肺毛玻璃樣病變ppt參考課件

肺部GGO病理解讀

及HRCT評(píng)價(jià)1GGO(ground-glassopacity,GGO)，肺毛玻璃樣病變，是周圍型肺癌最早期的CT表現(xiàn)容易被我們忽視或者被認(rèn)為是正常的CT圖像隨著CT技術(shù)的發(fā)展及人們健康意識(shí)的增強(qiáng)，我們將面臨越來越多這種的病人一、GGO的病理解讀2這是什么？3456ab7GGO的定義GGO定義

：在高分辨率CT(HRCT)上表現(xiàn)為密度輕度增加,但其內(nèi)的支氣管血管束仍可顯示的病變,縱隔窗上病灶往往不能顯示或僅能顯示磨玻璃樣病灶中的實(shí)性成分8GGO的病理解讀GGO病理：由于肺泡內(nèi)氣體減少、細(xì)胞數(shù)量相對(duì)增多、肺泡上皮細(xì)胞增生、肺泡間隔增厚及終末氣道部分充填等因素所致的病理變化。Pathology:

Ground-glassopacitymaybecausedbypartialairspacefilling;interstitialthickeningwithinflammation,edema,fibrosis,orneoplasticproliferation;orinterstitialthickeningwithpartialairspacefilling.9a.Transverselung-windowthin-section(1.25-mm-thick)CTscanshows8-mmround,well-definedGGOnodule(arrow)inleftupperlobe.b.Photomicrographshowscolumnartumorcellsgrowingalongthickenedalveolarwalls(lepidicgrowth).ab10AAHin55-year-oldman.

a.Transverselung-windowthin-section(2.5-mm-thick)CTscanshows12-mmround,well-definedGGOnodule(arrow)inleftupperlobe.

b.showsalveolarwallthickeningandincreasednumbersofalveolarliningcellswithminimalwallthickening.ab11

GGO演變?yōu)橹車头伟┑倪^程

肺泡上皮不典型樣增生（AAH）

原位癌（AIS）進(jìn)展期肺癌12肺癌前病變演化成原位癌的病理變化過程

基底細(xì)胞增生輕度不典型增生中度不典型增生重度不典型增生原位癌

肺泡上皮不典型樣增生（AAH）

原位癌（AIS）13肺腺癌病變病理衍化過程圖（腺癌）

侵襲性AISAAH14二、高分辨率CT對(duì)GGO的評(píng)價(jià)15肺良好的自然對(duì)比，是CT成像的有利條件；多排螺旋CT，主要是指16排以上螺旋CT，具有高時(shí)間、高空間、高密度辨分率以及高信噪比的成像特點(diǎn)；任意層厚重建，能檢出1mm的小病灶；高分辨率CT(HRCT)對(duì)肺內(nèi)小病灶細(xì)節(jié)的顯示優(yōu)于常規(guī)CT，能檢出0.5mm的小病灶，是評(píng)價(jià)GGO最佳的無創(chuàng)性方法。16肺多排螺旋CT掃描技術(shù)參數(shù)層厚(任意層厚重建）0.3-1mm重建算法高分辨率算法矩陣>512×512掃描時(shí)間<0.5sPicth<1mm曝光量（盡量低毫安）KV/mAS：120-140/50-80窗寬窗位肺窗：+700—-700Hu縱隔窗：50—300Hu靶重建FOV20-50cm17容積掃描準(zhǔn)備各向同性成像圖像處理多層、無間隔、連續(xù)的圖像18薄層，小FOV，多發(fā)方位重建19第一種分型第二種分型局限性GGO的CT分型20單純型GGO(pureGGO，pGGO):

整個(gè)病灶密度淺淡,內(nèi)見血管或支氣管壁,完全無實(shí)性組織成分,只能在肺窗下看到

混合型GGO(mixedGGO,mGGO):

病灶內(nèi)部見部分實(shí)性組織,相應(yīng)部分血管被遮蓋,實(shí)性病變部分可在縱隔窗下看到第一種分型21Ⅰ:單純磨玻璃樣影Ⅱ:密度不均的磨玻璃樣影

