胸腺瘤影像诊断及分期

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,单击此处编辑母版标题样式,1,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,胸腺瘤,影像诊断及分期,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,小结,影像评价,流行病学,前纵隔最常见的原发肿瘤,发病率相对较低，占所有成人恶性肿瘤的不到,1%,流行病学,常见于,40岁以上,成人,男女发,病率,相仿,胸腺原发上皮来源肿瘤：,胸腺瘤,和,胸腺癌,胸腺瘤最常见,流行病学,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,小结,影像评价,病理特征,恶性肿瘤,具有,转移潜能,病理特征,实性肿瘤,具有包膜,局限在胸腺区,病理特征,1/3 坏死、出血、囊变,1/3 侵犯包膜和邻近结构,病理特征,生长缓慢,侵袭性,远处转移罕见,胸腺瘤的WHO病理分类表,注：,a.,A,型；b,.,B1,型；,c.,B2,型；,d.,B,3型,病理分类局限性,几种WH,O分型共存,确定病理类型困难,病理分类局限性,部分胸腺,瘤不属于上述分类中的,任何一型,不具有临床预测价值,病理分类主要作用,区分,胸腺瘤,和,胸腺癌,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,影像评价,临床特征,局部效应,压迫和侵犯,临床特征,胸痛,呼吸困难,咳嗽,临床特征,重症肌无力,3050%,的胸腺瘤患者有重症肌无力表现,1015%,的重症肌无力患者有胸腺瘤,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,小结,影像评价,Masaoka-koga分期及临床处理原则,基于术后病理的分期,胸腺瘤的治疗,首选疗法,外科手术,预后因素,切除是否完全,胸腺瘤的治疗,术后放疗,取决于肿瘤是否有外侵,胸腺瘤的治疗,新辅助化疗,使部分进展期患者,重新获得,完全切除肿瘤的机会,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,小结,影像评价,影像学的作用,区分早期（期）及进展期（期）患者,影像学的作用,准确诊断,正确分期,影像学的作用,敏感识别,局部侵犯和远处播散,影像学的作用,筛选,术前新辅助化疗患者,影像学的作用,正确诊断,可切除的复发肿瘤,正常小儿胸腺,女性，,23,岁，尤文氏肉瘤患者。,a.,化疗开始前,b.,化疗结束后,3,个月，胸腺增生,a,b,女性，,25,岁，胸腺增生伴重症肌无力,a.,同相位,T,1,WI,；,b,.反相位,T,1,WI,a,b,胸腺瘤,X,线,表现,偏侧性前纵隔肿块,边界清楚,边缘光滑或呈分叶状,进展期,X,线征象,与肺的交界面不规则,膈肌升高（膈麻痹）,胸膜结节（胸膜转移）,侵袭性胸腺瘤,男，,55,岁，无明显临床症状,膈神经受累（右膈面抬高）男，,60,岁,胸膜转移 女，,36,岁,CT,表现,前纵隔肿块,边缘光滑或呈分叶状,多发生于胸腺的一叶,CT,表现,典型表现为均匀强化,约1/3因肿瘤坏死、出血或囊变而出现不均匀强化,CT,表现,囊性病变里的,软组织结节,提示该病变是囊性胸腺瘤而非先天性囊肿,胸腺瘤钙化,细点状,沿包膜线条状,肿瘤内粗大钙化,血管受侵征象,内腔轮廓不规则,被病灶包绕或闭塞消失,血管腔内软组织肿块，可延续至心腔内,胸膜播散,单或多发胸膜结节或肿块,平滑、结节状，或弥散分布,多见于前纵隔胸腺瘤同一侧,胸腔积液不常见，即使已经发生胸膜转移,肿瘤侵袭性依据,分叶状或形态不规则,瘤内囊变、坏死区,多灶性钙化,进展期征象,直径7cm以上,与期分级具有高度相关性,周围脂肪浸润,分叶状轮廓,以下,表现提示胸腺瘤可能性较小,纵隔淋巴结广泛转移,胸腔积液,肺转移,Stage I in,MDCT,and Masaoka staging system,WHO type A,，,Masaoka,stage I,stage II in,MDCT,and Masaoka staging system,stage in,MDCT,and Masaoka staging system,stage in,MDCT,and Masaoka staging system,stage in,MDCT,and Masaoka staging system,stage in,MDCT,and Masaoka staging system,stage in,MDCT,and Masaoka staging system,MRI,表现,T,1,WI低或等信号,T,2,WI高信号,与脂肪信号相近,MRI,表现,脂肪抑制技术有助于区分肿瘤与周围脂肪,WHO type B1 thymoma in a 47-year-old woman with left-sided neck pain.,(a),Axial T1-weighted MR image shows a rounded intermediate-signal-intensity mass,(M),in the anterior mediastinum.,(b),Axial fat-suppressed T2-weighted MR image demonstrates a 6-cm anterior mediastinal mass,(M),with high signal intensity at the level of the ascending aorta,(Ao),. The mass was diagnosed as a lymphocyte-rich WHO type