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1、孤立性肺结节的诊断现状,精选ppt,1,孤立性肺结节的诊断现状精选ppt1,Solitary Pulmonary Nodule (SPN),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ppt,2,Solitary Pulmonary Nodule (SP,概况,0.09%-0.20 所有胸片 150，000/年 （预计） 病因：肉芽肿性
2、疾病、肺癌、错构瘤 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：感染性肉芽肿 80 错构瘤 10,精选ppt,3,概况0.09%-0.20 所有胸片 150，000/年,病因,精选ppt,4,病因精选ppt4,Figure 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
3、area of increased opacity overlying the anterior aspect of the right second rib (arrow). (b) CT scan shows a healed fracture of the right second rib (arrow). Note the lytic lesions in the vertebral body secondary to multiple myeloma.,精选ppt,5,Figure 1a. Rib fracture in a,Figure 2a. Pseudonodule in a
4、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 adjacent electrocardiographic lead attachment pad (arrowhead). On a follow-up radiograph obtained after removal of the a
5、ttachment 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 the contiguous nodular area of increased opacity on the chest radiograph.,精选ppt,6,Figure 2a. Pseudonodule in a,
6、Figure 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) Posteroanterior chest radiograph obtained 2 years earlier shows that inte
7、rval 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 first rib. Had fluoroscopy been performed, costly CT could have been
8、avoided.,精选ppt,7,Figure 4a. Osteophyte of the,Figure 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 lower aspect of the thorax and a p
9、oorly 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 multiple cutaneous nodul
10、es.,精选ppt,8,Figure 5a. Cutaneous nodules,Figure 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) sho
11、w a branching tubular 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ppt,9,Figure 6a. Segmental bronchi,Figure 7a. Multiple ar
12、teriovenous malformations in a 23-year-old woman with 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
13、chest radiograph obtained earlier (not shown) demonstrated a possible small solitary pulmonary nodule in the right lower lobe.,精选ppt,10,Figure 7a. Multiple arteriov,Figure 2a: (a) Chest radiograph shows an incidental small nodule (arrow) at the left costophrenic angle. (b) Thin-section CT scan shows
14、 central fat attenuation (43 HU) in the nodule. Hamartoma was diagnosed.,精选ppt,11,Figure 2a: (a) Chest radiograp,Figure 4: CT scan in 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 intrapulmona
15、ry lymph node (arrow). Follow-up CT was not performed because of the patients advanced age.,精选ppt,12,Figure 4: CT scan in a 90-year,胸部CT检测情况,Radiology 2003;228:70-75,精选ppt,13,胸部CT检测情况病灶敏感性 大小mm74,精选ppt,14,精选ppt14,SPN 恶性危险因素,精选ppt,15,SPN 恶性危险因素精选ppt15,SPN 大小,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2c
16、m， 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ppt,16,SPN 大小常规胸片仅能辨别直径9mm以上结节Radiolo,SPN 部位,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-
17、49.,精选ppt,17,SPN 部位良性结节分布无规律性Radiology 2006,Transverse 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ppt,18,Transverse CT scan in a 75-yea,SPN边缘,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
18、生长非均质性不规整：倾向于恶性，可见于肉芽肿性疾病、类脂性肺炎等毛刺：,精选ppt,19,SPN边缘光滑：21恶性结节边界清，多见于转移瘤精选ppt,Figure 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
19、 specimen obtained with wedge resection shows a well-circumscribed, 2-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 infa
20、rction caused by intravascular worms.,光滑,精选ppt,20,Figure 8a. Lung nodule cause,Figure 9. Solitary metastasis from 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
21、%-5% of all resected solitary pulmonary nodules.,精选ppt,21,Figure 9. Solitary metastasi,分叶,Figure 10. Non-small cell lung cancer in a 63-year-old woman. Close-up chest CT scan of the right lung shows a lobulated and spiculated nodule in the lower lobe.,精选ppt,22,分叶Figure 10. Non-small cell,Figure 11a.
22、 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 nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged drainin
23、g 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ppt,23,Figure 11a. Arteriovenous ma,Figure 12. Intralobar sequestration in a 14-year-old boy. Chest CT scan shows a lobulate
24、d, well-marginated nodule with homogeneous attenuation in the right lower lobe. Intrapulmonary sequestration was confirmed at resection.,精选ppt,24,Figure 12. Intralobar seques,边缘不规整或细毛刺,Figure 13. Bronchioloalveolar cell carcinoma in a 65-year-old man. Chest CT scan shows an irregular nodule abutting
25、 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 with eccentric cavitation in the upp
26、er lobe.,精选ppt,25,边缘不规整或细毛刺Figure 13. Bronchio,SPN 内部特征,钙化脂肪密度结节衰减空洞空泡征支气管充气征,精选ppt,26,SPN 内部特征钙化精选ppt26,钙化,55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ppt,27,钙化 55良性结节有钙化精选ppt27,Figure 21. Granuloma in an asymptomatic 64-year-old man.
