1、呼吸系统影像诊断学 Imaging diagnostics of the respiratory system 郑州大学第一附属医院放射科 the first affiliated hospital radiology department of Zhengzhou University 张焱 Zhang Yan,呼吸系统疾病Disease of the Respiratory system,五.纵隔原发肿瘤（mediastinal tumor）指原发于纵隔的肿瘤primary mediastinal tumor 原发性纵隔肿瘤繁多The tumor primary in mediastinu
2、m,which are various,常见的纵隔肿瘤： Common primary mediastinum tumor 神经源性肿瘤Neurogenic tumor淋巴瘤Lymphoma 畸胎瘤Teratoma 胸腺瘤Thymoma胸内甲状腺等intrathoracic thyroid,临床症状： clinlcal symptom 胸骨后不适及隐痛 retrosternal malaise and vague pain 与肿瘤的大小、部位、良恶性有关related to the size, position and nature(benign or malignant),纵隔肿瘤所引起的症
3、状以压迫症状为主该类症状的出现，对肿瘤的定位及定性亦有帮助cardinal symptom:pressure symptom is the cardinal symptom of mediastinal tumor Which has helps to localization and qualitative analysis of the tumor,压迫邻近组织器官：press adjacent tissue and organa 上腔静脉综合征 superior vena cava syndrome ; SVCS 声嘶（喉反神经）trachyphonia Horner综合征（交感神经）H
4、orners syndrome(sympathetic nerve) 心率慢（迷走神经）slow heart rate (vagus nerve )吞咽困难（食道）hard to swallow (esophagus) 心脏受压oppression of heart 食管受压oppression of esophagus 气管受压等oppression of tracheal,（一）胸腺瘤（Thymoma）：较常见usual 约30%患者有重症肌无力myasthenia gravis 良性：benign 有完整包膜integrated integument ，可有囊变cystic change
5、侵袭性（恶性）：invasion (malignancy) 向邻近组织局部侵犯local invasion of adjacent tissue 常发生胸膜种植转移membrana pleuralisimplantation metastasis is usual 很少有血行或淋巴转移hematogenous metastasis or lymphatic metastasis is singularly,影像表现：imaging1.多位于前中纵隔偏上antemedial mediastina ，多向一侧突出extrude to one side 2.肿瘤为圆、椭圆或梭形致密影round ,
6、ovalor fusiform high density lesion ，偶呈片状lamellar lesion 边界清楚the border is clear (well-defined)3.恶性者呈分叶状therioma is sublobe ，部分边界毛糙part border Of them is coarse ，邻近胸膜受侵the adjacent pleura was invaded 4.瘤内可有斑片状钙化patchy calcification in the tumor5.囊变者可有蛋壳状钙化egg shell calcification with cystic change,（
7、二）畸胎类肿瘤（Teratoma） 系原始胚胎组织残留物形成的先天性肿瘤congenital tumor which grow up by residual primordial germ tissue分为囊性cystic（皮样囊肿dermoid cyst）和实性畸胎瘤Solid teratoma皮样囊肿：dermoid cyst 为良性benign，含外胚层animal-germ layer和少量中胚层衍生物mesoderm ramification（毛发hair、皮脂sebum等） 实性畸胎瘤：Solid teratoma 含三个胚层衍生物include three germ layer
8、ramifacation（毛发hair、牙teeth、骨bone、腺体gland、呼吸respiratory和胃肠道组织gastrointestinal tissue等） 可为良或恶性benign or malignant,影像学表现：imaging1.多位于心大血管交界区的前中纵隔antemedial mediastina ，向一侧突出extrude to one side 2.肿瘤呈圆或椭圆形密度不均匀肿块inhomogeneous density tumor （可含透明间隙、牙teeth 、骨bone等）皮样囊肿可见囊壁发生蛋壳状钙化egg shell calcification in
9、dermoid cyst3.良性者边清楚the border of the benign tumor is clear 4.恶性者分叶、边界不规则，发生粘连therioma is sublobe, irregularity boundary and adhesion,（三）胸内甲状腺肿（Intrathoracic goitre） 包括先天性异位甲状腺及胸骨后甲状腺肿性质为甲状腺肿、囊肿或癌 congenital aberrant thyroid and retrosternal struma 甲状腺肿struma、囊肿cyst或癌cancer,影像学表现：1.多位于前上纵隔antero-sup