Ⅲ:中央高密度,外圍淡薄模糊磨玻璃樣影

Ⅳ:單純結(jié)節(jié)影第二種分型22GGO分型和腫瘤發(fā)生及CT表現(xiàn)

Ⅰ型：純磨玻璃樣結(jié)節(jié),病理改變?yōu)槟[瘤細(xì)胞沿肺泡壁生長(zhǎng),無肺泡塌陷,腫瘤內(nèi)彈性纖維輕度增生23

Ⅱ型：低密度不均勻結(jié)節(jié),病理為腫瘤細(xì)胞沿肺泡壁生長(zhǎng),伴有散在肺泡塌陷,腫瘤內(nèi)彈性纖維、重度增生,但其網(wǎng)狀結(jié)構(gòu)仍保存24

Ⅲ型：中心高密度伴周邊磨玻璃樣結(jié)節(jié),病理為肺泡塌陷,瘤體中心彈性纖維增生,伴彈性纖維網(wǎng)狀結(jié)構(gòu)斷裂,周邊區(qū)腫瘤細(xì)胞伏壁生長(zhǎng)25

Ⅳ型：均勻軟組織密度結(jié)節(jié),病理上腫瘤呈實(shí)體生長(zhǎng),無含氣肺泡組織,腫瘤內(nèi)彈性纖維增生,網(wǎng)狀結(jié)構(gòu)中斷、破壞26Ⅰ型:單純磨玻璃樣陰影GGO發(fā)展成肺癌的動(dòng)態(tài)演變過程Ⅱ型:密度不均的磨玻璃樣陰影Ⅲ型:中央高密度,外圍淡薄模糊的磨玻璃樣陰影

Ⅳ型:單純結(jié)節(jié)影27GGO發(fā)展成肺癌CT表現(xiàn)的四步曲pGGO：pureGGO（純毛玻璃樣病變）mGGO:

mixedGGO（混合型毛玻璃樣病變）SOLIDSPN(<3cm)MASS

(>3cm，腫塊，實(shí)體瘤，進(jìn)展期肺癌)肺腺癌的演變過程是和CT的表現(xiàn)相對(duì)應(yīng)的28pGGO：AAHmGGO：AISMASS:腺癌從病理學(xué)角度看肺癌的CT圖像的演變過程29IllustrationoftherelationshipbetweentheNoguchihistologicclassificationofadenocarcinomaofthelung(NoguchitypesAthoughF)andcorrespondingCTappearancesoftheselesions.30Persistentnodularground-glassopacityinan80-year-oldmanwithadenocarcinoma.Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen.a.Initialthick-sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule(arrow)inthemiddlelobeoftherightlung.b.Follow-upCTimageobtained

12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent(arrow).c.Follow-upthin-sectionCTimageobtainedat

16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion(arrow).abc31BAC.Sequentialmagnified1-mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGOovera3-yearperiod.Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent,whichwasbettercharacterizedonsequentialimages.3233（一）肺惡性GGO的CT評(píng)價(jià)

34GGO和AAHAtypicaladenomatoushyperplasiaina53-year-oldwoman.a.Thin-sectionCTimageoftherightlungshowsan11-mmwell-definednodularground-glassopacitywithoutasolidcomponentinthelowerlobe.b.photomicrographshowsthickenedalveolarwallslinedbyanintermittentsinglelayerofatypicalcuboidalpneumocytes.ab35

Concurrentatypicaladenomatous

hyperplasiaandadenocarcinoma

ina71-year-oldwoman.Thin-sectionCTimageatthelevelofthecarinashowsan18-mm-diametermixednodularground-glassopacitywithasolid

componentintheupperlobeoftherightlunganda10-mmpurenodularground-glassopacity

inthelowerlobeoftheleftlung.AAHcarcinomaofthebronchioloalveolar36

MultipleAAHsina42-year-oldwoman.CTscansshowroundwell-defined,pureGGOnodules(arrow).PhotomicrographofthenoduleintheleftupperlobeshowAAH.abc37bronchioloalveolarcarcinomaina63-year-oldwoman.a.therightupperanteriorsegmentalbronchusshowsa10-mmwell-definednodularground-glassopacitywithoutasolidcomponentinthelowerlobeoftherightlung.Notethepresenceofpulmonaryvesselsinthelesion.b.Photomicrographspecimenshowsreplacementofthealveolarliningbyneoplasticcolumnarepithelium,withoutevidenceofstromalinvasion.GGO和BAC(AIS)ab38bronchioloalveolarcarcinomaina49-year-oldwoman.a.Theleveloftherightbronchusintermediusshowsa14-mmwell-definednodularground-glassopacitywithasolidcomponent(arrow)inthelowerlobeoftherightlung,abuttingthevertebralbody.b.PhotomicrographshowsBAC(AIS)ab39Adenocarcinomawithmixedacinarand

