孤立性肺結(jié)節(jié)的診斷現(xiàn)狀

1、孤立性肺結(jié)節(jié)的診斷現(xiàn)狀,長海醫(yī)院 呼吸內(nèi)科孫沁瑩,Solitary Pulmonary Nodule (SPN),定義：（coin leision) 任何肺內(nèi)或胸膜的病灶，在X線上表現(xiàn)直徑在2-30mm，邊緣清晰或不清晰的圓形或類圓形陰影。 Fleischer Society Glossary 肺實質(zhì)內(nèi)直徑《3cm圓形或類圓形的病灶，不

2、伴有淋巴結(jié)腫大，阻塞性肺炎或肺不張。

3、 Chest 2003；123：89-96,概況,0.09%-0.20％ 所有胸片 150，000/年 （預(yù)計） 病因：肉芽腫性疾病、肺癌、錯構(gòu)瘤 惡性結(jié)節(jié)：10－70％ 占手術(shù)切除肺結(jié)節(jié)的60-80% IA期肺癌術(shù)后5年生存率61-75％ 良性結(jié)節(jié)：感染性肉芽腫 80％ 錯構(gòu)瘤 10％,病因,Figure 1a.   Rib fracture in a 50

4、-year-old woman with multiple myeloma. (a) Close-up posteroanterior radiograph of the right upper lung shows a poorly marginated nodular area of increased opacity overlying the anterior aspect of the right second rib (ar

5、row). (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.,Figure 2a.   Pseudonodule in a 50-year-old man. (a) Close-u

6、p 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

7、follow-up radiograph obtained after removal of the attachment pad (not shown), no nodule was observed. (b) Front and back views of the electrocardiographic lead attachment pad show an eccentrically located silver nitrate

8、 pad, which explains the contiguous nodular area of increased opacity on the chest radiograph.,Figure 4a.   Osteophyte of the left first rib in a 60-year-old woman. (a) Posteroanterior chest radiograph shows a

9、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 interval growth has occurred (cf a).

10、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 fluoros

11、copy been performed, costly CT could have been avoided.,Figure 5a.   Cutaneous nodules in a 51-year-old man with neurofibromatosis and prostatic adenocarcinoma. (a) Posteroanterior radiograph shows numerous wel

12、l-marginated nodular areas of increased opacity projecting over the lower aspect of the thorax and a poorly marginated nodule overlying the upper aspect of the left hemithorax (arrow). Because the location of the upper n

13、odule 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 nodules.,Figure 6a.   Segmental b

14、ronchial 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

15、 lower level) show 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

16、atresia and obviated further work-up.,Figure 7a.   Multiple arteriovenous malformations in a 23-year-old woman with hereditary hemorrhagic telangiectasia. Contiguous chest CT scans reveal multiple small nodular

17、 areas of increased attenuation bilaterally with enlarged feeding and draining vessels, findings that are diagnostic for arteriovenous malformations. A chest radiograph obtained earlier (not shown) demonstrated a possibl

18、e small solitary pulmonary nodule in the right lower lobe.,Figure 2a: (a) Chest radiograph shows an incidental small nodule (arrow) at the left costophrenic angle. (b) Thin-section CT scan shows central fat attenuation (

19、–43 HU) in the nodule. Hamartoma was diagnosed.,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 congest

20、ed intrapulmonary lymph node (arrow). Follow-up CT was not performed because of the patient's advanced age.,胸部CT檢測情況,Radiology 2003;228:70-75,SPN 惡性危險因素,SPN 大小,常規(guī)胸片僅能辨別直徑9mm以上結(jié)節(jié)80％良性結(jié)節(jié)直徑小于2cm42％惡性結(jié)節(jié)直徑小于2cm， 15％惡性結(jié)節(jié)

21、直徑小于1cm,直徑8mm左右結(jié)節(jié)經(jīng)隨訪惡性發(fā)生率10-20%,直徑<4mm結(jié)節(jié)惡性發(fā)生率<1%非鈣化直徑小于1cm結(jié)節(jié)，42-92%為良性,Radiology 2006;239:34-49. Radiographics. 2000;20:43-58.,Radiology 2005;237:395-400.,SPN 部位,良性結(jié)節(jié)分布無規(guī)律性肺癌：右肺/左肺 1.5，上葉占70％IPF患者合并肺癌好發(fā)于下葉外周或發(fā)生

