g孤立性肺结节的诊断现状-课件.ppt
孤立性肺结节的诊断现状孤立性肺结节的诊断现状Solitary Pulmonary Nodule(SPN)n定义：（coinleision)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。Chest2003；123：89-96概况0.09%-0.20所有胸片150，000/年（预计）病因：肉芽肿性疾病、肺癌、错构瘤恶性结节恶性结节：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良性结节良性结节：感染性肉芽肿80错构瘤10病因病因Figure 2a.Pseudonoduleina50-year-oldman.(a)Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednodularareaofincreasedopacityprojectingoverthelung(arrow).Notetheadjacentelectrocardiographicleadattachmentpad(arrowhead).Onafollow-upradiographobtainedafterremovaloftheattachmentpad(notshown),nonodulewasobserved.(b)Frontandbackviewsoftheelectrocardiographicleadattachmentpadshowaneccentricallylocatedsilvernitratepad,whichexplainsthecontiguousnodularareaofincreasedopacityonthechestradiograph.Figure 4a.Osteophyteoftheleftfirstribina60-year-oldwoman.(a)Posteroanteriorchestradiographshowsapoorlydefinednodularareaofincreasedopacityoverlyingtheanterioraspectoftheleftfirstrib(arrow).(b)Posteroanteriorchestradiographobtained2yearsearliershowsthatintervalgrowthhasoccurred(cfa).Thisintervalgrowthraisedsuspicionformalignancy.(c)ContiguouschestCTscans(imageonrightobtainedatalowerlevel)revealthattheareaofincreasedopacityisalargeosteophyteofthefirstrib.Hadfluoroscopybeenperformed,costlyCTcouldhavebeenavoided.Figure 5a.Cutaneousnodulesina51-year-oldmanwithneurofibromatosisandprostaticadenocarcinoma.(a)Posteroanteriorradiographshowsnumerouswell-marginatednodularareasofincreasedopacityprojectingovertheloweraspectofthethoraxandapoorlymarginatednoduleoverlyingtheupperaspectofthelefthemithorax(arrow).Becausethelocationoftheuppernodulewasuncertain,CTwasperformed.(b)CTscanhelpsconfirmtheintraparenchymallocationofthenoduleintheleftupperlobe.(c)CTscandemonstratesmultiplecutaneousnodules.Figure 7a.Multiplearteriovenousmalformationsina23-year-oldwomanwithhereditaryhemorrhagictelangiectasia.ContiguouschestCTscansrevealmultiplesmallnodularareasofincreasedattenuationbilaterallywithenlargedfeedinganddrainingvessels,findingsthatarediagnosticforarteriovenousmalformations.Achestradiographobtainedearlier(notshown)demonstratedapossiblesmallsolitarypulmonarynoduleintherightlowerlobe.Figure 2a:(a)Chestradiographshowsanincidentalsmallnodule(arrow)attheleftcostophrenicangle.(b)Thin-sectionCTscanshowscentralfatattenuation(43HU)inthenodule.Hamartomawasdiagnosed.胸部CT检测情况病灶敏感性大小mm745mm82性质毛玻璃样65实性83部位外周80%中央61%Radiology2003;228:70-75SPN 恶性危险因素SPN大小n常规胸片仅能辨别直径9mm以上结节n80良性结节直径小于2cmn42恶性结节直径小于2cm，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5mm)n良性空洞：壁光滑、薄(16mm)n15%肺癌有空洞（病灶直径3cm）Figure 16.Aspergillusinfectionina48-year-oldmanwithleukemia.Close-upchestCTscanoftherightlungshowsathin-walledcavitarynodule.Figure 17.Squamouscelllungcancerina60-year-oldwoman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginatednoduleinthelowerlobe.Notetheeccentriccavitationandthickwalls.Figure 18:CTscaninan83-year-oldmanshowsa2.3-cmleftupperlobecavitarynodule.Thewallisvariableandthecavitywallisasthickas8mm.FNABrevealedsquamouscellcarcinoma.Figure 19:CTscaninan80-year-oldmanshowsarightupperlobe2.9-cmcavitarynodulewithasmooth,uniform2.5-mm-thickcavitywall.FNABrevealednonsmallcelllungcancer.Figure 18.Bullettrackfromagunshotwoundina20-year-oldman.Close-upposteroanteriorradiographoftherightlungshowsasmoothlymarginated,thick-wallednodulewitheccentriclucencyinthemidlung.Notethebulletfragmentsoverlyingtherightlung.Thesefindingsareconsistentwithparenchymalhematomaandabullettrack.