bronchioloalveolarcarcinomaina50-year-oldwoman.a.

Thin-sectionCTimageshowsa28-mmwell-definedmixedground-glassopacitylesionwithperipheralground-glassopacityintheupperlobeoftheleftlung.Themassabutsthepleura.b.

PhotomicrographofahistologicspecimenshowsBAC(AIS).ab40BACandAAH

ina63-year-oldwoman.a.lung-windowCTscanshowsa19-mmovoid,well-defined,pureGGOnoduleinthe

leftlowerlobe.Thislesionwasconfirmedas

BAC

afterbasalsegmentectomy.b.

lung-windowthin-sectionCTscanshowsa9-mmround,well-defined,pureGGOnodule(arrow)

intheleftupperlobe.

Thislesionwasconfirmed

asAAHafterwedgeresection.c.

Noduleintheleftlowerlobeshowscolumnarorcuboidalcellliningthickenedalveolarwallswithoutevidenceofstromal,vascular,orpleuralinvasion.abc41a.Transverselung-windowthin-section(1-mm-thick)CTscanshowsa22-mmirregularGGOnodulewithbubble-lucencyintheleftlowerlobe.

Thislesionwasconfirmedas

adenocarcinoma

withapredominantBACcomponentafterlobectomy.b.Transverselung-windowthin-section(1-mm)CTscanshowsa12-mmround,well-definedpureGGOnoduleintherightupperlobe.Thislesionwasconfirmedas

BAC.

AAdenocarcinomawithapredominantBACcomponentandBACina48-yearoldwoman.

ab42

65-year-old-womanwithmultiplepureground-glassopacities(PGGOs)a.MultiplesmallPGGOswerefoundinalllobesoflung.ComputedtomographicslicerevealsthreePGGOs(arrows)intherightupperlobe.Thelobe,includingthemaximalPGGO(10mmindiameter),wasremoved.b.Comprehensivehistologicexaminationofresectedspecimensdemonstratedexistenceofmanysmallerlesionsrevealing

bronchioloalveolarcarcinomaoratypicaladenomatoushyperplasia.During37monthsofpostoperativefollow-up,onlyaslightincreaseinsizeordensitywasrecognizedinsomeresidualPGGOsscatteredinalllobes.ab43Adenocarcinomaina56-year-oldman.a.Thin-sectionCTimageobtainedshowsa14-mmnodularground-glassopacitywithnosolidcomponentintheupperlobeoftherightlung.b.Photomicrographofahistologicspecimenshows

adenocarcinoma

withdensesclerosis.GGO與腺癌ab44CTscan(1-mmsection)ofmixedsubtypeadenocarcinomawithBACcomponent(NoguchitypeClesion)showsanodulewithpureGGO,demonstratingthatalthoughnonsolidnodulesarelikelyto

representAAHorBAC,aninvasivecomponentmayrarelybepresentasinthiscase.45CTscanina64-year-oldmanshowsanoval2.1-cmleftlowerlobenonsolidnodule(arrow).FNABrevealed

adenocarcinoma.46支氣管充氣造影征軸位示：左上肺毛玻璃陰影47分葉征冠狀位48毛刺征矢狀位BAC49CT:左上肺毛玻璃陰影短毛刺征50冠狀位重建51矢狀位重建典型胸膜凹陷征BAC52左上肺尖段純毛玻璃結(jié)節(jié):1.0×0.9cm53冠狀位重建：局灶性純磨玻璃密度影(Focalpureground—glassopacity，pGGO54矢狀位局部放大BAC55峰值時(shí)間后移F，68，腺鱗癌,HRCT動(dòng)態(tài)增強(qiáng)特征56（二）肺良性GGO的CT評(píng)價(jià)57肺局灶性間質(zhì)纖維化與GGO

