孤立性肺結(jié)節(jié)：良性與惡性對比

Solitarypulmonarynodule:benignversusmalignant

孤立性肺結(jié)節(jié)：良性(liánɡxìnɡ)與惡性對比第一頁，共三十一頁。編輯課件Thedifferentialdiagnosisofasolitarypulmonarynoduleisbroadandmanagementdependsonwhetherthelesionisbenignormalignant.孤立性肺結(jié)節(jié)的鑒別診斷是很多的，處理方法依賴于該病變是良性還是惡性

InthisoverviewwewilldiscusssomeofthenewfeaturesthatcanhelptodifferentiatebetweenbenignandmalignantnodulesbaseduponCTandPET-CTfindings.在此篇文章，我們著重討論(tǎolùn)下一些有助于鑒別良惡性結(jié)節(jié)的新特征，此特征是基于CT與PET-CT的檢查結(jié)果第二頁，共三十一頁。編輯課件CT:benignversusmalignantCalcification

SizeGrowth

Shape

Margin

AirBronchogramsign

SolidandGround-glasscomponents

Contrastenhancement

第三頁，共三十一頁。編輯課件CT:良性(liánɡxìnɡ)與惡性鈣化大小生長速度形狀(xíngzhuàn)邊緣支氣管含氣征實(shí)性或磨玻璃樣增強(qiáng)特征第四頁，共三十一頁。編輯課件Calcification鈣化(gàihuà)Diffuse,central,laminatedorpopcorncalcificationsarebenignpatternsofcalcification.彌漫性，中心(zhōngxīn)性，分層，爆米花鈣化是良性鈣化，第五頁，共三十一頁。編輯課件Thesetypesofcalcificationareseeningranulomatousdiseaseandhamartomas這些(zhèxiē)形式的鈣化最常見于錯構(gòu)瘤、肉芽腫性病變第六頁，共三十一頁。編輯課件Theexceptiontotheruleaboveiswhenpatientsareknowntohaveaprimarytumor.

Forinstancethediffusecalcificationpatterncanbeseeninpatientswithosteosarcomaorchondrosarcoma.

SimilarlythecentralandpopcornpatterncanbeseeninpatientswithGI-tumorsandpatientswhopreviouslyhadchemotherapy.一些病人(bìngrén)有原發(fā)腫瘤病史，可以表現(xiàn)為良性鈣化例如骨肉瘤、軟骨肉瘤可以表現(xiàn)彌漫性鈣化。胃腸間質(zhì)瘤的病人化療后可以表現(xiàn)為中心性或苞米花鈣化。第七頁，共三十一頁。編輯課件Size大小(dàxiǎo)Asolitarypulmonarynodule(SPN)isdefinedasasingleintraparenchymallesionlessthan3cminsizeandnotassociatedwithatelectasisorlymphadenopathy.

Alesiongreaterthan3cmindiameteriscalledamass.

孤立性結(jié)節(jié)定義(dìngyì)為小于3cm，不伴有肺不張、淋巴結(jié)轉(zhuǎn)移，大于3cm的為腫塊Thisdistinctionismade,becauselesionsgreaterthan3cmareusuallymalignant,whilesmallerlesionscanbeeitherbenignormalignant.以3cm為界，因?yàn)榇笥?cm的通常是惡性的，而小于3cm的可能是良性或惡性。第八頁，共三十一頁。編輯課件RelationshipbetweenSPN-sizeandchanceofmalignancyinpatientswithhighriskforlungcancer

結(jié)節(jié)(jiéjié)大小與惡性度具有密切相關(guān)性第九頁，共三十一頁。編輯課件Growth生長(shēngzhǎng)速度ComparisonwithpriorimagingstudiesisoftenthemostusefulproceduretodeterminetheimportanceofthefindingofaSPN,sincestabilityover2yearsishighlyassociatedwithbenignity.與前次影像結(jié)果相比是鑒別孤立性結(jié)節(jié)良惡性的一個(gè)非常有用(yǒuyònɡ)的方法。如果超過2年以上保持不變，這個(gè)結(jié)節(jié)就是良性結(jié)節(jié)第十頁，共三十一頁。編輯課件Shape形態(tài)(xíngtài)Japanesescreeningstudiesshowedthatapolygonalshapeandathree-dimensionalratio>1.78wasasignofbenignity(2,3).

