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1、,胸腺瘤 影像诊断及分期,胸腺瘤影像诊断及分期,流行病学,前纵隔最常见的原发肿瘤,发病率相对较低，占所有成人恶性肿瘤的不到1%,流行病学,常见于40岁以上成人男女发病率相仿,胸腺原发上皮来源肿瘤：胸腺瘤和胸腺癌胸腺瘤最常见,流行病学,胸腺瘤影像诊断及分期,病理特征,恶性肿瘤具有转移潜能,病理特征,实性肿瘤具有包膜局限在胸腺区,病理特征,1/3 坏死、出血、囊变1/3 侵犯包膜和邻近结构,病理特征,生长缓慢侵袭性远处转移罕见,胸腺瘤的WHO病理分类表,注：a. A型；b. B1型；c. B2型；d. B3型,病理分类局限性,几种WHO分型共存确定病理类型困难,病理分类局限性,部分胸腺瘤不属于上述
2、分类中的任何一型不具有临床预测价值,病理分类主要作用,区分胸腺瘤和胸腺癌,胸腺瘤影像诊断及分期,临床特征,局部效应压迫和侵犯,临床特征,胸痛呼吸困难咳嗽,临床特征,重症肌无力3050%的胸腺瘤患者有重症肌无力表现1015%的重症肌无力患者有胸腺瘤,胸腺瘤影像诊断及分期,Masaoka-koga分期及临床处理原则,基于术后病理的分期,胸腺瘤的治疗,首选疗法 外科手术预后因素 切除是否完全,胸腺瘤的治疗,术后放疗取决于肿瘤是否有外侵,胸腺瘤的治疗,新辅助化疗使部分进展期患者重新获得完全切除肿瘤的机会,胸腺瘤影像诊断及分期,影像学的作用,区分早期（期）及进展期（期）患者,影像学的作用,准确诊断正确分
3、期,影像学的作用,敏感识别局部侵犯和远处播散,影像学的作用,筛选术前新辅助化疗患者,影像学的作用,正确诊断可切除的复发肿瘤,正常小儿胸腺,女性，23岁，尤文氏肉瘤患者。a. 化疗开始前 b. 化疗结束后3个月，胸腺增生,女性，25岁，胸腺增生伴重症肌无力 a.同相位T1WI；b.反相位T1WI,a,b,胸腺瘤X线表现,偏侧性前纵隔肿块边界清楚边缘光滑或呈分叶状,进展期X线征象,与肺的交界面不规则膈肌升高（膈麻痹）胸膜结节（胸膜转移）,侵袭性胸腺瘤 男，55岁，无明显临床症状,膈神经受累（右膈面抬高）男，60岁,胸膜转移 女，36岁,CT表现,前纵隔肿块边缘光滑或呈分叶状多发生于胸腺的一叶,CT
4、表现,典型表现为均匀强化约1/3因肿瘤坏死、出血或囊变而出现不均匀强化,CT表现,囊性病变里的软组织结节提示该病变是囊性胸腺瘤而非先天性囊肿,胸腺瘤钙化,细点状沿包膜线条状肿瘤内粗大钙化,血管受侵征象,内腔轮廓不规则被病灶包绕或闭塞消失血管腔内软组织肿块，可延续至心腔内,胸膜播散,单或多发胸膜结节或肿块平滑、结节状，或弥散分布多见于前纵隔胸腺瘤同一侧胸腔积液不常见，即使已经发生胸膜转移,肿瘤侵袭性依据,分叶状或形态不规则瘤内囊变、坏死区多灶性钙化,进展期征象,直径7cm以上与期分级具有高度相关性周围脂肪浸润分叶状轮廓,以下表现提示胸腺瘤可能性较小,纵隔淋巴结广泛转移胸腔积液肺转移,Stage
5、I in MDCT and Masaoka staging system,WHO type A ，Masaoka stage I,stage II in MDCT and Masaoka staging system,stage in MDCT and Masaoka staging system,stage in MDCT and Masaoka staging system,stage in MDCT and Masaoka staging system,stage in MDCT and Masaoka staging system,stage in MDCT and Masaoka s
6、taging system,MRI表现,T1WI低或等信号T2WI高信号与脂肪信号相近,MRI表现,脂肪抑制技术有助于区分肿瘤与周围脂肪,WHO type B1 thymoma in a 47-year-old woman with left-sided neck pain. (a) Axial T1-weighted MR image shows a rounded intermediate-signal-intensity mass (M) in the anterior mediastinum. (b) Axial fat-suppressed T2-weighted MR image
7、demonstrates a 6-cm anterior mediastinal mass (M) with high signal intensity at the level of the ascending aorta (Ao). The mass was diagnosed as a lymphocyte-rich WHO type B1 thymoma at resection.,a,b,Stage III thymoma in a 52-year-old man with chest pain and dyspnea. (a) Axial double-inversion-reco