Focalinterstitialfibrosisina40-year-oldwomana.Thin-sectionCTimageshowsa25-mmwell-definednodularground-glassopacitywithnosolidcomponentinthelowerlobeoftheleftlung.b.Photomicrographofahistologicshowsthelesion(arrow)withalveolarseptalthickeningandfibrosisandwithintraalveolarinfiltrationbyinflammatorycells.ab58A36-year-oldwomanwithtwonodularGGOsa.Transversethin-sectionCTscanshowsa5.1-mmwelldefinedroundpureGGOnoduleintherightmiddlelobe.

focalinterstitialfibrosis.b.Theother9-mmmixedGGOnodulecontainingacentralsolidportionisshownintherightlowerlobe.

bronchioloalveolarcarcinoma

ab59Focalnonspecificinterstitialpneumonia.a,b.Thin-sectionCTscansattheleveloftheleftpulmonaryarteryandaorticarch,respectively,showthreefociofpersistentGGO.c.Histologicspecimenshowsthickeningofthealveolarwallwithchronicinflammatoryinfiltrates.Notumorwasidentified.abc60A34-year-oldwomanwith

focalinterstitialfibrosis

showingaroundpureGGOlesiona.Transversethin-sectionCTscanshowsan8.5-mmwell-definedroundnodulewithpureGGO.Therewasnoevidenceofspiculationorvascularconvergencearoundthelesion.

b.Photomicrographofresectionspecimenshowsalveolarinterstitialthickeningwith

fibrosis

andtypeIIpneumocyteproliferationab61

A50-year-oldwomanwith

focalinterstitialfibrosisappearingasmixedGGOwithaspiculatedmarginandpleuraltraction.a.Transversethin-sectionCTscanshowsamixedGGOnoduleintheleftupperlobe.Notethespiculatedmarginandpleuralretraction.b.Thisfollow-upthin-sectionCTtaken2monthslatershowsasimilarappearance.Thelesionwasresectedundertheimpressionofprimarylungcancer.Thepathologicdiagnosiswasoffocalinterstitialfibrosiswithoutevidenceofmalignancyab62A66-year-oldmanwith

focalinterstitialfibrosiswithapolygonalshapeandperi-lobularlineardensity.TransversethinsectionCTscanshowsanodularGGOlesionwithperi-lobularlinearopacities(arrow)aroundthelesionintherightupperlobe.Notethepleuraltractionaroundthelesion63Nodular

fibrosis

withconcavemarginsin67-year-oldman.Bothreviewersinterpretedlesionashavingconcavemargins(arrow),airbronchograms(arrowheads),andpredominantlyground-glassappearanceontransversehigh-resolutionCTimages.Lesionsizewasmeasured8mmbyreviewer1and8.5mmbyreviewer2.Pathologicdiagnosiswas

nodularfibrosis.64Nodularfibrosiswithpolygonalshapein72-year-oldman.Bothreviewersinterpretedlesion(arrow)ashavingcoarsespiculation,pleuraltag,andpolygonalshape,andasbeingpredominantlysolidontransversehighresolutionCTimages.Lesionsizewasmeasuredas8mmbyreviewer1and9mmbyreviewer2.Pathologicdiagnosiswas

nodularfibrosis.65Intrapulmonarylymphnodethatshowedperipheralsubpleurallesionin53-year-oldwoman.Bothreviewersregardedlesion(arrow)aspredominantlysolidlesionattachedtomajorfissureontransversehigh-resolutionCTimages.Lesionsizewasmeasured9mmbybothreviewers.Pathologicdiagnosiswasintrapulmonarylymphnode.肺內(nèi)淋巴結(jié)與GGO66CTscanina90-year-oldwomanwithchroniccongestiveheartfailureshowsatinynoduleadjacenttotherightmajorfissurethatislikelytorepresent

acongestedintrapulmonarylymphnode

(arrow).

