高分辨率肺部ct

1、HIGH RESOLUTION LUNG CT,天鐵醫(yī)院放射中心 王獻忠,HRCT掃描技術,,正常HRCT.,,中央肺動脈。,,支氣管與相鄰肺動脈直徑大致相等。,,肺動脈常分為兩個直徑相當的分支。,,肺靜脈常分成許多細小的分支,這些分支與主支構成直角。,,葉間裂（厚度小于1mm，邊緣光滑，均一厚度）,常見偽影,雙側下肺近心臟處，肺血管脈動偽影。低密度區(qū)， 可以錯當作擴大的支氣管。,常見偽影,主葉裂偽影。,常見偽影,血管雙重偽影。

2、,The Secondary Pulmonary Lobule肺小葉（直徑1-2.5CM）,,小葉支氣管、終末細支氣管,,肺動脈pulmonary artery,,小葉間隔interlobular septa,,肺靜脈pulmonary vein,,腺泡pulmonary acini,,正常小葉間隔normal septa,,正常小葉中心動脈,,centrilobular artery 2,,肺靜脈Pulmonary veins,,,,

3、RETICULAR OPACITIES,網狀結構,肺間質病變,發(fā)生于：慢性間質性肺炎、彌漫性間質纖維化、結節(jié)病、癌性淋巴管炎、結締組織?。t斑狼瘡、類風濕性關節(jié)炎、硬皮病、皮肌炎）、塵肺（矽肺、煤矽肺、石棉肺）、組織細胞?。?、淋巴管平滑肌瘤病。ＣＴ：界面征、小葉間隔增厚、小葉中心結構增厚、胸膜下線、長疤痕線（扭曲肺結構）、蜂窩樣改變、結節(jié)影、牽拉性支擴、磨玻璃樣改變。,網狀結構reticular opacities,F/60y乳腺癌

4、術后，現呼吸困難。,分析：（1）小葉間隔增厚thickening of interlobular septa,,分析：（2）支氣管血管周圍間質增厚thickening of the peribronchovascular interstitium,支氣管袖口癥："peribronchial cuffing",分析：(3)斜裂增厚thickening of the major fissure,,分析：（3）大結節(jié)影La

5、rge nodules,,上病例為癌性淋巴管炎。,網狀陰影：病理上主要為小葉間隔增厚、小葉內間隔增厚、小葉核心增厚、胸膜下線影、蜂窩肺和支氣管血管周圍間質增厚等改變?？梢娪谔匕l(fā)性間質性肺炎、結節(jié)病、癌性淋巴管炎、特發(fā)性含鐵血黃素沉積、感染性疾病等。 雙肺網狀陰影多見與特發(fā)性間質性肺炎、結締組織病肺浸潤、結節(jié)病等。單側以癌性淋巴管炎和放射性肺炎為主。,,,測試：M/73y，咳嗽、喘憋,,Is septal thickening a p

6、redominant finding?,Is septal thickening a predominant finding? (a) Yes (b) No小葉間隔增厚？,右側肺小葉間隔增厚。,,,Are the septa smooth or nodular in appearance?(a) Smooth.(b) Nodular小葉間隔光滑增厚還是結節(jié)狀增厚？,smooth 光滑增厚,,支氣管血管間質Is there t

7、hickening of the peribronchovascular interstitium?,(a) Yes(b) No支氣管血管間質是增厚的？,支氣管袖口癥peribronchial cuffing,,胸膜下間質Is there thickening of the subpleural interstitium?,(a) Yes(b) No胸膜下間質是增厚的？,斜裂增厚thickening of the major f

8、issure,,What is the most likely diagnosis?可能的診斷？,(a) Pulmonary edema肺水腫(b) Interstitial fibrosis間質纖維化(c) Lymphangitic spread of carcinoma癌性淋巴管炎,右肺門腫塊，縱隔淋巴結腫大。,,,PLC results from hematogenous spread to lung, with su

9、bsequent interstitial and lymphatic invasion, or, as in this case, direct lymphatic spread of tumor from hilar or mediastinal lymph nodes. 癌性淋巴管炎—血性播散到肺淋巴系統(tǒng)。,淋巴播散圖表,,,79-year-old man with known lymphoma 79歲、淋巴瘤病史,,,Are

