,especiallybilateralenlargementofhilarandparatracheallymphnodes.呼吸系統(tǒng)常見疾病第116頁惡性淋巴瘤淋巴組織惡性腫瘤發(fā)燒，周圍淋巴結(jié)增大及全身衰弱上腔靜脈阻塞綜合征縱隔淋巴結(jié)增大，常見于血管前、氣管旁、主肺動(dòng)脈窗、肺門等部位呼吸系統(tǒng)常見疾病第117頁惡性淋巴瘤X線表現(xiàn)腫塊向縱隔兩側(cè)突出，氣管受壓CT表現(xiàn)縱隔內(nèi)多組淋巴結(jié)增大，可融合成塊侵及鄰近結(jié)構(gòu)呼吸系統(tǒng)常見疾病第118頁Malignant

lymphoma呼吸系統(tǒng)常見疾病第119頁Malignantlymphoma呼吸系統(tǒng)常見疾病第120頁Malignantlymphoma

CTandMRIaremoresensitivethanradiograph.Theenlargedlymphnodesormassmostlyshowsofttissuedensityorsignalintensity.呼吸系統(tǒng)常見疾病第121頁Malign