10、erior mediastina，与颈部甲状腺相连 connect with thyroid 2.肿块呈卵圆或梭形orbicular-ovate or fusiform ， 边界清楚 well-defined3.随吞咽移动 move with swallow 4.肿块内可发生斑片状钙化patchy calcification occurred in the tumor 5.压迫气管，甚至食管移位the tracheal is pressed and the esophagus shift indeed,胸 腺 瘤 thymoma,thymoma A high density lesion in
11、 the antero-superior mediastinaIt is well-defined and slightly enhanced.,胸腺瘤CT表现 the CT film of thymoma,畸 胎 瘤 Teratoma,畸胎瘤CT表现,胸 内 甲 状 腺 肿 Intrathoracic goitre,（四）淋巴瘤（Malignant lymphoma） 系发生于淋巴结的全身性肿瘤lymph nodes derived general tumor 病理及临床：pathology and clinic分为霍奇金病Hodgkin disease及非霍奇金淋巴瘤non-Hodgkin
12、 lymphoma好发于青少年the callan及老年人the elderly病程短，进展快 the course is short and the progress is fast常有发热fever、浅表淋巴结肿大enlargement of superficial lymph nodes淋巴瘤对放射线敏感sensitivity to radiotherapy，小剂量照（2030Gy）即可明显缩小，但不能完全治愈It maybe shrink obviously after small dose(20-30Gy) irradiate but could not cure.,影像表现：1.常
13、见两侧上、中纵隔淋巴结肿大 lymphadenectasis of bilateral superior and middle mediastinum，呈分叶状向两侧肺野突出extrude to both lung field lobatusly侧位见纵隔、肺门淋巴结肿大enlargement of hilar or mediastinal lymph nodes at lateral position，生长较大时可侵犯前纵隔 invasion anterior mediastinal when grow large.2.气管常受压变窄 the tracheal is oppressed an
14、d narrowing3.有时向肺内逆行浸润和侵犯胸膜和心包 Retrogradely infiltrate in the lung and invading pleura and pericardium sometimes.,淋 巴 瘤 lymphoma,（五）囊肿 cyst 支气管囊肿Bronchogenic cyst 食管囊肿esophagal cyst 心包囊肿pericardial cyst,1.支气管囊肿（Bronchogenic cyst）系胚胎原始前肠的气管芽突脱落的胚胎组织演变而成 Grow up by fall off tissue of tracheal gemmule
15、of priming foregut.属良性病变，位于气管旁paratracheal和气管分叉bifurcatio tracheae附近病理：为薄壁含液囊状物与支气管不通 it is bladder contains liquid with thin wall and blind to the bronchi,影像学表现：1.囊肿位于上、中纵隔气管和其分叉附近 the cyst is near to the bifurcatio tracheae and superior and middle mediastinum tracheae2.囊肿呈边缘光滑锐利的椭圆形均匀密度增高影symmetri
16、cal ellipsis high density lesion with smooth and sharpness boarder一般无分叶、无钙化 without sublobe and calcification3.囊肿随呼吸活动及变形 move and transmutate with breath,支 气 管 囊 肿 bronchocele,支气管囊肿CT表现,2.食管囊肿（esophagal cyst） ：食管囊肿的发病机制与支气管囊肿类似the pathogenesis is similar to bronchogenic cyst常发生于纵隔内食管中13处之左、右侧 lie i
17、n left or right side of 1/3 epimere part of esophagus in mediastinum,较多见于小儿child囊肿具有腺体功能，故逐渐增大，较早出现近结构的压迫症状可出现气急breath lessness、发绀cyanosis、吞咽困难hard to swallow等亦可继发肺炎pneumonia及胸膜炎pleurisy,食管囊肿位于食管旁paraesophageal密度均匀density is symmetrical，CT值多在10-15HU边缘光滑boarder is smooth，变换体位可见轻度变形slightly transmutat
18、e when posture alternated增强检查仅见囊壁轻度强化Intensive examination only show slight intensification of the cyst wall,食管囊肿esophagal cyst,3.心包囊肿 pericardial cyst,影像学表现：病变多呈圆形或椭圆形 shape of the cyst is mostly rotundity or ellipse轮廓光整、清楚 the contour is smooth and clear多位于右侧心膈角处mostly lie in right cardiodiaphragm