10、HRCT findings of interlobular septal septal thickening visible?,(a) Yes(b) No小葉間隔增厚？？？,雙側光滑增厚的小葉間隔,All scans show marked smooth thickening of interlobular septa involving both lungs in a symmetrical fashion.,Is there t

11、hickening of the peribronchovascular interstitium?,(a) Yes(b) No支氣管血管間質是否增厚？？？,增厚的支氣管血管間質,,Is there thickening of the subpleural interstitium?,(a) Yes(b) No胸膜下間質增厚？,斜裂增厚,,,What is the most likely diagnosis?最可能的診斷？？？

12、(a) Pulmonary edema(b) Interstitial fibrosis(c) Lymphangitic spread of lymphoma,,Diagnosis: Lymphangitic spread of lymphoma, with interlobular septal thickening。癌性淋巴管炎（小葉間隔增厚）,lymphocytic interstitial pneumonitis (LI

13、P),,,淋巴間質局限性肺炎,,58-year-old man with heart disease,,,Do HRCT findings include interlobular septal thickening?(a) Yes(b) No小葉間隔增厚？？？,雙側小葉間隔增厚,,,Is there thickening of the peribronchovascular interstitium?(a) Yes(b) N

14、o支氣管血管間質增厚？？？,支氣管血管間質增厚,,,Is there thickening of the subpleural interstitium?(a) Yes(b) No胸膜下間質增厚？？？,,NO!!!,,What is the most likely diagnosis?(a) Pulmonary edema肺水腫(b) Interstitial fibrosis間質纖維化(c) Lymphangitic s

15、pread of carcinoma癌性淋巴管炎最可能的診斷？,,(a) Pulmonary edema肺水腫Correct. Because of the history of heart disease心臟病史, characteristic abnormalities典型的異常, symmetry對稱, and the predominance of septal thickening in dependent lung, t

16、his diagnosis must be considered 考慮most likely.,文獻：間質性肺水腫,（1）肺血重新分布：左心衰--肺淤血。（2）支氣管周圍袖口癥：正常厚度約1mm—結締組織內液體存積—增厚。X-肺紋理及肺門血管增粗、模糊.（3）肺透過度下降：液體分布到支氣管血管周圍、小葉間隔、小葉內支氣管血管周圍、肺泡間隔—透過度下降。（4）間隔線：Kerley B線—x上與肋膈角處與胸膜垂直。（5）胸膜增厚：液

17、體—入臟層胸膜下薄層結締組織—胸膜下結締組織水腫--水腫位于臟層胸膜與結體組織間，不隨體位移動。（６）胸腔積液：胸膜腔內液體來自壁層胸膜。,不同原因的肺水腫,（１）心源性肺水腫：左心衰（見于心梗、二尖瓣病變。（２）腎性肺水腫：急慢性腎功能衰竭，可合并尿毒癥－－水鈉潴留、左心衰－肺水腫－－上腔靜脈、奇靜脈增寬（血管蒂增寬。（3）肺微血管損傷性肺水腫：除肺水腫外，還可見出血及細胞滲出– 肺血分布正常、無袖口癥、間隔線。肺泡實變斑片狀，

18、肺野外為分布。毒性氣體吸入、胃液吸入、藥物、溺水、顱內壓升高、高原性肺水腫、復張性肺水腫。,,,9.a 53-year-old woman with and abnormal chest radiograph and mild shortness（短缺） of breath,,,,,Is septal thickening present?(a) Yes(b) No小葉間隔增厚嗎？,增厚的小葉間隔,,,Are the septa

19、smooth or nodular in appearance?(a) Smooth(b) Nodular小葉間隔增厚是結節(jié)狀還是光滑增厚？,小葉間隔結節(jié)狀增厚,,胸膜下間質結節(jié)影,,支氣管袖口癥,,,Possible diagnoses include:(a) pulmonary edema肺水腫(b) interstitial fibrosis間質纖維化(c) lymphangitic spread of lymphom

