齊魯醫(yī)學(xué)孤立性肺結(jié)節(jié)：良性與惡性對(duì)比

1、The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is benign or malignant.孤立性肺結(jié)節(jié)的鑒別診斷是很多的，處理方法依賴于該病變是良性還是惡性In this overview we will discuss some of the new features that can help to differentiate between benign and malignant nodules based

2、upon CT and PET-CT findings.在此篇文章，我們著重討論下一些有助于鑒別良惡性結(jié)節(jié)的新特征，此特征是基于CT與PET-CT的檢查結(jié)果12021/7/27 星期二CT: benign versus malignantCalcification Size Growth Shape Margin Air Bronchogram sign Solid and Ground-glass components Contrast enhancement 22021/7/27 星期二CT:良性與惡性鈣化大小生長(zhǎng)速度形狀邊緣支氣管含氣征實(shí)性或磨玻璃樣增強(qiáng)特征32021/7/27 星期二C

3、alcification 鈣化Diffuse, central, laminated or popcorn calcifications are benign patterns of calcification. 彌漫性，中心性，分層，爆米花鈣化是良性鈣化，42021/7/27 星期二These types of calcification are seen in granulomatous disease and hamartomas這些形式的鈣化最常見于錯(cuò)構(gòu)瘤、肉芽腫性病變52021/7/27 星期二The exception to the rule above is when patie

4、nts are known to have a primary tumor.For instance the diffuse calcification pattern can be seen in patients with osteosarcoma or chondrosarcoma.Similarly the central and popcorn pattern can be seen in patients with GI-tumors and patients who previously had chemotherapy.一些病人有原發(fā)腫瘤病史，可以表現(xiàn)為良性鈣化例如骨肉瘤、軟骨

5、肉瘤可以表現(xiàn)彌漫性鈣化。胃腸間質(zhì)瘤的病人化療后可以表現(xiàn)為中心性或苞米花鈣化。62021/7/27 星期二Size 大小A solitary pulmonary nodule (SPN) is defined as a single intraparenchymal lesion less than 3 cm in size and not associated with atelectasis or lymphadenopathy.A lesion greater than 3 cm in diameter is called a mass.孤立性結(jié)節(jié)定義為小于3cm，不伴有肺不張、淋巴結(jié)轉(zhuǎn)移

6、，大于3cm的為腫塊This distinction is made, because lesions greater than 3 cm are usually malignant, while smaller lesions can be either benign or malignant. 以3cm為界，因?yàn)榇笥?cm的通常是惡性的，而小于3cm的可能是良性或惡性。72021/7/27 星期二Relationship between SPN-size and chance of malignancy in patients with high risk for lung cancer結(jié)

7、節(jié)大小與惡性度具有密切相關(guān)性82021/7/27 星期二Growth 生長(zhǎng)速度Comparison 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.與前次影像結(jié)果相比是鑒別孤立性結(jié)節(jié)良惡性的一個(gè)非常有用的方法。如果超過2年以上保持不變，這個(gè)結(jié)節(jié)就是良性結(jié)節(jié)92021/7/27 星期二Sh

8、ape 形態(tài)Japanese screening studies showed that a polygonal shape and a three-dimensional ratio 1.78 was a sign of benignity (2,3).日本的一項(xiàng)研究表明，多變形和三維立體比率大于1.78是良性結(jié)節(jié)的標(biāo)志A polygonal shape means that the lesion has multiple facets (multi-sided).多邊形意味這個(gè)病灶具有多個(gè)面A peripheral subpleural location was also a sign o

9、f benignity in this study 在這項(xiàng)研究中，周圍的胸膜下的病變也是良性結(jié)節(jié)的一個(gè)標(biāo)志102021/7/27 星期二The 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

10、sign.112021/7/27 星期二Margin 邊緣Corona radiata sign - highly associated with malignancy (figure) 放射冠征Lobulated or scalloped margins - intermediate probability 分葉征和鋸齒征122021/7/27 星期二Smooth margins - more likely benign unless metastatic in origin 邊緣光滑見于良性結(jié)節(jié)，除外轉(zhuǎn)移瘤132021/7/27 星期二Air Bronchogram sign空氣支氣管征R