空泡征：n空泡征为肿瘤内小的低密度影，多为23mm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。n多见于BAC或腺癌支气管充气征n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。n在恶性SPN的发生率为269650n而在良性SPN，其发生率仅为0059SPN与支气管的关系nI型：支气管被SPN截断nII型：支气管进入SPN呈锥状中断n型：支气管在SPN内呈长段开放状，并可进一步分叉n型：支气管紧贴SPN边缘走行，管腔形态正常nV型：支气管紧贴SPN边缘走行，管腔受压变扁Clinical Radiology(2004)59,11211127I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nI型：支气管被SPN截断nII型：支气管进入SPN呈锥状中断n型：支气管在SPN内呈长段开放状，并可进一步分叉n型：支气管紧贴SPN边缘走行，管腔形态正常nV型：支气管紧贴SPN边缘走行，管腔受压变扁Clinical Radiology(2004)59,11211127恶性结节最常见的肿瘤一支气管关系是I型，其次为型，V型最少见；良性结节最常见的是V型，其次为I型，未见到型。就肿瘤一支气管关系类型而言，I型恶性SPN多于良性SPN，后者主要见于结核球；型仅见于恶性SPN；型可见于恶性和良性SPN，但前者的支气管形态僵硬，管腔保持通畅甚或轻度扩张；后者支气管形态柔软，走向自然，管腔扩张度不如恶性肿瘤，并常见支气管有多个树枝状分又及支气管呈断续状表现；IV型以恶性SPN占绝大多数V型则以良性SPN多见。SPN一支气管关系类型的病理基础膨胀性生长：瘤细胞增殖、堆积，呈实性压迫、推移邻近肺组织，由于肿瘤为支气管源性，故导致支气管在肿瘤边缘截断。伏壁性生长：以肺结构为支架，瘤细胞沿肺泡壁和肺泡隔爬行，经肺泡孔扩展，同时可经淋巴道、小气道或以直接浸润的方式从1个肺小叶扩展到另1个肺小叶，而支气管仍保持通畅，形成支气管充气征。n支气管管壁由外向内的肿瘤浸润、管壁产生的纤维性增殖性反应使支气管管壁增厚、僵硬，加上瘤内成纤维化反应的牵拉，使瘤内的支气管不仅未被肿瘤压扁，反而保持高度的通畅，甚至有所扩张，形成恶性肿瘤的含气支气管征特有的表现。n良性结节边缘的支气管未受肿瘤侵犯和成纤维化反应的影响，管壁仍很柔软，易受膨胀性生长的结节压迫，导致管腔变扁甚至闭塞。结核球引起支气管截断是由于后者参与形成包膜。炎性假瘤的含气支气管征由肺实质的渗出、实变、机化衬托引起，支气管形态自然，常见树枝状分叉，管腔内可有分泌物、出血或血栓，使支气管表现为断续状。SPN血管特征n恶性结节增强超过良性结节nCT增强值低于15HU倾向于良性nCT净增值超过25HU，清除值5-31HU倾向恶性AJR2007;188:57-68Graphoffourdifferenttypesoftime-attenuationcurveofnodulehemodynamicsinconsiderationofbothwash-inandwashoutphasesofdynamicCT.Radiology2005;237:675-683Patterns of Nodule Enhancement at Early and Delayed Enhancement CTPatterns of Nodule Enhancement according to Histologic DiagnosisFig.4AMetastaticadenocarcinomain57-year-oldmanwithrectalcancershowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTandpositiveuptakeonintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows9-mmnodule(arrow)inleftupperlobe.Fig.3AAdenocarcinomain67-year-oldmanshowsnetenhancementof25Handwashoutof5-31HatdynamichelicalCTandpositiveuptakeatintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows16-mmnodule(arrow)inleftupperlobehaslobulatedandspiculatedmargin.Figure 3a.CTscansoftuberculomawithtypeIIenhancement(31HUwashout)ina45-year-oldwoman.Serialimageswithdynamicenhancementcurvefortheleftlowerlobenoduleshowpeakenhancementis165HU;netenhancement,133HU;absolutelossofenhancement(washout),90HU;andtimetopeakenhancement,1minute.病理学基础：周围型肺癌的血供源于支气管动脉，肿瘤间质内血管丰富，且分化不成熟，血管分布紊乱，基底膜不完整，管壁通透性高，有利于大分子造影剂渗入细胞间隙，部分肺癌微血管扩张，利于造影剂在血管内停留。结核球是中央的干酪坏死区为纤维包膜所包裹，干酪坏死因乏血管而无强化。周围型肺癌明显高于结核球。从时间密度曲线观察，两者截然不同，结核球的曲线低平，无明显峰值。而周围型肺癌动态增强后2min内达到高峰，周围型肺癌的主要强化形态是完全强化，少部分周围性强化。结核球的主要强化形态是无强化及包膜样强化，结核球的不同强化形态取决于包膜的富血管、完整度及厚度。炎性结节形成过程中，肺动脉水平上发生弥漫性血栓，血供直接源于支气管动脉，造影剂通过相对较直的、结构正常的血管进入间质，进入血管周围间质的造影剂因淋巴管的通畅加快了引流。部分恶性及良性病灶持续强化无清除可能与局部组织纤维化的程度数量相关。