20、a(d) sarcoidosis結節(jié)病最可能的診斷？,,sarcoidosis結節(jié)病Correct. Nodular thickening of interlobular septa and fissures can be seen in this disease and lymphangitic spread of carcinoma. （小葉間隔結節(jié)狀改變可見于結節(jié)病、癌性淋巴管炎、塵肺）。支氣管血管間質、胸膜下間質結節(jié)狀改

21、變—對結節(jié)病有特征性的診斷。,Case 10 in a 42-year-old man with mild shortness（短缺） of breath for a number of years,,,Is septal thickening visible?(a) Yes(b) No Next Page  小葉間隔增厚嗎？,增厚的小葉間隔,,扭曲的肺結構,,葉間裂的扭曲,,,Diagnosis: End

22、-stage sarcoidosis with fibrosis and interlobular septal thickening.結節(jié)病伴隨征象：肺結構扭曲、小葉間隔結節(jié)狀增厚、牽拉性支擴、蜂窩肺等。,文獻：肺間質病變,界面征：支氣管血管間質增厚—支氣管血管束增粗、支氣管袖口癥；液體—邊緣光滑、腫瘤或肉芽組織—結節(jié)狀界面。胸膜下線：近胸膜面1cm內弧線狀影—為肺纖維化征象。長疤痕線：蜂窩肺：結節(jié)影：小結節(jié)—2-5mm，肉

23、芽、腫瘤、纖維組織。肺結構扭曲變形及牽拉支擴：磨玻璃樣改變：,,,Case11in a 68-year-old woman with rheumatoid arthritis（風濕性關節(jié)炎） and progressive 累計shortness 短缺of breath over a 2-year period,,,,,The predominant abnormal finding on these scans is?(a) i

24、nterlobular septal thickening小葉間隔增厚。(b) honeycombing蜂窩肺主要的異常表現？,蜂窩肺,,部分層面小葉間隔增厚,,,What does honeycombing reflect histologically?(a) Interstitial edema肺間質水腫(b) Interstitial infiltration 滲透by cells(c) Interstitial fib

25、rosis蜂窩肺的組織學—肺間質纖維化的后期表現。,,Diagnosis: Rheumatoid lung disease, with fibrosis and honeycombing. 風濕性肺疾病，肺纖維化、蜂窩肺。壁厚0.8-1MM，胸膜下3-4cm范圍內或近葉裂處；早期囊腔小而少；囊壁為折疊破壞的肺泡壁及氣道壁。,,,Case 12 in a 74-year-old woman with progressive shor

26、tness of breath over 6 months,,,The most significant abnormal finding in this study is:(a) interlobular septal thickening小葉間隔增厚(b) honeycombing蜂窩肺(c) subpleural emphysema胸膜下肺氣腫主要的異常表現？,蜂窩肺,,What is the most likely di

27、agnosis?(a) Idiopathic pulmonary fibrosis (IPF)特發(fā)性肺間質纖維化(b) Autoimmune disease (e.g., rheumatoid lung disease)自身免疫性疾病(c) End-stage hypersensitivity pneumonitis過敏性肺炎(d) Asbestosis石棉肺(e) Drug-related lung injury麻醉藥物肺損

28、害(f) Sarcoidosis結節(jié)病最可能的診斷？,IPF: 特發(fā)性肺間質纖維化,磨玻璃密度：肺野周圍—活動性肺泡炎癥。網狀改變：小葉間隔、小葉中心結構增厚—蜂窩狀改變的前期。蜂窩狀改變：胸膜下間質纖維化：胸膜下弧線狀影、臟層胸膜及葉間胸膜增厚。肺氣腫：小葉中心型肺氣腫。肺實變：支擴：,蜂窩肺,,牽拉性支擴,,小葉間隔增厚,,Case 13 86-year-old man with chronic myelogenou

29、s leukemia骨髓性的白血病, treated using methotrexate化療, now complains of shortness of breath 氣短.,,,,,Does this man show evidence of fibrosis and UIP?(a) Yes(b) No顯示明顯的纖維化和普通間質性肺炎？？屑性間質性肺炎（DIP）、普通性間質性肺炎（UIP） 。,,(a) YesCorre

