孤立性肺结节：良性与恶性对比.ppt

n nThe differential diagnosis of a solitary pulmonary nodule is The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is broad and management depends on whether the lesion is benign or malignant.benign or malignant.n n孤立性肺结节的鉴别诊断是很多的，处理方法依赖于孤立性肺结节的鉴别诊断是很多的，处理方法依赖于该病变是良性还是恶性该病变是良性还是恶性In this overview we will discuss some of the new features that In this overview we will discuss some of the new features that can help to differentiate between benign and malignant can help to differentiate between benign and malignant nodules based upon CT and PET-CT findings.nodules based upon CT and PET-CT findings.n n在此篇文章，我们着重讨论下一些有助于鉴别良恶性结在此篇文章，我们着重讨论下一些有助于鉴别良恶性结节的新特征，此特征是基于节的新特征，此特征是基于CTCT与与PET-CTPET-CT的检查结果的检查结果第一页，共三十页。CT:benign versus malignantn nCalcification Calcification n nSize Size n nGrowth Growth n nShape Shape n nMargin Margin n nAir Bronchogram sign Air Bronchogram sign n nSolid and Ground-glass components Solid and Ground-glass components n nContrast enhancement Contrast enhancement 第二页，共三十页。CT:良性与恶性良性与恶性n n钙化n n大小n n生长速度n n形状n n边缘n n支气管含气征n n实性或磨玻璃样n n增强特征第三页，共三十页。Calcification 钙化钙化n nDiffuse,central,laminated or popcorn calcifications are benign patterns of calcification.n n弥漫性，中心性，分层，爆米花钙化是良性钙化，第四页，共三十页。n nThese types of calcification are seen in granulomatous disease and hamartomasn n这些形式的钙化最常见于错构瘤、肉芽肿性病变第五页，共三十页。n nThe exception to the rule above is when patients are known to have The exception to the rule above is when patients are known to have a primary tumor.a primary tumor.For instance the diffuse calcification pattern can be seen in patients For instance the diffuse calcification pattern can be seen in patients with osteosarcoma or chondrosarcoma.with osteosarcoma or chondrosarcoma.Similarly the central and popcorn pattern can be seen in patients Similarly the central and popcorn pattern can be seen in patients with GI-tumors and patients who previously had chemotherapy.with GI-tumors and patients who previously had chemotherapy.n n一些病人有原发肿瘤病史，可以表现为良性钙化一些病人有原发肿瘤病史，可以表现为良性钙化n n例如骨肉瘤、软骨肉瘤可以表现弥漫性钙化。例如骨肉瘤、软骨肉瘤可以表现弥漫性钙化。n n胃肠间质瘤的病人化疗后可以表现为中心性或苞米花钙胃肠间质瘤的病人化疗后可以表现为中心性或苞米花钙化。化。第六页，共三十页。Size 大小大小n nA solitary pulmonary nodule(SPN)is defined as a single A solitary pulmonary nodule(SPN)is defined as a single intraparenchymal lesion less than 3 cm in size and not intraparenchymal lesion less than 3 cm in size and not associated with atelectasis or lymphadenopathy.associated with atelectasis or lymphadenopathy.A lesion greater than 3 cm in diameter is called a mass.A lesion greater than 3 cm in diameter is called a mass.孤立性结节定义为小于孤立性结节定义为小于3cm3cm，不伴有肺不张、淋巴结转，不伴有肺不张、淋巴结转移，大于移，大于3cm3cm的为肿块的为肿块n nThis distinction is made,because lesions greater than 3 cm This distinction is made,because lesions greater than 3 cm are usually malignant,while smaller lesions can be either are usually malignant,while smaller lesions can be either benign or malignant.benign or malignant.n n以以3cm3cm为界，因为大于为界，因为大于3cm3cm的通常是恶性的，而小于的通常是恶性的，而小于3cm3cm的可能是良性或恶性。的可能是良性或恶性。第七页，共三十页。Relationship between SPN-size and chance of malignancy in patients with high risk for lung cancer结节大小与恶性度具有密切相关性结节大小与恶性度具有密切相关性第八页，共三十页。Growth 生长速度n nComparison with prior imaging studies is often the most useful procedure to determine the importance of the finding of a SPN,since stability over 2 years is highly associated with benignity.n n与前次影像结果相比是鉴别孤立性结节良恶性的一个非常有用的方法。如果超过2年以上保持不变，这个结节就是良性结节第九页，共三十页。Shape 形态n nJapanese screening studies showed that a polygonal shape and Japanese screening studies showed that a polygonal shape and a three-dimensional ratio 1.78 was a sign of benignity(2,3).a three-dimensional ratio 1.78 was a sign of benignity(2,3).