8、very MR image demonstrates a 4-cm lobulated mass that abuts the pericardium (arrow). (b) Contrast-enhanced multiplanar double-inversion-recovery short-axis MR image demonstrates tumor invasion of the pericardium (arrow) and epicardial fat (arrowhead), findings that were confirmed at thymectomy and p
9、ericardial resection.,a,b,胸腺瘤期 女性，54岁，头面部肿胀，肿瘤侵犯上腔静脉，包绕右冠状动脉,MRI表现,囊变坏死表现为长T1、长T2信号,MRI表现,瘤内纤维间隔和结节表现为低信号，有助于囊性胸腺瘤和先天性囊肿的鉴别,Cystic thymoma in an asymptomatic 35-year-old woman. Coronal T2- weighted MR image shows an anterior mediastinal septate cystic thymoma with a septated soft-tissue nodule (arro
10、w).,囊性胸腺瘤,MRI表现,瘤内出血信号与血肿期龄有关含铁血黄素沉着表现为T1及T2WI上的低信号,MRI表现,肿瘤的包膜和瘤内的纤维分隔提示肿瘤侵袭性较低,PET/CT,Thymic hyperplasia in a 16-year-old boy who had undergone chemotherapy for osteosarcoma 4 months earlier. (a) Contrast-enhanced chest CT scan shows thymic enlargement. (b) PET/CT scan obtained to monitor for oste
11、osarcoma recurrence or metastases shows diffuse FDG uptake in the thymus (arrow). At 7-month follow-up PET/CT, the uptake had resolved, a finding consistent with thymic hyperplasia.,a,b,PET/CT,Stage IVa thymoma in a 50-year-old man. (a) Contrast-enhanced chest CT scan shows a primary mass (M) and a
12、pleural drop metastasis (arrow). (b) On an axial fused FDG PET/CT image, the primary tumor (M) and the drop metastasis (arrow) are FDG avid.,Pleural recurrence in a 38-year-old woman with previously treated stage IVa thymoma. (a) Postoperative baseline CT scan shows normal right basilar pleura adjac
13、ent to the attachment of the diaphragm to the chest wall (arrow). (b) Follow-up contrast-enhanced chest CT scan obtained 2 years later shows increased diaphragmatic pleural thickening (arrow). (c) Axial fused FDG PET/CT image shows FDG-avid pleural recurrence (arrow).,鉴别诊断,胸腺其它原发肿瘤如胸腺癌、胸腺的良性肿瘤等,鉴别诊断
14、,非胸腺来源肿瘤性病变包括淋巴瘤、生殖细胞肿瘤、小细胞肺癌等,鉴别诊断,纵隔的转移瘤,复发与随访,胸腺瘤是惰性肿瘤需长期随访,复发与随访,复发病灶早发现很重要如能完全切除，与术后不复发者预后类似，5年生存率可以达到65%80%,复发与随访,胸腺瘤完全手术切除后平均复发时间大约5年（37年）,复发与随访,期胸腺瘤复发平均时间是10年,复发与随访,期胸腺瘤平均复发时间仅为3年,复发与随访,ITMIG推荐胸腺瘤术后最初5年，胸部CT复查最少每年1次然后间隔一年用胸部X光摄片取代CT，直至术后11年最后转为每年一次的胸部X线摄片,复发与随访,a期胸腺瘤、胸腺癌术后肿瘤不完全切除其它高危肿瘤半年一次胸部CT随访直至满3年,胸腺瘤影像诊断及分期,影像学在胸腺瘤的诊断、分期及随访中发挥着重要作用，CT是重要的断面成像方法肿瘤的分期及手术切除的程度是最重要的决定预后的因素影像科医师必须熟悉进展期胸腺瘤的影像特征，从而筛选出需行术前新辅助化疗的患者，从而提高该类患者的疗效,小结,Thank youfor your attention!,