27、 Close-up chest CT scan of the left lung shows a soft-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 centra
28、l popcornlike calcification in the upper lobe.,精选ppt,28,Figure 21. Granuloma in an a,Figure 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 calcifi
29、cation and laminated fibrous tissue.,精选ppt,29,Figure 22a. Histoplasmoma in,Figure 28a. Granulomatous disease in a 48-year-old woman. (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
30、 demonstrates the diffuse solid calcification in the nodule, a finding that is typical of a benign cause,精选ppt,30,Figure 28a. Granulomatous di,Figure 8: Transverse CT scan shows a 1-cm-diameter left lower lobe nodule with central nidus calcification. This finding is indicative of benign disease.,精选p
31、pt,31,Figure 8: Transverse CT scan s,Figure 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 irregular margins that represents pulmonary carcinoma (black arrow). The calcification seen on
32、the radiograph is caused by a calcified granuloma anterior to the tumor (white arrow).,精选ppt,32,Figure 9a: (a) Chest radiograp,Figure 10: CT scan in an 80-year-old man shows a 2.2-cm-diameter nodule in the left upper lobe with eccentric calcification. FNAB of the nodule revealed adenocarcinoma.,Figu
33、re 11: CT scan shows eccentric dense calcification in a right lower lobe carcinoid tumor,精选ppt,33,Figure 10: CT scan in an 80-ye,Figure 12: CT scan shows calcified right lower lobe nodule that resembles a benign granuloma (arrow). The patient had a history of osteosarcoma. Open lung biopsy revealed
34、metastatic disease.,精选ppt,34,Figure 12: CT scan shows calci,Figure 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ppt,35,Figure 24. Typical pulmonary,Figure 25a. Non-small cell lung
35、 cancer in a 45-year-old woman. (a) Close-up chest radiograph 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
36、that is typical of malignancy. Adenocarcinoma was confirmed at resection.,精选ppt,36,Figure 25a. Non-small cell l,Figure 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 con
37、sistent with engulfed granuloma. Unlike that in calcified granulomas, calcification in engulfed granuloma is typically peripheral and constitutes only a small part of the nodule.,精选ppt,37,Figure 26. Lung cancer in a,Figure 27a. Metastatic osteosarcoma in a 21-year-old man. (a) Close-up chest CT scan
38、 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 CT scan obtained 8 months later reveals interval growth of the nodule, which has high attenuation and a lobulated contour. Resection revealed metastatic osteos
39、arcoma.,精选ppt,38,Figure 27a. Metastatic osteo,脂肪密度,良性：错构瘤、脂肪瘤恶性：脂肉瘤、肾透明细胞癌,精选ppt,39,脂肪密度良性：错构瘤、脂肪瘤精选ppt39,Figure 19a. Hamartoma in an asymptomatic man. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat. These findings are typical featu
40、res 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-eosin stain) helps confirm the presence of adipose tissue (arrow) and shows epithel
41、ial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma.,精选ppt,40,Figure 19a. Hamartoma in an,Figure 20a. Pulmonary hamartoma in a 74-year-old woman. (a) Chest CT scan obtained with 10-mm collimation demonstra
42、tes 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ppt,41,Figure 20a. Pulmonary hamart,结节衰减,非实性（
43、毛玻璃样）：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ppt,42,结节衰减非实性（毛玻璃样）：精选ppt42,Figure 14: CT scan in an 81-year-old man shows a 2.8-cm irregular, partly solid left upper lobe nodule with pleural ta
44、gs. FNAB revealed bronchioloalveolar 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ppt,43,Figure 14: CT scan in an 81-ye,空洞(5mm),良性空洞：壁光滑、薄(16mm) 15%肺癌有空洞（病灶直径3cm ）,精选ppt,44,空洞(5mm)良性空洞：壁光滑、薄(4mm)
45、精选ppt4,Figure 16. Aspergillus infection in a 48-year-old man with leukemia. Close-up chest CT scan of the right 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 nod
46、ule in the lower lobe. Note the eccentric cavitation and thick walls.,精选ppt,45,Figure 16. Aspergillus infec,Figure 18: CT scan in an 83-year-old man 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.,Fi
47、gure 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 nonsmall cell lung cancer.,精选ppt,46,Figure 18: CT scan in an 83-ye,Figure 18. Bullet track from a gunshot wound in a 20-year-old man. Close-up postero
48、anterior 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 are consistent with parenchymal hematoma and a bullet track.,精选ppt,47,Figure 18. Bullet track from,空泡征：,空泡征
49、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ppt,48,空泡征：精选ppt48,支气管充气征,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
50、率仅为00 59,精选ppt,49,支气管充气征是指结节内见到充气的支气管，CT表现为气体密度小,SPN与支气管的关系,I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ppt,50,SPN与支气管的关系I型：支气管被SPN截断Clinical,I型：支气管被SPN截断,精选ppt,51,I型：支气管被SPN截断精选ppt51,II型：支气管进入SPN呈锥状中断,精选pp