日本的一项研究说明，多变形和三维立体比率大于日本的一项研究说明，多变形和三维立体比率大于1.781.78是良性结节的标志是良性结节的标志n nA polygonal shape means that the lesion has multiple facets A polygonal shape means that the lesion has multiple facets(multi-sided).(multi-sided).多边形意味这个病灶具有多个面多边形意味这个病灶具有多个面A peripheral subpleural A peripheral subpleural location was also a sign of benignity in this study location was also a sign of benignity in this study n n在这项研究中，周围的胸膜下的病变也是良性结节的一个在这项研究中，周围的胸膜下的病变也是良性结节的一个标志标志第十页，共三十页。n nThe three-dimensional ratio is measured by obtaining the maximal transverse dimension and dividing it by the maximal vertical dimension.A large three-dimensional ratio indicates that the lesion is relatively flat,which is a benign sign.第十一页，共三十页。Margin 边缘n nCorona radiata sign-highly associated with malignancy(figure)放射冠征n nLobulated or scalloped margins-intermediate probability 分叶征和锯齿征第十二页，共三十页。n nSmooth margins-more likely benign unless metastatic in origin n n边缘光滑见于良性结节，除外转移瘤第十三页，共三十页。Air Bronchogram sign空气支气管征n nRecent studies have showed that an air bronchogram is more commonly seen in malignant pulmonary nodules.It is most commonly seen in BAC(bronchoalveolar cell carcinoma)and adenocarcinoma.n n最近一项研究说明，在恶性结节中经常看见空气支气管征，主要见于支气管肺泡癌或腺癌第十四页，共三十页。n nThe case on the left shows an airbronchogram seen as a linear lucency(broad arrow)and as a more cystic lucency(small arrow)due to the fact that the bronchus is seen en face.第十五页，共三十页。n nOn the left two solitary pulmonary nodules.Based upon the morphology,which lesion has the most malignant features?n n以下两个结节有哪些恶性特征呢第十六页，共三十页。n nThe lesion on the far left has a spicuated margin and has The lesion on the far left has a spicuated margin and has lucencies within it.lucencies within it.The lesion next to it is lobulated in contour and has some The lesion next to it is lobulated in contour and has some spicules radiating to the pleura.spicules radiating to the pleura.It is however homogeneous in attenuation.It is however homogeneous in attenuation.Based on these findings we should be most concerned that Based on these findings we should be most concerned that the lesion on the far left is malignant.the lesion on the far left is malignant.It proved to be an adenocarninoma,while the other one It proved to be an adenocarninoma,while the other one was a fungal infection.was a fungal infection.The lucencies and frank air bronchograms should not The lucencies and frank air bronchograms should not mislead you in thinking that it probably is infection.mislead you in thinking that it probably is infection.第十七页，共三十页。Solid and Ground-glass components实性与磨玻璃样n nAnother result from screening studies is that nodules containing a Another result from screening studies is that nodules containing a ground-glass component are more likely to be malignant(5).ground-glass component are more likely to be malignant(5).n n另一项研究说明，含有磨玻璃样密度的结节很可能是恶性结节。另一项研究说明，含有磨玻璃样密度的结节很可能是恶性结节。n nPartly solid lesions with ground-glass components had a malignancy rate Partly solid lesions with ground-glass components had a malignancy rate of 63%.of 63%.局部实性和磨玻璃样密度是恶性结节的可能性事局部实性和磨玻璃样密度是恶性结节的可能性事63%63%n nNonsolid-only ground-glass lesions had a malignancy rate of 18%.Nonsolid-only ground-glass lesions had a malignancy rate of 18%.完完全磨玻璃样密度结节全磨玻璃样密度结节16%16%是恶性结节是恶性结节n nOnly solid lesions had a malignancy rate of only 7%.Only solid lesions had a malignancy rate of only 7%.完全实性结节是完全实性结节是仅仅7%7%是恶性结节是恶性结节第十八页，共三十页。n nPartly solid nodule containing ground-glass component most likely to be malignant第十九页，共三十页。n nOn the far left a lesion that only has a ground-glass appearance and next to it a lesion that has both ground-glass and solid components.The likelihood of malignancy is 1:5 for the lesion on the far left and 2:3 for the lesion with both ground-glass and solid components.