日本(rìběn)的一項(xiàng)研究表明，多變形和三維立體比率大于1.78是良性結(jié)節(jié)的標(biāo)志Apolygonalshapemeansthatthelesionhasmultiplefacets(multi-sided).

多邊形意味這個(gè)病灶具有多個(gè)面Aperipheralsubpleurallocationwasalsoasignofbenignityinthisstudy在這項(xiàng)研究中，周圍的胸膜下的病變也是良性結(jié)節(jié)的一個(gè)標(biāo)志第十一頁，共三十一頁。編輯課件Thethree-dimensionalratioismeasuredbyobtainingthemaximaltransversedimensionanddividingitbythemaximalverticaldimension.

Alargethree-dimensionalratioindicatesthatthelesionisrelativelyflat,whichisabenignsign.第十二頁，共三十一頁。編輯課件Margin邊緣(biānyuán)Coronaradiatasign-highlyassociatedwithmalignancy(figure)放射(fàngshè)冠征Lobulatedorscallopedmargins-intermediateprobability分葉征和鋸齒征第十三頁，共三十一頁。編輯課件Smoothmargins-morelikelybenignunlessmetastaticinorigin邊緣光滑見于良性(liánɡxìnɡ)結(jié)節(jié)，除外轉(zhuǎn)移瘤第十四頁，共三十一頁。編輯課件AirBronchogramsign

空氣(kōngqì)支氣管征Recentstudieshaveshowedthatanairbronchogramismorecommonlyseeninmalignantpulmonarynodules.

ItismostcommonlyseeninBAC(bronchoalveolarcellcarcinoma)andadenocarcinoma.最近一項(xiàng)研究表明，在惡性結(jié)節(jié)中經(jīng)?？匆?kànjiàn)空氣支氣管征，主要見于支氣管肺泡癌或腺癌第十五頁，共三十一頁。編輯課件Thecaseontheleftshowsanairbronchogramseenasalinearlucency(broadarrow)andasamorecysticlucency(smallarrow)duetothefactthatthebronchusisseenenface.第十六頁，共三十一頁。編輯課件Onthelefttwosolitarypulmonarynodules.

Baseduponthemorphology,whichlesionhasthemostmalignantfeatures?下列兩個(gè)結(jié)節(jié)有哪些惡性(èxìng)特征呢第十七頁，共三十一頁。編輯課件Thelesiononthefarlefthasaspicuatedmarginandhaslucencieswithinit.

Thelesionnexttoitislobulatedincontourandhassomespiculesradiatingtothepleura.

Itishoweverhomogeneousinattenuation.

Basedonthesefindingsweshouldbemostconcernedthatthelesiononthefarleftismalignant.

Itprovedtobeanadenocarninoma,whiletheotheronewasafungalinfection.

Thelucenciesandfrankairbronchogramsshouldnotmisleadyouinthinkingthatitprobablyisinfection.第十八頁，共三十一頁。編輯課件SolidandGround-glasscomponents

實(shí)性與磨玻璃(bōlí)樣Anotherresultfromscreeningstudiesisthatnodulescontainingaground-glasscomponentaremorelikelytobemalignant(5).