22、纖維化部位50％腺癌位于外周，鱗癌多為中央型,Radiology 2006;239:34-49.,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 carcino

23、ma.,SPN邊緣,光滑：21％惡性結(jié)節(jié)邊界清，多見于轉(zhuǎn)移瘤分葉：25％良性結(jié)節(jié)有分葉，惡性組織生長非均質(zhì)性不規(guī)整：傾向于惡性，可見于肉芽腫性疾病、類脂性肺炎等毛刺：,Figure 8a.   Lung nodule caused by Dirofilaria (canine heartworm) in an asymptomatic 70-year-old man. (a) Close-up CT scan

24、of the right lung shows a peripheral, smoothly marginated, noncalcified lung nodule. (b) Photograph of a specimen obtained with wedge resection shows a well-circumscribed, 2-cm nodule with yellow areas of geographic necr

25、osis. (c) High-power photomicrograph (original magnification, x175; hematoxylin-eosin stain) shows intravascular Dirofilaria. Most infections manifest as lung nodules from embolic infarction caused by intravascular worms

26、.,光滑,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 metast

27、ases account for 3%-5% of all resected solitary pulmonary nodules.,分葉,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 no

28、dule in the lower lobe.,Figure 11a.   Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia. (a) Close-up posteroanterior radiograph of the right lung shows a lobulated, wel

29、l-marginated nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged draining vein (arrowhead). (c) CT scan shows the nidus of the malformation. (d) Pulmonary angiogram

30、helps confirm arteriovenous malformation. Note the early draining vein (arrows).,Figure 12.   Intralobar sequestration in a 14-year-old boy. Chest CT scan shows a lobulated, well-marginated nodule with homogene

31、ous attenuation in the right lower lobe. Intrapulmonary sequestration was confirmed at resection.,邊緣不規(guī)整或細毛刺,Figure 13.   Bronchioloalveolar cell carcinoma in a 65-year-old man. Chest CT scan shows an irregular

32、nodule abutting 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 wom

33、an. Close-up chest CT scan of the right lung shows a spiculated nodule with eccentric cavitation in the upper lobe.,SPN 內(nèi)部特征,鈣化脂肪密度結(jié)節(jié)衰減空洞空泡征支氣管充氣征,鈣化,55％良性結(jié)節(jié)有鈣化結(jié)節(jié)直徑小于3cm，有下列鈣化形式之一考慮良性：中心性，分層，彌漫性，爆米花樣，超過結(jié)節(jié)面積10％13％肺

34、癌有不同程度的鈣化－偏心樣鈣化 類癌、轉(zhuǎn)移性骨肉瘤、軟骨肉瘤、結(jié)腸癌、卵巢癌也可表現(xiàn)為良性鈣化,Figure 21.   Granuloma in an asymptomatic 64-year-old man. Close-up chest CT scan of the left lung shows a soft-tissue nodule with central calcification in the u

35、pper 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 central popcornli

36、ke calcification in the upper lobe.,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 rese

37、cted specimen helps confirm central calcification and laminated fibrous tissue.,Figure 28a.   Granulomatous disease in a 48-year-old woman. (a) Chest CT scan (10-mm collimation) shows a nodule with peripheral c

38、alcification and a calcified right hilar node. (b) Thin-section CT scan (3-mm collimation) better demonstrates the diffuse solid calcification in the nodule, a finding that is typical of a benign cause,Figure 8: Transver

39、se CT scan shows a 1-cm-diameter left lower lobe nodule with central nidus calcification. This finding is indicative of benign disease.,Figure 9a: (a) Chest radiograph shows a right upper lobe nodule with central calcifi

40、cation. 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 the radiograph is caused by a calcified g

41、ranuloma anterior to the tumor (white arrow).,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.,Figur

42、e 11: CT scan shows eccentric dense calcification in a right lower lobe carcinoid tumor,Figure 12: CT scan shows calcified right lower lobe nodule that resembles a benign granuloma (arrow). The patient had a history of o

43、steosarcoma. Open lung biopsy revealed metastatic disease.,Figure 24.   Typical pulmonary carcinoid tumor in a 68-year-old woman. Chest CT scan shows a lobulated lesion with scattered punctate calcifications in

44、 the left lower lobe.,Figure 25a.   Non-small cell lung 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 pr

45、esence of emphysema and upper lobe bullae. (b) Close-up chest CT scan of the right lung reveals amorphous calcification in the nodule, a pattern that is typical of malignancy. Adenocarcinoma was confirmed at resection.,F