第二十页，共三十页。n nLEFT:1 in 5 malignant左边图是5个病灶1个为恶性结节n nRIGHT:2 in 3 malignantn n右边图是3个病灶2个为恶性结节第二十一页，共三十页。Contrast enhancement比照增强n nContrast enhancement less than 15 HU has a very high predictive value for benignity(99%).After a baseline scan,4 consecutive scans at 1 minute interval are performed.比照增强小于15HU是良性病变的可能性99%第二十二页，共三十页。n nThis applies only for nodules with the following selection criteria:n nNodule 5mm 结节大于5mmn nRelatively spherical 相对圆形n nHomogeneous,no necrosis,fat or calcificationn n均匀，无坏死、钙化 n nNo motion or beam hardening artifacts n n没有运动、硬射线伪影第二十三页，共三十页。PET-CT:benign versus malignantn n PET-CT plays an increasingly important role in the evaluation of solitary nodules.n nPET-CT在肺结节的评价中起着很重要作用第二十四页，共三十页。n nPET has a very high sensitivity 95%,but a lesser PET has a very high sensitivity 95%,but a lesser specificity of only 81%specificity of only 81%n nPETPET有很高的敏感性有很高的敏感性95%95%，但特异性仅为，但特异性仅为81%81%n nPET is false positive in granulomatous disease PET is false positive in granulomatous disease n nPETPET是假阳性在炎症性疾病中国是假阳性在炎症性疾病中国n nPET is usually false negative in size 10 mm and low-grade PET is usually false negative in size 10 mm and low-grade malignancy including bronchoalveolar carcinoma and malignancy including bronchoalveolar carcinoma and carcinoid carcinoid n n当病变小于当病变小于19 mm19 mm时或低度恶性时，时或低度恶性时，PETPET表现为假阴性，表现为假阴性，包括支气管肺泡癌和类癌包括支气管肺泡癌和类癌第二十五页，共三十页。False negative PET in a patient with adenocarcinoma.Activity is not sufficient for the diagnosis malignancy.第二十六页，共三十页。Conclusion结论n nIn the differentiation of benign versus malignant solitary pulmonary nodules nowadays new imaging features have to be added.We especially have to look for the presence of areas of ground-glass opacity,air bronchograms or cavities and the three-dimensional ratios of a lesion.n n在肺结节的鉴别诊断中，一些征象将被增加，包括磨玻璃密度、空气支气管征、空洞及三维立体比率第二十七页，共三十页。n nWith the increasingly important role of PET-CT,we have to be aware of the accuracy of PET-CT and we should have an idea about the prevalence of infectious and non-infectious granulomatous disease in the area that we practice.n n我们应该充分意识到PET-CT的重要性，在实践诊断中应该注意感染性与 非感染性疾病的流行情况第二十八页，共三十页。Referencesn nCT Screening for Lung Cancer:Five-year Prospective ExperienceCT Screening for Lung Cancer:Five-year Prospective Experience Stephen J.Swensen et al Stephen J.Swensen et al Radiology 2005;235:259-265.Radiology 2005;235:259-265.n nIndeterminate Solitary Pulmonary Nodules Revealed at Population-Based CT Screening of the Lung:Using Indeterminate Solitary Pulmonary Nodules Revealed at Population-Based CT Screening of the Lung:Using First Follow-Up Diagnostic CT to Differentiate Benign and Malignant LesionsFirst Follow-Up Diagnostic CT to Differentiate Benign and Malignant Lesions Shodayu Takashima et al.Shodayu Takashima et al.AJR 2003;180:1255-1263 AJR 2003;180:1255-1263 n nSmall Solitary Pulmonary Nodules(1 cm)Detected at Population-Based CT Screening for Small Solitary Pulmonary Nodules(1 cm)Detected at Population-Based CT Screening for Lung Cancer:Reliable High-Resolution CT Features of Benign LesionsLung Cancer:Reliable High-Resolution CT Features of Benign Lesions Shodayu Takashima et al.Shodayu Takashima et al.AJR 2003;180:955-964 AJR 2003;180:955-964 n nCT Screening for Lung Cancer Frequency and Significance of Part-Solid and Nonsolid CT Screening for Lung Cancer Frequency and Significance of Part-Solid and Nonsolid NodulesNodules Claudia I.Henschke et alClaudia I.Henschke et alAJR 2002;178:1053-1057 AJR 2002;178:1053-1057 第二十九页，共三十页。内容总结The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is benign or malignant.。右边图是3个病灶2个为恶性结节。178:1053-1057第三十页，共三十页。