30、ct. Findings indicative of usual interstitial pneumonitis (UIP) visible in this patient include:honeycombing; 蜂窩肺irregular fissures; 葉裂扭曲irregular interlobular septal thickening; 小葉間隔不規(guī)則增厚。traction bronchiectasis.牽拉性

31、支擴,蜂窩肺,,葉裂扭曲,,不規(guī)則小葉間隔增厚,,,,牽拉性支擴,,,The most likely diagnosis is:可能的診斷？(a) idiopathic pulmonary fibrosis (IPF)(b) lung involvement by leukemia白血病肺浸潤。(c) drug-related lung injury化療藥物肺損害。,(c) drug-related lung injuryCor

32、rect. The pattern of fibrosis seen in this patient is nonspecific, and could be caused by IPF. The recent history of treatment with methotrexate makes drug-related fibrosis most likely. Lung involvement by leukemia would

33、 likely result in an appearance similar to that of lymphangitic spread of carcinoma with septal thickening being the predominant finding. IPF一可有同種表現，但患者有最近化療史，白血病肺浸潤小葉間隔增厚明顯。,,,Case 14 in a 63-year-old man with a histor

34、y of scleroderma硬皮病 and progressive shortness of breath進行性喘憋,,,Findings include: interlobular septal thickening; 小葉間隔增厚。traction bronchiectasis; 牽拉性支擴subpleural honeycombing; 胸膜下蜂窩肺irregular fissures.葉裂扭曲,小葉間隔增厚,,牽

35、拉性支擴,,胸膜下蜂窩肺,,斜裂扭曲,,,Can you be confident that lung fibrosis is present?(a) Yes(b) No你能確定肺纖維化存在？,YesCorrect. The presence of honeycombing is diagnostic of fibrosis. Traction bronchiectasis is also strongly suggestive

36、of fibrosis. Interlobular septal thickening and irregular fissures are nonspecific, and cannot be relied upon to diagnose fibrosis. 蜂窩肺、牽拉性支擴—肺纖維化存在。小葉間隔增厚、斜裂扭曲對肺纖維化的診斷意義不大。,,Diagnosis: Scleroderma, with lung fibrosis,

37、 honeycombing, and traction bronchiectasis 硬皮病—肺纖維化：蜂窩肺、牽拉性支擴。結締組織病及肺血管炎—主要為肺間質病變。肺內實變—肺泡內滲出、肉芽腫形成、肺泡內出血、水腫。肺內多發(fā)結節(jié)—肺內血管炎、肉芽腫、肺栓塞所形成。常見于：wengner\類風濕性關節(jié)炎。肺間質病變—肺間質性肺炎、肺泡炎—間質纖維化、蜂窩肺。,,,Case 15 in a 61-year-old woman wi

38、th progressive shortness of breath進行性喘憋 .,,Which of the following findings are shown on this scan?上圖包含癥像:(a) Honeycombing蜂窩肺(b) A subpleural line胸膜下線(c) A peripheral and subpleural distribution外圍胸膜下分布(d) All of the

39、above以上全包括,All of the aboveCorrect. Small subpleural cysts are present typical of mild honeycombing. 輕度的蜂窩肺An irregular line parallels the pleural surface, termed a subpleural line. 胸膜下線,Which of the following is most l

40、ikely in this case?最符合的診斷？(a) Idiopathic pulmonary fibrosis (IPF)特發(fā)性間質纖維化(b) Autoimmune disease (e.g., rheumatoid lung disease)自身免疫性疾病(c) End-stage hypersensitivity Pneumonitis過敏性肺炎(d) Asbestosis石棉肺(e) Drug-rela

41、ted lung injury藥物肺損害(f) Sarcoidosis結節(jié)病,,Idiopathic pulmonary fibrosis (IPF)Correct. Idiopathic pulmonary fibrosis (IPF). In the absence a history to suggest one of the specific diagnoses on this list, IPF is most likel

42、y. It accounts for 60% of cases having this appearance. IPF在該病例無特異性，60%有該表現。,,,Case 16 in a 34-year-old man with progressive shortness of breath喘憋,,,,The predominant abnormality in this case is:明顯的異常表現(a) honeycombing

