医学孤立性肺结节PETCT良恶性鉴别诊疗专题课件

单击此处编辑母版标题样式,*,*,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,孤立性肺结节PETCT良恶性鉴别诊疗,孤立性肺结节的鉴别诊断，在临床中经常遇到。根据结节的良恶性差异，处理方法有很大差别。在这篇文章中，我们主要探讨CT和PET-CT的相关征象在孤立性肺结节良恶性鉴别诊断中的意义。,The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is benign or malignant.In this overview we will discuss some of the new features that can help to differentiate between benign and malignant nodules based upon CT and PET-CT findings,目录（contents）,CT征象,钙化,大小,生长速度,形状,边界,充气支气管征,实性和磨玻璃成分,强化特征,PET-CT,征象,结论,CT: benign versus malignant,Calcification,Size,Growth,Shape,Margin,Air Bronchogram sign,Solid and Ground-glass components,Contrast enhancement,PET-CT: benign versus malignant,Conclusion,钙化,良性钙化征象： 弥漫性 中心性 层状 爆米花样,弥漫性、中心性、层状及爆米花样钙化多见于良性结节。主要见于肉芽肿性疾病和错构瘤。,其他类型钙化多见于恶性结节，不应该认为属于良性表现。,在已知有原发肿瘤存在的情况下，其钙化类型不一定适用此结论。例如：骨肉瘤或软骨肉瘤的病人，其钙化多表现为弥漫性；同样的，中心性和爆米花样钙化也可见于胃肠道肿瘤或接受过化疗的病人。,Calcification,Diffuse, central, laminated or popcorn calcifications are benign patterns of calcification.These types of calcification are seen in granulomatous disease and hamartomas.All other patterns of calcification should not be regarded as a sign of benignity.,The exception to the rule above is when patients 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.,结节大小,结节大小与恶性可能性之间的关系,孤立性肺结节（SPN）定义：肺实质内小于等于3cm的病灶（需除外肺不张和肿大的淋巴结）。大于3cm的病灶称为肿块（mass）。,之所以这样定义，是因为大于3cm的病灶多为恶性，而更小的病灶可能是良心或恶性。,Swensen. et al 研究了SPN大小与恶性可能性之间的关系（上图），结论是小的结节，良性可能性大。超过2000例小于4mm的结节，无一例属于恶性。,Size,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.This distinction is made, because lesions greater than 3 cm are usually malignant, while smaller lesions can be either benign or malignant.,Swensen et al studied the relationship between the size of a SPN and the chance of malignancy in a cohort at high risk for lung cancer (1).Their findings are listed in the table on the left.They concluded that benign nodule detection rate is high, especially if lesions are small.Of the over 2000 nodules that were less than 4 mm in size, none was malignant,生长速度,与以前的CT片进行比较，在结节定性方面具有重要意义。超过2年无变化的结节多为良性。,Growth,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.,形状,左：横断图像；右：冠状重建图像。三维比值=（最大）横径/长径,日本的相关研究证实，多角形、三维比值大于1.78的结节，多为良性。在肺的外围、胸膜下的结节也多为良性。,三维比值=（最大）横径/长径。大的三维比值说明病灶的形状是扁平的（是“片”不是“块”），这是良性的特征。,Shape,Japanese screening studies showed that a polygonal shape and a three-dimensional ratio 1.78 was a sign of benignity (2,3).A polygonal shape means that the lesion has multiple facets (multi-sided).A peripheral subpleural location was also a sign of benignity in this study.,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 sign.,边缘,辐射冠征,：绝大多数都为恶性（上图：恶性病灶周围的辐射冠征-毛刺）。,病灶边缘呈,分叶状,的，可以是良性或恶性,边缘,光滑,，多为良性。,Margin,Corona radiata sign,- highly associated with malignancy (figure),Lobulated or scalloped margins,- intermediate probability,Smooth margins,- more likely benign unless metastatic in origin,充气支气管征,最新研究表明，有充气支气管征的结节多为恶性。主要见于BAC（细支气管肺泡癌）和腺癌。,上图显示充气的支气管呈线样（粗箭）或囊状（细箭）透亮区，这是支气管走向不同造成的。