19、atic angle，心包pericardial其它部位亦可发生侧位胸片lateral chest film呈滴水状drip shape，上尖下圆the up is sharp and the under is rotundity，变换体位后囊肿形态亦会发生变化,CT：平扫：pre-contrast images病变与心包不能分割 the cyst could not separate from pericardial壁光整，多无钙化 the wall is smoth and integrated and without calcification腔内为液体密度intracavity is
20、liquid density增强：囊内无强化，囊壁强化亦不明显without intensification in the cyst and intensification of the wall is not obvious,MRI： T1WI低信号low signal intensity on T1 weghted imaging，但略高于游离水slightly higher than free water，囊壁呈线状略高信号影the wall is slightly linear high signal intensity lesion 粘液性囊肿myxoid cyst T1WI呈均匀的
21、高信号，说明囊液中蛋白含量较高T2WI多为信号均匀的高信号symmetrical high signal intensity,心包囊肿 pericardial cyst （MRI）,鉴别诊断differential diagnosis ： Different with 主要应与心包憩室pericardial diverticulum鉴别:主要鉴别点是应该观察其是否与心包相通communicate with pericardia or not is the main differential point有时鉴别困难，如果改变体位病变缩小则可以提示心包憩室之可能 Altering position
22、 when hard to differentiate .It maybe pericardial diverticulum if the pathylogical changes lessen,心包憩室 pericardial diverticula,附：生殖细胞肿瘤 germinoma ： 良性畸胎瘤benign dermoid tumor占纵隔生殖细胞肿瘤mediastinum germinoma的75%以上 纵隔恶性生殖细胞肿瘤malignant mediastinum germinoma较少，以精源细胞瘤seminoma最常见，其他有内胚窦瘤endodermal sinus tumo
23、r、胚胎癌embryonal carcinoma、绒毛膜上皮癌chorion epithelioma等大多位于前纵隔majority in anterior mediastinum ，少数在后纵隔 minority in posterior mediastinum,精源细胞瘤,（六）神经原性肿瘤（Neurogenic tumors）后纵隔最常见肿瘤包括：神经纤维瘤 neurofibroma神经鞘瘤 neurilemmoma节细胞神经瘤 ganglioneuroma神经纤维肉瘤 neurofibrosarcoma神经母细胞瘤 neuroblastoma肿块一般位于脊柱旁沟paravertebra
24、l chimb或椎间孔anterior foramina vertebral偶尔也位于前、中纵隔,影像表现：1.肿块常位于后上纵隔posterior superior mediastinum，向一侧突出侧位lateral position与脊柱spine重叠overlap2.肿块一般呈圆形或椭圆形，边界清楚的密度增高影,3.肿块位于椎间孔anterior foramina vertebra，则呈哑铃形dumbbell，并破坏骨质destruction of bone而出现边界光滑的压迹4.节细胞神经瘤常呈三角形shape of ganglioneuroma is triangle mostly
25、神经母细胞瘤可发生钙化neuroblastoma is calcificationable5.恶性肿块呈分叶状，破坏邻近骨骼the malignancy is sublobe and destroy the near bone,神经原性肿瘤（节细胞神经瘤ganglioneuroma ）,神经源性肿瘤,神经鞘瘤CT表现椎间孔扩大、破坏 enlargement and destruction of anterior foramina vertebra,（七）纵隔肿块与肺内肿块的鉴别诊断：Differential diagnosis of intramediastinal mass and intr
26、apulmonary mass 1、鉴别方法：（1）透视转动患者观察rotate the patient and observation （2）体层摄影tomography（3）CT及MRI,2.鉴别：（1）肺内肿块随呼吸动，纵隔肿块则无the intrapulmonary mass would be moving with breath but the intramediastinal mass not （2）肺内肿块与纵膈之间有一密度减低带，纵隔肿块则无There is lesion of low density between the intrapulmonary mass and me
27、diastinal,（3）肺内肿块与纵隔交界为锐角，纵隔肿块为钝角 the included angle of mediastinal and intrapulmonary mass is sharp but the intramediastinal is obtuse.（4）肿块的最大纵径在肺内为肺内肿块，在纵隔内为纵隔肿块maximal diameter of the intrapulmonary mass is in pulmonary and the intramediastinal mass in mediastinal（5）肺内肿块使气、食管轻度移位，纵膈块则显著the intra