46、igure 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 consistent with "en

47、gulfed" granuloma. Unlike that in calcified granulomas, calcification in engulfed granuloma is typically peripheral and constitutes only a small part of the nodule.,Figure 27a.   Metastatic osteosarcoma in

48、 a 21-year-old man. (a) Close-up chest CT scan 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 r

49、eveals interval growth of the nodule, which has high attenuation and a lobulated contour. Resection revealed metastatic osteosarcoma.,脂肪密度,良性：錯構(gòu)瘤、脂肪瘤惡性：脂肉瘤、腎透明細胞癌,Figure 19a.   Hamartoma in an asymptomatic man

50、. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat. These findings are typical features of hamartoma. (b) Photograph of a resected specimen demonstrates a

51、 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 sho

52、ws epithelial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma.,Figure 20a.   Pulmonary hamartoma in a 74-year-old w

53、oman. (a) Chest CT scan obtained with 10-mm collimation demonstrates a nodule (arrow), but its internal morphologic features are poorly visualized. (b) Thin-section CT scan obtained with 1-mm collimation better demonstra

54、tes a punctate area of fat within the nodule (arrow), a finding that is diagnostic for hamartoma.,結(jié)節(jié)衰減,非實性（毛玻璃樣）：34％為惡性，直徑大于1.5cm圓形惡性風(fēng)險度增加（多見于BAC 、腺癌有BAC特征）良性：炎癥性病變，癌前病變（不典型腺瘤樣增生，支氣管肺泡過度增生）部分實性：40-50%直徑小于1.5cm結(jié)節(jié)為惡性，實性

55、成分位于中央?yún)^(qū)提示侵襲性腺癌實性：15％直徑小于1cm病灶為惡性，轉(zhuǎn)移性病灶多為實性,Figure 14: CT scan in an 81-year-old man shows a 2.8-cm irregular, partly solid left upper lobe nodule with pleural tags. FNAB revealed bronchioloalveolar cell carcinoma.,Figur

56、e 13: CT scan in a 64-year-old man shows an oval 2.1-cm left lower lobe nonsolid nodule (arrow). FNAB revealed adenocarcinoma.,空洞(>5mm),良性空洞：壁光滑、薄(16mm) 15%肺癌有空洞（病灶直徑>3cm ）,Figure 16.   Aspergillus i

57、nfection 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

58、 radiograph of the right lung shows a smoothly marginated nodule in the lower lobe. Note the eccentric cavitation and thick walls.,Figure 18: CT scan in an 83-year-old man shows a 2.3-cm left upper lobe cavitary nodule.

59、The wall is variable and the cavity wall is as thick as 8 mm. FNAB revealed squamous cell carcinoma.,Figure 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-

60、thick cavity wall. FNAB revealed non–small cell lung cancer.,Figure 18.   Bullet track from a gunshot wound in a 20-year-old man. Close-up posteroanterior radiograph of the right lung shows a smoothly marginate

61、d, 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.,空泡征：,空泡征為腫瘤內(nèi)小的低密度影，多為2～3 mm大小，

62、1個或多個，CT掃描僅限于1～2個層面見到?？张菡魇俏撮]塞的小支氣管或肺泡，主要原因同支氣管空氣征一樣，為癌細胞呈伏壁生長，部分肺泡腔和細支氣管未被腫瘤組織填充，腫瘤內(nèi)的纖維組織或瘢痕組織的牽拉而擴張。多見于BAC或腺癌,支氣管充氣征,是指結(jié)節(jié)內(nèi)見到充氣的支氣管，CT表現(xiàn)為氣體密度小管影。此征多見于中高分化的腺癌，癌細胞沿著支氣管呈伏壁生長，肺的支架結(jié)構(gòu)未被破壞，腫瘤內(nèi)的支氣管結(jié)構(gòu)仍保存。有此征象的腫瘤與無此征象的腫瘤相比，具有相對低

63、度惡性的生物學(xué)行為。在惡性SPN的發(fā)生率為26．9％ ～65．0％ 而在良性SPN，其發(fā)生率僅為0．0％ ～5．9％,SPN與支氣管的關(guān)系,I型：支氣管被SPN截斷II型：支氣管進入SPN呈錐狀中斷Ⅲ型：支氣管在SPN內(nèi)呈長段開放狀，并可進一步分叉Ⅳ型：支氣管緊貼SPN邊緣走行，管腔形態(tài)正常V型：支氣管緊貼SPN邊緣走行，管腔受壓變扁,Clinical Radiology (2004) 59, 1121–1127,I型：支氣