,Air Bronchogram sign,Recent 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.,The case on the left shows an airbronchogram seen as a linear lucency (broad arrow) and as a more cystic lucency (small arrow) due to the fact that the bronchus is seen en face.,图中两个SPN，根据形态表现，哪个更像恶性的？,左边的结节边缘呈毛刺状，内部有透亮区；右侧者呈分叶状，边缘毛刺并与胸膜粘连，但是内部均质。,基于上面的表现，我们认为左侧者更像恶性的。最终证实，左侧者为腺癌，右侧为真菌感染。,On the left two solitary pulmonary nodules.Based upon the morphology, which lesion has the most malignant features?,The lesion on the far 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 be an adenocarcinoma, 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.,实性和磨玻璃成分,一项研究表明：结节内含有磨玻璃样成分的，更倾向于属于恶性。,结节内既含有部分实性成分，又含有磨玻璃成分的，为恶性的可能性为63%。,没有实性成分，只有磨玻璃成分的，恶性可能性有18%。,全部为实性成分的，恶性可能性为7%。,Solid and Ground-glass components,Another result from screening studies is that nodules containing a ground-glass component are more likely to be malignant.,Partly solid lesions with ground-glass components had a malignancy rate of 63%.,Nonsolid - only ground-glass lesions had a malignancy rate of 18%.,Only solid lesions had a malignancy rate of only 7%.,左侧者只有磨玻璃成分；右侧者既有磨玻璃成分又含有实性成分。,左侧者恶性可能性为1/5;右侧者恶性可能性为2/3.,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 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.,强化特征,增强扫描强化程度小于15HU的，有99%的可能性为良性。平扫后增强扫描，每一分钟扫描一次，连续4次。,结节满足以下条件者，才能采用这种方法评价：,结节5mm,相对呈球形,内部均质，没有坏死、脂肪和钙化,图像无明显伪影,Contrast enhancement,Contrast enhancement less than 15 HU has a very high predictive value for benignity (99%).After a baseline scan, 4 consecutive scans at 1 minute interval are performed.This applies only for nodules with the following selection criteria:,Nodule 5mm,Relatively spherical,Homogeneous, no necrosis, fat or calcification,No motion or beam hardening artifacts,PET-CT,PET-CT在实性结节评价方面起着越来越重要的作用。,在进行PET-CT检查时，你必须意识到：,PET-CT敏感性高达95%，但特异性只有81%；,肉芽肿性疾病可以呈假阳性；,小于10mm的结节、良性肿瘤以及低度恶性的结节包括支气管肺泡癌可以呈假阴性。,上图为一例腺癌病人，结节并不显示为高代谢状态，所以呈假阴性。,PET-CT: benign versus malignant,PET-CT plays an increasingly important role in the evaluation of solitary nodules.,When you perform PET-CT, you have to realize the following:,PET has a very high sensitivity 95%, but a lesser specificity of only 81%,PET is false positive in granulomatous disease,PET is usually false negative in size 10 mm and low-grade malignancy including bronchoalveolar carcinoma and carcinoid,With these specificity numbers, there will be false positives in about 20%, depending on the background prevalence of granulomatous disease. On the left a patient with an adenocarcinoma, that was not hypermetabolic on the PET, so it is a false negative PET.,结论,在良恶性肺结节的鉴别诊断中，我们要尤其注意以下影像学特征：磨玻璃征、充气支气管征及结节的三维比值。,在进行PET-CT检查时，要注意PET-CT的准确性问题，要注意感染性或非感染性肉芽肿性疾病诊断的可能性。,Conclusion,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 opacity, air bronchograms or cavities and the three-dimensional ratios of a lesion.,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.,