43、蜂窩肺(b) intralobular interstitial thickening小葉間質增厚,intralobular interstitial thickeningCorrect. Honeycombing is not visible in this patient. A fine irregular reticular不規(guī)則的網狀改變pattern is present in the lung periphery,

44、representing intralobular interstitial thickening.小葉間質增厚 In some patients with pulmonary fibrosis, this finding will predominate. Other findings of fibrosis in this patient include traction bronchiectasis.牽拉性支擴 The diffe

45、rential diagnosis of this appearance is identical as that for honeycombing.,小葉間質增厚,,牽拉性支擴,,,Diagnosis: Idiopathic pulmonary fibrosis特發(fā)性間質纖維化, with intralobular interstitial thickening.,,,Case 17in a 71-year-old man with

46、 progressive shortness of breath,,,,,The predominant abnormality in this case is:突出的表現(a) honeycombing蜂窩肺(b) intralobular interstitial thickening小葉間質增厚,intralobular interstitial thickeningCorrect. Honeycombing is n

47、ot clearly seen in this patient. A fine but irregular reticular pattern不規(guī)則的網狀改變 is present in the lung periphery外圍, representing intralobular interstitial thickening小葉間質增厚. In some patients with pulmonary fibrosis, this

48、finding will predominate. Other findings 其他征象of fibrosis in this patient include traction bronchiectasis牽拉性支擴, and irregular interlobular septal thickening不規(guī)則小葉間隔增厚. The differential diagnosis of this appearance is ident

49、ical to that for honeycombing.,小葉間質增厚,,牽拉性支擴,,不規(guī)則小葉間隔增厚,,,Diagnosis: Idiopathic pulmonary fibrosis特發(fā)性間質纖維化, with intralobular interstitial thickening.,,,Case 18, in a 55-year-old salami manufacturer 臘腸制造商with progressiv

50、e shortness of breath,,The most likely diagnosis in this case is:最可能的診斷(a) Idiopathic pulmonary fibrosis (IPF)特發(fā)性間質纖維化(b) Autoimmune disease (e.g., rheumatoid lung disease)自身免疫系統(tǒng)疾病(c) End-stage hypersensitivity pneu

51、monitis過敏性肺炎(d) Asbestosis石棉肺(e) Drug-related lung injury藥物肺損害(f) Sarcoidosis結節(jié)病,,Any diagnosis is possible. 任何診斷都是可能的。,Case 19 in 34-year-old woman with lupus erytematosus 狼瘡紅斑,,,,,Can you diagnose fibrosis?能診斷纖維化？

52、(a) Yes(b) No,YesCorrect. HRCT obtained in the supine and prone positions 仰臥和俯臥位shows a number of findings indicating fibrosis指示, including: honeycombing which is mild in degree; 輕度蜂窩肺traction bronchiectasis; 牽拉性支擴

53、intralobular interstitial thickening;小葉間質增厚interlobular septal thickening小葉間隔增厚; and a subpleural distribution.胸膜下分布,輕度蜂窩肺,,牽拉性支擴,,小葉間質增厚,,小葉間隔增厚,,,Diagnosis: Systemic lupus erythematosus（SLE系統(tǒng)性紅斑狼瘡肺部表現—肺結締組織病, with f

54、ibrosis and honeycombing.,,,Case 20 in a 65-year-old woman with rheumatoid arthritis風濕性關節(jié)炎 and mild dyspnea 輕度呼吸困難,,,Can you diagnose fibrosis?能診斷纖維化？(a) Yes(b) No,,Correct including: traction bronchiectasis;牽拉性支擴

55、intralobular interstitial thickening;小葉間質增厚 a subpleural line.胸膜下線,牽拉性支擴,,小葉間質增厚,,胸膜下線,,,Diagnosis: Rheumatoid lung disease肺結締組織病, with mild pulmonary fibrosis輕度肺纖維化 and intralobular interstitial thickening小葉間質增厚.,,,Ca

56、se 21 in a 26-year-old woman with mixed connective tissue disease混合結締組織病, basilar crackles on physical examination雙肺底水泡音, and restrictive disease on pulmonary function tests 肺功能受限,,,,,Can you diagnose fibrosis?能診斷纖維化？(