B1 thymoma at resection.,a,b,Stage III thymoma in a 52-year-old man with chest pain and dyspnea.,(a),Axial double-inversion-recovery MR image demonstrates a 4-cm lobulated mass that abuts the pericardium (arrow).,(b),Contrast-enhanced multiplanar double-inversion-recovery short-axis MR image demonstrates tumor invasion of the pericardium (arrow) and epicardial fat (arrowhead), findings that were confirmed at thymectomy and pericardial resection.,a,b,胸腺瘤,期 女性，,54,岁，头面部肿胀，肿瘤侵犯上腔静脉，包绕右冠状动脉,MRI,表现,囊变坏死,表现为长T,1,、长T,2,信号,MRI,表现,瘤内纤维间隔和结节,表现为低信号，有助于,囊性,胸腺瘤,和,先天性囊肿,的鉴别,Cystic thymoma in an asymptomatic 35-year-old woman. Coronal T2- weighted MR image shows an anterior mediastinal septate cystic thymoma with a septated soft-tissue nodule (arrow).,囊性胸腺瘤,MRI,表现,瘤内出血信号与血肿期龄有关,含铁血黄素沉着表现为T,1,及T,2,WI上的低信号,MRI,表现,肿瘤的包膜和瘤内的纤维分隔,提示,肿瘤侵袭性较低,PET/CT,Thymic hyperplasia in a 16-year-old boy who had undergone chemotherapy for osteosarcoma 4 months earlier.,(a),Contrast-enhanced chest CT scan shows thymic enlargement.,(b),PET/CT scan obtained to monitor for osteosarcoma recurrence or metastases shows diffuse FDG uptake in the thymus (arrow). At 7-month follow-up PET/CT, the uptake had resolved, a finding consistent with thymic hyperplasia.,a,b,PET/CT,Stage IVa thymoma in a 50-year-old man.,(a),Contrast-enhanced chest CT scan shows a primary mass,(M),and a pleural drop metastasis (arrow).,(b),On an axial fused FDG PET/CT image, the primary tumor,(M),and the drop metastasis (arrow) are FDG avid.,Pleural recurrence in a 38-year-old woman with previously treated stage IVa thymoma.,(a),Postoperative baseline CT scan shows normal right basilar pleura adjacent to the attachment of the diaphragm to the chest wall (arrow).,(b),Follow-up contrast-enhanced chest CT scan obtained 2 years later shows increased diaphragmatic pleural thickening (arrow).,(c),Axial fused FDG PET/CT image shows FDG-avid pleural recurrence (arrow).,鉴别诊断,胸腺其它原发肿瘤,如胸腺癌、胸腺的良性肿瘤等,鉴别诊断,非胸腺来源肿瘤性病变,包括淋巴瘤、生殖细胞肿瘤、小细胞肺癌等,鉴别诊断,纵隔的转移瘤,复发与随访,胸腺瘤是惰性肿瘤,需长期随访,复发与随访,复发病灶,早发现很重要,如能完全切除，与术后不复发者预后类似，5年生存率可以达到65%80%,复发与随访,胸腺瘤完全手术切除后,平均复发时间,大约5年,（37年）,复发与随访,期,胸腺瘤,复发平均时间是10年,复发与随访,期,胸腺瘤,平均复发时间仅为3年,复发与随访,ITMIG推荐,胸腺瘤术后最初5年，胸部CT复查最少每年1次,然后间隔一年用胸部X光摄片取代CT，直至术后11年,最后转为每年一次的胸部X线摄片,复发与随访,a期胸腺瘤、胸腺癌术后,肿瘤不完全切除,其它高危肿瘤,半年一次胸部CT随访直至满3年,胸腺瘤,影像诊断及分期,病理特征,流行病学,临床特征,分期,&,治疗,小结,影像评价,影像学在胸腺瘤的诊断、分期及随访中发挥着重要作用，CT是重要的断面成像方法,肿瘤的分期及手术切除的程度是最重要的决定预后的因素,影像科医师必须熟悉进展期胸腺瘤的影像特征，从而筛选出需行术前新辅助化疗的患者，从而提高该类患者的疗效,小结,Thank you,for your attention!,