11、ecent 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.最近一項(xiàng)研究表明，在惡性結(jié)節(jié)中經(jīng)?？匆娍諝庵夤苷?，主要見于支氣管肺泡癌或腺癌142021/7/27 星期二The case on the left shows an airbronchogram seen as a line

12、ar lucency (broad arrow) and as a more cystic lucency (small arrow) due to the fact that the bronchus is seen en face.152021/7/27 星期二On the left two solitary pulmonary nodules.Based upon the morphology, which lesion has the most malignant features? 下列兩個(gè)結(jié)節(jié)有哪些惡性特征呢162021/7/27 星期二The lesion on the far

13、left has a spicuated margin and has lucencies within it. The lesion next to it is lobulated in contour and has some spicules radiating to the pleura.It is however homogeneous in attenuation.Based on these findings we should be most concerned that the lesion on the far left is malignant.It proved to

14、be an adenocarninoma, while the other one was a fungal infection.The lucencies and frank air bronchograms should not mislead you in thinking that it probably is infection. 172021/7/27 星期二Solid and Ground-glass components實(shí)性與磨玻璃樣Another result from screening studies is that nodules containing a ground

15、-glass component are more likely to be malignant (5).另一項(xiàng)研究表明，含有磨玻璃樣密度的結(jié)節(jié)很可能是惡性結(jié)節(jié)。Partly solid lesions with ground-glass components had a malignancy rate of 63%. 部分實(shí)性和磨玻璃樣密度是惡性結(jié)節(jié)的可能性事63%Nonsolid - only ground-glass lesions had a malignancy rate of 18%. 完全磨玻璃樣密度結(jié)節(jié)16%是惡性結(jié)節(jié)Only solid lesions had a malig

16、nancy rate of only 7%.完全實(shí)性結(jié)節(jié)是僅7%是惡性結(jié)節(jié)182021/7/27 星期二Partly solid nodule containing ground-glass component most likely to be malignant192021/7/27 星期二On 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

17、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.202021/7/27 星期二LEFT: 1 in 5 malignant左邊圖是5個(gè)病灶1個(gè)為惡性結(jié)節(jié)RIGHT: 2 in 3 malignant右邊圖是3個(gè)病灶2個(gè)為惡性結(jié)節(jié)212021/7/27 星期二Contrast enhancement對(duì)比增強(qiáng)Contrast enhancement less than 15 HU has a very high

18、 predictive value for benignity (99%).After a baseline scan, 4 consecutive scans at 1 minute interval are performed.對(duì)比增強(qiáng)小于15HU是良性病變的可能性（99%）222021/7/27 星期二This applies only for nodules with the following selection criteria:Nodule 5mm 結(jié)節(jié)大于5mmRelatively spherical 相對(duì)圓形Homogeneous, no necrosis, fat or c

19、alcification均勻，無壞死、鈣化 No motion or beam hardening artifacts 沒有運(yùn)動(dòng)、硬射線偽影232021/7/27 星期二PET-CT: benign versus malignant PET-CT plays an increasingly important role in the evaluation of solitary nodules. PET-CT在肺結(jié)節(jié)的評(píng)價(jià)中起著很重要作用242021/7/27 星期二PET has a very high sensitivity 95%, but a lesser specificity of

20、 only 81% PET有很高的敏感性95%，但特異性僅為81%PET is false positive in granulomatous disease PET是假陽性在炎癥性疾病中國PET is usually false negative in size 10 mm and low-grade malignancy including bronchoalveolar carcinoma and carcinoid 當(dāng)病變小于19 mm時(shí)或低度惡性時(shí)，PET表現(xiàn)為假陰性，包括支氣管肺泡癌和類癌252021/7/27 星期二False negative PET in a patient

21、with adenocarcinoma. Activity is not sufficient for the diagnosis malignancy.262021/7/27 星期二Conclusion結(jié)論In 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 op

22、acity, air bronchograms or cavities and the three-dimensional ratios of a lesion. 在肺結(jié)節(jié)的鑒別診斷中，一些征象將被增加，包括磨玻璃密度、空氣支氣管征、空洞及三維立體比率272021/7/27 星期二With 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.我們應(yīng)該充分意識(shí)到PET-CT的重要性，在實(shí)踐診斷