57、a) Yes(b) No,,YesCorrect.Including: traction bronchiectasis; 牽拉性支擴intralobular interstitial thickening小葉間質增厚;a subpleural distribution胸膜下分布,牽拉性支擴,,小葉間質增厚,,,Diagnosis: Mixed connective tissue disease混合結締組織病, with pu

58、lmonary fibrosis, and intralobular interstitial thickening,,,Case 22, in a 81-year-old man with significant occupational exposure to asbestos 石棉職業(yè)史,,,,,Is pulmonary fibrosis present?肺纖維化存在？(a) Yes(b) No,YesCorrect. F

59、indings of fibrosis include: traction bronchiectasis; 牽拉性支擴intralobular interstitial thickening; 小葉間質增厚a subpleural distribution. 胸膜下分布irregular interlobular septal thickening不規(guī)則的小葉間隔增厚,牽拉性支擴,,小葉間質增厚,,胸膜下分布,,小葉間隔增厚,,

60、,Diagnosis: 石棉肺Asbestosis with traction bronchiectasis 牽拉性支擴and intralobular interstitial thickening小葉間質纖維化.,縱隔窗,,pleural thickening and calcification 胸膜增厚、鈣化,,椎旁區(qū)域,,橫膈胸膜肥厚鈣化,,Case 24 in a 58-year-old man with a history

61、 of asbestos exposure石棉史,,可見椎旁胸膜增厚、不規(guī)則線狀影,,,The pleural thickening is typical of asbestos exposure胸膜增厚是典型的石棉肺表現. Would you diagnose asbestosis診斷石棉肺嗎?(a) Yes(b) No,,NoCorrect. Linear opacities線狀影 as seen in this case (

62、termed parenchymal bands肺實質帶) are common in patients with pleural thickening胸膜增厚, but are not necessarily associated不必須考慮 with lung fibrosis肺纖維化.,肺實質帶parenchymal bands,位于下肺部，肺內條狀影；肺實質內的纖維化。,,盡管如此，結合病史，考慮Asbestos exposure

63、 with pleural disease and parenchymal bands 石棉至椎旁胸膜增厚、肺實質帶。,,,Case 25 in a 67-year-old man with a history of asbestos exposure 石棉史,,NoCorrect. HRCT at lung windows shows irregular linear opacities不規(guī)則的線狀影 ( “crow‘s feet”

64、烏鴉腳), without evidence of honeycombing無蜂窩肺, intralobular interstitial thickening小葉間質增厚, or traction bronchiectasis牽拉性支擴. This appearance does not indicate asbestosis無石棉特征. Linear opacities, as seen in this case (parenchy

65、mal bands肺實質帶) are common in patients with pleural thickening related to asbestos exposure, but are not necessarily associated with lung fibrosis不必須考慮肺纖維化. They represent focal areas of atelectasis焦點為肺膨脹不全, associated 聯系

66、with the pleural thickening, or focal areas of scarring焦點區(qū)疤痕.,烏鴉腳（"crow's feet"),,,即,盡管如此，結合病史考慮Asbestos exposure with pleural disease and parenchymal bands 。另一病例：胸膜下線椎旁胸膜增厚,,,,,Case 26 in a 56-year-old m

67、an with significant occupational exposure to asbestos 石棉史,,,Is there pleural thickening 胸膜增厚you would consider考慮 likely 可能due to asbestos exposure石棉?(a) Yes(b) No,Yescorrect. A focal焦點, calcified pleural plaque胸膜鈣斑 is

68、 visible anteriorly, typical of asbestos exposure石棉肺典型表現. Although plaques are more likely posterior in location常見后胸膜, this appearance is highly suggestive高度提示.,,Can a definite diagnosis of pulmonary fibrosis on the pron

69、e lung window scans be made?肺窗能明確診斷肺纖維化嗎？ (a) Yes(b) No,NoCorrect. There is mild septal thickening 輕度間隔增厚and reticulation 網狀in the posterior subpleural region后胸膜下 on the right. This is unassociated 無聯系with adjacent臨近

70、pleural thickening. This is a very subtle abnormality輕微的異常 which could represent the earliest stage of asbestosis石棉肺早期表現. However, in the absence of a more definite abnormality明確的異常 or similar 類似findings on the left, it