28、pulmonary mass cause the tracheal and esophagus shift slightly,（八）纵隔肿瘤与纵隔淋巴结结核的鉴别诊断 Differential diagnosis of mediastinal mass and intramediaseinal lymphnodi tuberculosis 1.淋巴结核多见于青少年adolescent 2.淋巴结核多发生在右上纵隔旁right superior mediastinum ，80%为单侧unilateral 3.淋巴结核肿块边界清楚well-defined，有时呈分叶状sometimes lobul
29、ated 4.结核菌素试验tubercalin test,郑州大学第一附属 医院,呼吸系统影像诊断学 Imaging diagnostics of the respiratory system 郑州大学第一附属医院放射科 the first affiliated hospital radiology department of Zhengzhou University 张焱 Zhang Yan,(六) 肺肿瘤 pulmonary tumours,分类：.原发性 Primary ：（1）良性 benign （少见 singularly ）（2）恶性malignant 支气管肺癌bronchiog
30、enic cancer （98%）肺肉瘤sarcoma .继发性secondary （肺转移瘤metastasis）,1.原发性支气管肺癌（Primary bronchogenic carcinoma of lung）:近年来肺癌的发病率与死亡率急剧上升incidence and mortality of lung cancer sharp rised 吸烟smoking 、大气污染atmospheric pollution及工业致癌物质industrial carcinogen为主要的致病因素causative agent,（1）病理 pathology ：癌起源于支气管上皮bronchia
31、l epithelium ，腺体glandular organ或细支气管及肺泡上皮epithelium of the bronchiole or alveolus,肺癌组织学分型 histological type：小细胞肺癌small cell lung cancer; SCLC及非小细胞肺癌nonsmall-cell lung cancer; NSCLC 非小细胞肺癌nonsmall-cell lung cancer; NSCLC分为：鳞癌squamocellular cancer腺癌adenocarcinoma 腺鳞癌adenosquamous carcinoma 大细胞癌 large
32、cell carcinoma,大体病理分型 macropathology ：中央型 central type ：周围型 peripheral：弥漫型 diffuse ：,按照肺癌的发生部位可以分为三型 position ：中心型 central type ：系指发生于肺段以上支气管的肺癌above the segmental bronchi 外围型 peripheral ：系指发生于肺段支气管以下的肺癌below the segmental bronchi 细支气管肺泡癌bronchioalveolar carcinoma ：系指发生于细支气管或肺泡上皮的肺癌epithelium of the
33、 bronchiole or alveolus,生长方式 growth pattern ：管内型intracanalicular type （息肉polypus 、菜花状cauliflowwer ）管壁型wall type （管腔狭窄或闭塞straitness or occlusion ）管外型extratubal type （肺内肿块intrapulmonary mass）,（2）临床clinic：咳嗽cough 、咳血emptysis 、胸痛chest pain 、气促polypnea 压迫症状pressure symptom ：上腔静脉综合征superior vena cava synd
34、rome ，膈神经nervi phrenicus和喉返神经recurrent laryngeal nerve麻痹paralysis等肺外症状extrapulmonary symptom ：杵状指achropachy 、肺性肥大性骨关节病hypertrophic pulmonary arthropathy等,不同部位的肺癌可有以下几种生长方式 growth pattern ：管内型intracanalicular type ：癌瘤向管腔内生长，形成息肉样或菜花样肿块，逐渐引起支气管阻塞intracanalicular polypoid or cauliflower-like mass block
35、 bronchus 管壁型wall type ：癌瘤沿支气管壁浸润生长along bronchus ，可使管壁增厚the wall thickening ，造成支气管狭窄或阻塞straitness or occlusion 管外型extratubal type ：癌瘤穿透支气管壁向外生长，在肺内形成肿块penetrate the wall excentric growth ， intrapulmonary mass型多为中心型肺癌的生长方式growth pattern of the central lung cancer,肺段以下较小支气管的肺癌，很易侵入肺内形成肿块intrapulmonar
36、y mass is usual in the lung cancer below the segmental bronchi 细支气管或肺泡上皮的肺癌the cancer from epithelium of the bronchiole or alveolus 初期可沿肺泡壁生长，形成孤立结节状肿块initial stage ，grow along the wall of alveolus ，form a isolated node 晚期可经支气管及淋巴管播散，形成弥散性斑片状或粟粒状癌灶 advanced stage disseminated along bronchus and lymp
37、h vessel form diffuse carcinomatosis,（3）影像表现：中心型 central type ：,A.支气管改变bronchus ：支气管管壁增厚和管腔狭窄（正常支气管壁厚度均匀，约为1-3mm） the wall thickening and straitness B.肺门肿块mass in hilus pulmonis ，常伴有go with阻塞性肺气肿obstructive emphysema 、阻塞性肺炎obstructive pneumonia 、阻塞性肺不张obstructive atelectasis C.侵犯纵隔mediastinum encroa