另一項(xiàng)研究表明，含有磨玻璃樣密度的結(jié)節(jié)很可能是惡性結(jié)節(jié)。Partlysolidlesionswithground-glasscomponentshadamalignancyrateof63%.部分(bùfen)實(shí)性和磨玻璃樣密度是惡性結(jié)節(jié)的可能性事63%Nonsolid-onlyground-glasslesionshadamalignancyrateof18%.完全磨玻璃樣密度結(jié)節(jié)16%是惡性結(jié)節(jié)Onlysolidlesionshadamalignancyrateofonly7%.完全實(shí)性結(jié)節(jié)是僅7%是惡性結(jié)節(jié)第十九頁，共三十一頁。編輯課件Partlysolidnodulecontainingground-glasscomponentmostlikelytobemalignant第二十頁，共三十一頁。編輯課件Onthefarleftalesionthatonlyhasaground-glassappearanceandnexttoitalesionthathasbothground-glassandsolidcomponents.

Thelikelihoodofmalignancyis1:5forthelesiononthefarleftand2:3forthelesionwithbothground-glassandsolidcomponents.第二十一頁，共三十一頁。編輯課件LEFT:1in5malignant

左邊(zuǒbian)圖是5個(gè)病灶1個(gè)為惡性結(jié)節(jié)RIGHT:2in3malignant右邊圖是3個(gè)病灶2個(gè)為惡性結(jié)節(jié)第二十二頁，共三十一頁。編輯課件Contrastenhancement

對比(duìbǐ)增強(qiáng)Contrastenhancementlessthan15HUhasaveryhighpredictivevalueforbenignity(99%).

Afterabaselinescan,4consecutivescansat1minuteintervalareperformed.

對比增強(qiáng)(zēngqiáng)小于15HU是良性病變的可能性（99%）

第二十三頁，共三十一頁。編輯課件Thisappliesonlyfornoduleswiththefollowingselectioncriteria:Nodule>5mm結(jié)節(jié)大于5mmRelativelyspherical相對圓形Homogeneous,nonecrosis,fatorcalcification均勻，無壞死(huàisǐ)、鈣化Nomotionorbeamhardeningartifacts沒有運(yùn)動、硬射線偽影第二十四頁，共三十一頁。編輯課件PET-CT:benignversusmalignantPET-CTplaysanincreasinglyimportantroleintheevaluationofsolitarynodules.PET-CT在肺結(jié)節(jié)的評價(jià)(píngjià)中起著很重要作用第二十五頁，共三十一頁。編輯課件PEThasaveryhighsensitivity95%,butalesserspecificityofonly81%PET有很高的敏感性95%，但特異性僅為81%PETisfalsepositiveingranulomatousdiseasePET是假陽性在炎癥性疾病中國PETisusuallyfalsenegativeinsize<10mmandlow-grademalignancyincludingbronchoalveolarcarcinomaandcarcinoid當(dāng)病變小于19mm時(shí)或低度惡性時(shí)，PET表現(xiàn)為假陰性(yīnxìng)，包括支氣管肺泡癌和類癌第二十六頁，共三十一頁。編輯課件FalsenegativePETinapatientwithadenocarcinoma.

Activityisnotsufficientforthediagnosismalignancy.

第二十七頁，共三十一頁。編輯課件Conclusion

結(jié)論(jiélùn)Inthedifferentiationofbenignversusmalignantsolitarypulmonarynodulesnowadaysnewimagingfeatureshavetobeadded.

Weespeciallyhavetolookforthepresenceofareasofground-glassopacity,airbronchogramsorcavitiesandthethree-dimensionalratiosofalesion.在肺結(jié)節(jié)的鑒別(jiànbié)診斷中，一些征象將被增加，包括磨玻璃密度、空氣支氣管征、空洞及三維立體比率第二十八頁，共三十一頁。編輯課件WiththeincreasinglyimportantroleofPET-CT,wehavetobeawareoftheaccuracyofPET-CTandweshouldhaveanideaabouttheprevalenceofinfectiousandnon-infectiousgranulomatousdiseaseintheareathatwepractice.我們應(yīng)該充分意識到PET-CT的重要性，在實(shí)踐診斷(zhěnduàn)中應(yīng)該注意感染性與非感染性疾病的流行情況第二十九頁，共三十一頁。編輯課件ReferencesCTScreeningforLungCancer:Five-yearProspectiveExperi