67GGO與霉菌灶Thin-sectionCTimageatthelevelofthemainpulmonaryarteryshowsa23-mmpoorlydefinednodularground-glassopacityintheupperlobeoftheleftlung.Thelesionincludesseveralperipheralsolidportions(arrows)andasubtlegroundglassopacity(arrowhead).68Eosinophilicpneumoniaina36-year-oldmanwithperipheralbloodeosinophilia.a.Thin-sectionCTimageattheleveloftheaorticarchshowsanill-definedareaofnodularground-glassopacityintheupperlobeoftherightlung.

b.Thin-sectionCTimageattheleveloftheupperlobarbronchusintheleftlungshowsasimilarnodularground-glassopacity.ab69GGO與結(jié)核灶FalsepositivePETinpatientwith

tuberculosis.a.Thin-sectionaxialCTscanthroughtheupperlobesatlungwindowsshowsaleftupperlobenodulewithirregularmargins.b.FusedimagefromPET-CTshowsincreasedmetabolicactivitywithinthenodule.SurgicalresectionrevealedagranulomawithculturespositiveforMycobacteriumtuberculosis.ab70（三）GGO的CT處理原則和步驟CT隨訪GGO變化的重要性體積不變體積變大體積變小密度變實(shí)代謝較低711、體積不變72Persistentnodularground-glassopacityina69-year-oldman.a.Thin-sectionCTimageobtainedattheleveloftheleftbrachiocephalicveinshowsa14-mmpoorlydefinedroundnodularground-glassopacityintheupperlobeoftheleftlung.b.Follow-upthin-sectionCTimageobtained4monthslatershowsthepersistenceandstableappearanceofthelesion.Thepathologicdiagnosis,obtainedafterawedgeresection,wasfocal

interstitialfibrosis.ab73Purenodularground-glassopacityconfirmedasfocalinterstitialfibrosis

A.Thin-sectionCTshows30mmpurenodularground-glassopacityintherightupperlobe.

B.Onfollow-upCTscanaftersevenmonths,anintervalchangewasnotnoted.

ab74Purenodularground-glassopacityconfirmedasatypicaladenomatoushyperplasiaina58-year-oldman.

A.Initialthin-sectionCTshowsa15mmpurenodularground-glassopacity

B.Onthin-sectionCTafter2months,anintervalchangewasnotnoted.Alllesionswerepathologicallyconfirmedasatypicaladenomatoushyperplasiabymultifocalwedgeresection.ab75Purenodularground-glassopacityconfirmedas

atypicaladenomatoushyperplasiaa.

InitialCTshows8mmpurenodularground-glassopacityintherightupperlobe.b.

Thin-sectionCTafter10monthsshowspersistentpurenodulargroundglassopacitywiththesamesize.ab762、體積變大體積變大一般為惡性病變77

SmalladenocarcinomadetectedonscreeningCT.ａ.InitialaxialthinsectionCTattheleveloftherightupperlobebronchusshowsa4mmnoduleintherightupperlobe.ｂ.RepeatCTscan3monthslateratthesamelevelshowsslightenlargementofthenodule.Biopsyrevealedadenocarcinoma.ab78GrowthofsmallnoduleonfollowupCT.

(adenocarcinoma)ａ.Initialthin-sectionaxialCTconedtotheleftlungshowsasmallleftupperlobenodulemeasuringapproximately4mmindiameter.ｂ.Repeatscan6monthslatershowsintervalgrowthofthelesion.Aninvasive

adenocarcinoma

wasfoundatsurgery.ab79

BAC.

Sequentialmagnified1-mmCTsectionsthroughtherightupperlobeshowminimalincreaseinsizeofanodulewithGGO

overa3-yearperiod.

Thecentralareaofhigherattenuationrepresentsavesselbifurcationandnotasolidcomponent,whichwasbettercharacterizedonsequentialimages.80Sequentialmagnified5-mmCTsectionsthroughtheleftupperlobeshowGGO．initiallymeasuring8mminsizeovera3-yearperiod.Histologicanalysisshowedmixedsubtype

adenocarcinomacomposedofacinaradenocarcinoma(40%)andBAC(60%).81Computedtomogramfrom57-year-oldman(patient1)withlong-termfollow-upofpureground-glassopacity(PGGO)formorethan10years.Patienthadundergoneoperationfor

adenocarcinomaoriginatinginrightupperlobe

10yearspreviously.ａ.SmallPGGOinleftupperlobe(arrow)waspointedoutasafunctionoftheretrospectivereviewofconventionalCTtakenatthatoperation.ｂ.Onfollow-up124monthslater,high-resolutioncomputedtomographyshows

enlargementofPGGOfrom8mm(A)to25mmindiameter.ｃ.Mostoftheresectedspecimenreveals

bronchioloalveolarcarcinomaabc82

Mixedsubtype

adenocarcinoma,

progressionofGGOtoanodulewithmixedsolidcomponentandGGO.