38、chment D.纵隔及肺门淋巴结肿大lymphadenectasis in mediastinum and hilus pulmonis,右肺上叶不张atelectasis insuperior lobe of right lung,中央型肺癌（癌块、肺不张、横S征） central lung cancer,外围型肺癌 peripheral lung cancer ：肿瘤位于肺段以下到细支气管之间的支气管between the segmental bronchi and the bronchiole,主要征象 main character ：A.肿块征 mass：早期early stage直
39、径diameter2cm，轮廓模糊weakened contours ，密度稍高之结节slightly high density lesion、球状或小片状影globosity or lamellar 密度有时不均、出现空泡征vacuole sign等the density is inhomogeneous 中晚期呈分叶状肿块，边缘有短毛刺，亦可有癌洞等middlelate stage the mass is lobulated, shallow needling and cavity 癌块倍增时间平均约3月average doubling time is about 3 months,B.转
40、移征 同中央型metastatic is the same as central lung cancer C.阻塞征 在病灶周围，较中央型范围小obstruction is less-than central lung cancer D.胸膜受侵征（局限性增厚localized thickening，胸膜凹陷征pleural indentation sign等）pleura is encroached,发生于肺尖部的癌称肺上沟癌（pancoast tumor）apical 可侵蚀邻近肋骨及椎体并可压迫臂丛引起臂痛encroach rib and vertebrae ,press brachia
41、l plexus 也可压迫颈部交感神经而引起Horner综合征press cervical sympathetic nerve 表现为同侧眼睑下垂、瞳孔缩小homolateral ptosis and myosis,细支气管肺泡癌 bronchioalveolar carcinoma ：肿瘤位于细支气管或肺泡上皮 epithelium of the bronchiole or alveolus A.早期early stage ：为孤立的结节状或肺炎样浸润影isolated invasion lesion，内有含气的小透明区aerated transparent zone （空泡征vacuole
42、 sign ）B.晚期 later period ：一侧肺或两肺出现多数大小不等unilateral or bilateral multiply inequality of size 、境界不清ill-defined的结节或斑片状影nodular or patchy lesion，发展则融合成大片絮状影patchy shadow,周 围 型 肺 癌peripheral lung cancer （早期early stage ）,周围型肺癌peripheral lung cancer （中晚期middlelate stage ）,Age/Sex: 57/M Chief complaints: co
43、ugh, sputum, and mild fever for 6 monthsSquamous cell lung cancer (with cystic lung to lung metastasis),周围型肺癌（空洞、胸膜凹陷征） peripheral lung cancer,肺 上 沟 癌 伴 骨 转 移 Pancoast cancer with osseous metastasis,双肺细支气管肺泡癌bilateral bronchioalveolar carcinoma,2.肺转移性肿瘤（Metastatic tumors of lung）临床特点clinical feature
44、：原发瘤经血行、淋巴或直接方式至肺hematogenous metastasis,lymphatic metastasis or direct metastasis 主要症状有咳嗽cough 、咳血emptysis 、气短polypnea和胸痛chest pain等,（2）影像学表现imaging ： 血行转移 hematogenous metastasis ：A.多见于两肺中、下肺野外带bilateral besides middle and lower field 常多发multiple ，少单发B.呈大小不等I nequality of size ，密度均匀homogeneous des
45、ity，边界清楚的棉球状致密影sharply marginated globular high density lesionC.少数呈粟粒状或片状模糊影，也可出现空洞或钙化few is miliary or patchy fuzzy image ,may have cavity or calcification,淋巴转移 lymphatic metastasis ：A.单侧或双侧肺门、纵隔淋巴结肿大unilateral or bilateral lymphadenectasis in mediastinum and hilus pulmonisB.自肺门向肺野呈放射状分布索条状、条点状或网状致密影。radial cord, stipple or reticular shadow 直接转移 direct metastasis ：A.邻近肺的组织如纵隔、胸壁、胸膜有肿瘤mass in adjacent tissue such as mediastinum, chest wall and pleura B.肺内出现大小不等转移灶intrapulmonary metastasis inequality of size,肺 转 移 瘤 两 例（血行转移）,