64、管被SPN截斷,II型：支氣管進入SPN呈錐狀中斷,Ⅲ型：支氣管在SPN內(nèi)呈長段開放狀，并可進一步分叉,Ⅲ型：支氣管在SPN內(nèi)呈長段開放狀，并可進一步分叉,Ⅳ型：支氣管緊貼SPN邊緣走行，管腔形態(tài)正常,V型：支氣管緊貼SPN邊緣走行，管腔受壓變扁,I型：支氣管被SPN截斷II型：支氣管進入SPN呈錐狀中斷Ⅲ型：支氣管在SPN內(nèi)呈長段開放狀，并可進一步分叉Ⅳ型：支氣管緊貼SPN邊緣走行，管腔形態(tài)正常V型：支氣管緊貼SPN邊緣走行，

65、管腔受壓變扁,Clinical Radiology (2004) 59, 1121–1127,惡性結(jié)節(jié)最常見的腫瘤一支氣管關(guān)系是I型，其次為Ⅳ型，V型最少見；良性結(jié)節(jié)最常見的是V型，其次為I型，未見到Ⅱ型。就腫瘤一支氣管關(guān)系類型而言，I型惡性SPN多于良性SPN，后者主要見于結(jié)核球；Ⅱ型僅見于惡性SPN；Ⅲ型可見于惡性和良性SPN，但前者的支氣管形態(tài)僵硬，管腔保持通暢甚或輕度擴張；后者支氣管形態(tài)柔軟，走向自然，管腔擴張度不如惡性

66、腫瘤，并常見支氣管有多個樹枝狀分又及支氣管呈斷續(xù)狀表現(xiàn)；IV型以惡性SPN占絕大多數(shù)V型則以良性SPN多見。,SPN一支氣管關(guān)系類型的病理基礎(chǔ),膨脹性生長：瘤細胞增殖、堆積，呈實性壓迫、推移鄰近肺組織，由于腫瘤為支氣管源性，故導(dǎo)致支氣管在腫瘤邊緣截斷。伏壁性生長：以肺結(jié)構(gòu)為支架，瘤細胞沿肺泡壁和肺泡隔爬行，經(jīng)肺泡孔擴展，同時可經(jīng)淋巴道、小氣道或以直接浸潤的方式從1個肺小葉擴展到另1個肺小葉，而支氣管仍保持通暢，形成支氣管充氣征。,

67、,支氣管管壁由外向內(nèi)的腫瘤浸潤、管壁產(chǎn)生的纖維性增殖性反應(yīng)使支氣管管壁增厚、僵硬，加上瘤內(nèi)成纖維化反應(yīng)的牽拉，使瘤內(nèi)的支氣管不僅未被腫瘤壓扁，反而保持高度的通暢，甚至有所擴張，形成惡性腫瘤的含氣支氣管征特有的表現(xiàn)。良性結(jié)節(jié)邊緣的支氣管未受腫瘤侵犯和成纖維化反應(yīng)的影響，管壁仍很柔軟，易受膨脹性生長的結(jié)節(jié)壓迫，導(dǎo)致管腔變扁甚至閉塞。結(jié)核球引起支氣管截斷是由于后者參與形成包膜。炎性假瘤的含氣支氣管征由肺實質(zhì)的滲出、實變、機化襯托引起，支氣管

68、形態(tài)自然，常見樹枝狀分叉，管腔內(nèi)可有分泌物、出血或血栓，使支氣管表現(xiàn)為斷續(xù)狀。,SPN血管特征,惡性結(jié)節(jié)增強超過良性結(jié)節(jié)CT增強值低于15HU傾向于良性CT凈增值超過25HU，清除值5-31HU傾向惡性,AJR 2007; 188:57-68,Graph of four different types of time-attenuation curve of nodule hemodynamics in consideration

69、 of both wash-in and washout phases of dynamic CT.,Radiology 2005;237:675-683,Patterns of Nodule Enhancement at Early and Delayed Enhancement CT,Patterns of Nodule Enhancement according to Histologic Diagnosis,Fig. 4A —M

70、etastatic adenocarcinoma in 57-year-old man with rectal cancer shows net enhancement of 25 H and washout of 5-31 H on dynamic helical CT and positive uptake on integrated PET/CT. Lung window of transverse thin-section