a.Magnified1-mmCTsectionshowsadiscreteGGO(arrows).

b.Follow-upCTscanobtained1yearlatershowsclearprogressionofthedisease,withthedevelopmentofacentralsolidcomponent,althoughthereisnoappreciableenlargementofthelesion(arrows).ab83Mixedsubtype

adenocarcinoma.aMagnified1-mmCTsectionthroughtheleftlowerlobeshowsanodulewithmixedsolidcomponentandGGO.bFollow-upCTscanobtained6monthslatershowsincreaseintheextentofthesolidcomponentwithinthenodule.ab84Persistentnodularground-glassopacityinan80-year-oldmanwith

adenocarcinoma.

ａ．Initialthick-sectionCTimageobtainedattheleveloftherightinferiorpulmonaryveinshowsasubtlenodule(arrow)inthemiddlelobeoftherightlung.ｂ．Follow-upCTimageobtained12monthslatershowsanincreaseinthelesionsizeandanadditionalsubtleinternalsolidcomponent(arrow).ｃ．Follow-upthin-sectionCTimageobtainedat16monthsshowsanincreaseinthesizeofthesolidcomponentwithinthelesion(arrow).Adenocarcinomawasfoundathistopathologicanalysisofanexcisedspecimen.abc85

a.TransverseCTscanina75-year-oldmanshowsa2.0-cm-diameternonsolidleftupperlobenodule.FNABrevealednomalignantcells.

b.ThelesionwasfollowedupwithserialCT;25monthslater,thenodulewasslightlyincreasedinsizeandhadconvertedtoapartlysolidattenuationlesionwithairbronchograms.Volumetricmeasurementshowedthedoublingtimeoftheopacitytobe

1375days.RepeatFNABshowedbronchioloalveolarcellcarcinoma.ab86３、體積變小體積變小一般為良性病變87Resolutionofnodularground-glassopacityovertimehelpsdeterminethebenignityofalesionina50-year-oldman.Initialthin-sectionCTimageattheleveloftheinferiorpulmonaryveinshowsa12-mmpoorlydefinednodularground-glassopacityintherightlowerlobe.Follow-upCTimageobtainedapproximately2monthslatershowsthatthelesioninahasresolved.ab88Focalinflammationmimickingadenocarcinoma.

a.Magnified1-mmCTsectionthroughtherightupperlobeshowsnoduleswithGGOinitiallydiagnosedasprobableBAC.b.Follow-upCTscanobtained3monthslatershowsnearcompleteresolutionofthelesion(arrow),(focalnonspecificinflammation).ab89Transversethin-sectionCTscansshowtransientPSNwithmultiplicityina43-year-oldman.a.Scanshowsa16-mmPSN(arrow)intheleftupperlobe.Thispatienthadeosinophilia(eosinophilcount,574permicroliter).b.Follow-upscanobtained1monthlatershowsdisappearanceofthePSN.ab90Transversethin-sectionCTscansshowtransientPSNwithill-definedborderin37-year-oldman.a.Scanshowsa27-mmPSN(arrow)withanill-definedborderintherightupperlobe.Thispatienthadbloodeosinophilia(eosinophilcount,1577permicroliter).b.Atfollow-upCTperformed3weekslater,thePSNhasdisappeared.ab91ResolutionofspiculatedSPNcausedbyinfection.a.AxialCTscanatleveloftrachealcarinaina52-year-oldsmokerwhohasfever,cough,andhemoptysisshowsaspiculatednoduleintheleftupperlobe.b.RepeataxialCT5weekslatershowsmarkeddecreaseinthesizeofthenodule.Thepatienthadbeentreatedintheintervalwithbroadspectrumantibioticsforapresumedinfec