SPN生长速度评价n大部分恶性结节倍增时间30-400天n2年随访病灶稳定，倍增时间至少730天倾向良性疾病n倍增时间小于7天，超过465天倾向良性n直径小于1cm病灶较难评价Radiographics.2000;20:59-66Td=Tilog2/3log(Di/Do)Ti=intervaltime Di=initialdiameter Do=finaldiameterFigure 1.Effectofinitialnodulesizeonperceptionofgrowth.Schematicillustratestwovolumedoublingsofa4-mmnoduleanda3-cmnodule.Becausetheeyeperceivesthearithmeticincreaseindiameterratherthanthechangeinvolume,thesmallernoduleappearstobegrowingmoreslowlythanthelargerone,eventhoughbotharedoublinginvolumeatthesamerate.Figure 21a:(a)CTscaninan80-year-oldmanshowsa2.5-cmrightupperlobenoduleattheposteriorsegment.(b)RepeatCTscanobtainedpriortotreatmentperformed2monthslatershowsrapidintervalenlargement.Thevolumetricdoublingtimewas26days.FNABrevealedmixedsmallcellandnonsmallcellcarcinoma.Bayesian Analysis临床、影像学资料EffectofageandsmokinghistoryonpCainanindeterminatepulmonarynodule.Close-upchestCTscanoftherightlungshowsa7-mm,smoothlymarginated,noncalcifiednoduleinthemiddlelobe.Onthebasisofdecisionanalysis,observationwouldbethemostcost-effectivemanagementstrategyina35-year-oldnonsmoker(pCa=0.01)orcurrentsmoker(pCa=0.05),andbiopsywouldbethemostcost-effectivemanagementstrategyina70-year-oldnonsmoker(pCa=0.07)orcurrentsmoker(pCa=0.50)其他辅助检查对于SPN诊断价值nPETn核素显像PETn直径1-3cm实性结节，敏感性94特异性83nSUV值超过2.5即为阳性n假阳性：局部感染，炎症，肉芽肿性疾病n假阴性：病灶直径小于1cm，类癌，BACFigure 7a.Non-smallcelllungcancerina65-year-oldman.(a)ChestCTscanshowsasmallnoduleintheleftlowerlobe.(b)AxialFDGPETscanshowsmarkedFDGaccumulationinthenodule,afindingthatissuspiciousformalignancy.Lungcancerwasconfirmedatresection.Figure 8a.Pulmonarycystina42-year-oldmanwithemphysemawhowasundergoingpre-lungtransplantationevaluation.(a)Posteroanteriorradiographshowsemphysemaandawell-marginatednoduleintheleftlowerlobe.(b)ChestCTscanhelpsconfirmthehomogeneousleftlowerlobenodule.(c)AxialFDGPETscanobtainedatthesamelevelasbshowsnoincreasedmetabolicactivityintheregionofthenodule.Thesefindingsareconsistentwithbenignity,andhemorrhagiccystwasdiagnosedatlungtransplantation18monthslater.Figure 20:FDGPETscanshowsalingularnodule(arrow)withastandardizeduptakevalueofmorethan2.5.FNABrevealedcarcinoidtumor.ig.5AAdenocarcinomawithpredominantlynonmucinousbronchioloalveolarcarcinomacomponentin49-year-oldwomanshowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTbutlittle18F-FDGuptakeonintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows25-mmsemisolidnodule(arrow)ofmixedsolidandground-glassattenuationinleftupperlobe.Fig.5CAdenocarcinomawithpredominantlynonmucinousbronchioloalveolarcarcinomacomponentin49-year-oldwomanshowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTbutlittle18F-FDGuptakeonintegratedPET/CT.PETimage(left)showsrelativelylittle18F-FDGuptakeinnodule,withmaximumstandardizeduptakevalueof1.4.PETimagewasintegratedwithCTimage(right).Arrowonright=nodule.6ASmalladenocarcinomain49-year-oldwomanshowsnetenhancementof25Handwashoutof5-31HondynamichelicalCTbutnegligible18F-FDGuptakeonintegratedPET/CT.Lungwindowoftransversethin-section(2.5-mmcollimation)CTscanshows9-mmnodule(arrow)inrightupperlobe.SPN活检nFNABnVATSn开胸肺活检Radiology2005;237:395-400.小结nCT检查可提高肺内小结节的检出率n动态螺旋CT可做为SPN最初评价手段nPET/CT更具敏感性nSPN高度怀疑恶性，可通过VATS切除
