下载

1下载券

加入VIP
  • 专属下载特权
  • 现金文档折扣购买
  • VIP免费专区
  • 千万文档免费下载

上传资料

关闭

关闭

关闭

封号提示

内容

首页 肺内多发小结节鉴别

肺内多发小结节鉴别.pdf

肺内多发小结节鉴别

laofa
2011-07-03 0人阅读 举报 0 0 暂无简介

简介:本文档为《肺内多发小结节鉴别pdf》,可适用于自然科学领域

DOI:chestChestNaidichSuhailRaoof,AlexeyAmchentsev,IoannisVlahos,AjayGoudandDavidPAlgorithmPictorialEssay:MultinodularDisease:AHighResolutionCTScanDiagnosticThisinformationiscurrentasofSeptember,http:wwwchestjournalorgcgicontentfulllocatedontheWorldWideWebat:Theonlineversionofthisarticle,alongwithupdatedinformationandservices,isISSN:maybereproducedordistributedwithoutthepriorwrittenpermissionofthecopyrightholderDundeeRoad,NorthbrookILAllrightsreservedNopartofthisarticleorPDFpublishedmonthlysinceCopyrightbytheAmericanCollegeofChestPhysicians,CHESTistheofficialjournaloftheAmericanCollegeofChestPhysiciansIthasbeenbyKimYongMionSeptember,wwwchestjournalorgDownloadedfromPictorialEssay:MultinodularDisease*AHighResolutionCTScanDiagnosticAlgorithmSuhailRaoof,MD,FCCPAlexeyAmchentsev,MDIoannisVlahos,MDAjayGoud,MDandDavidPNaidich,MD,FCCPTheevaluationofpatientspresentingwithmultinodularpulmonarydiseaseprovidesanimportantclinicalchallengeforphysiciansThedifferentialdiagnosisincludesanextensivelistofbenignandmalignantprocessesmakingthemanagementofthesecasesfrequentlyproblematicWiththeintroductionofhighresolutionCT(HRCT)scanning,theabilitytoassessvariouspatternsofdiffusemultinodulardiseasehasevolvedintoanessentialpartofthediagnosticprocessThepurposeofthisarticleistodevelopanapproachtothediagnosisofmultinodularparenchymaldiseaseusingHRCTscanpatternrecognitionasapointofdeparture(CHEST:–)Keywords:algorithmmultinodularmultiplenodulesAbbreviations:HP�hypersensitivitypneumonitisHRCT�highresolutionCTILD�interstitiallungdiseaseLCH�LangerhanscellhistiocytosisLIP�lymphocyticinterstitialpneumonitisRB�respiratorybronchiolitisForthepurposesofthisreport,multinodulardiseasewillbedefinedinapatientinwhichtherearetoomanynodulestoeasilycountonroutineCTscanstudies,withmostofthesenodulesmeasuring�cmindiameterWhilethemostcommoncauseofmultiplepulmonarynodulesismetastaticdisease,itisapparentthatthisdefinitionencompassesawiderangeoflungdiseases,bothbenignandmalignantItisourcontentionthatuseofadedicateddiagnosticalgorithmbasedoncharacteristichighresolutionCT(HRCT)scanfeaturescoupledwithclinicalfindingscanprovideeitheraspecificdiagnosisoramarkedlyshortenedlistofdifferentialdiagnosesinamajorityofpatientspresentingwithdiffuselungnodulesAlgorithmOverviewDuetoitsabilitytoevaluatethelungparenchymaincrosssection,eliminatingthesuperimpositionofdensities,CTscanningoffersauniqueopportunitytoevaluatelungnodulesinexquisitedetailThisincludesfirsttheabilitytoassesslesionsbyanatomicdistribution,andsecondbymorphology–AnatomicLocalizationThisincludestheconsiderationofthefollowingpatterns:diffusevsfocalorclusteredcentral(peribronchovascular)vsperipheral(subpleuralorperifissural)anduppervslowerlungdistributionMostimportantly,nodulesalsoneedtobecharacterizedbytheirrelationtosecondarylobularanatomyallowingadistinctionbetweencentrilobularnodulesandthosethatpredominantlyinvolvethelobularperiphery,includingtheinterlobularsepta–(Fig)Forexample,diseasessuchassarcoidosisthatlocalizewithinoradjacenttolymphaticspredomi*FromtheDivisionofPulmonaryandCriticalCareMedicine(DrsRaoofandAmchentsev),NewYorkMethodistHospital,Brooklyn,NYtheDepartmentofRadiology(DrsVlahosandNaidich),TischHospital,NewYorkUniversityMedicalCenter,NewYork,NYandtheDepartmentofRadiology(DrGoud),BrighamandWomen’sHospital,Boston,MANofinancialorotherpotentialconflictsofinterestexistforanyoftheauthorsManuscriptreceivedJanuary,revisionacceptedJanuary,ReproductionofthisarticleisprohibitedwithoutwrittenpermissionfromtheAmericanCollegeofChestPhysicians(wwwchestjournalorgmiscreprintsshtml)Correspondenceto:SuhailRaoof,MD,FCCP,Chief,PulmonaryandCriticalCareMedicine,MedicalDirector,RespiratoryTherapyDepartment,NewYorkMethodistHospital,PulmonaryDivision,SixthSt,Brooklyn,NYemail:SurnyporgCHESTChestImagingforClinicianswwwchestjournalorgCHESTMARCH,byKimYongMionSeptember,wwwchestjournalorgDownloadedfromnateinthoseregionsinwhichlymphaticsaremostextensive,specificallyalongthepleuralandfissuralsurfaces,withintheinterlobularseptae,andalongtheperibronchovascularaxialinterstitium(Fig)Diseasesthatareprimarilyhematogenousinorigin,suchasmiliaryinfectionsorhematogenousmetastases,giverisetonodulesthatarerandomlydistributedthroughoutthesecondarylobule,withthegreatestprofusioninthelungbases(Fig)Thesepatternsareclearlyseparatefromnodulesthatresultfrominhalationaldisorderssuchasoccurinpatientswithendobronchialspreadofinfectionorhypersensitivitypneumonitis(HP),inwhichnodulesarepredominantlycentrilobularindistribution,sparingthelobularperiphery(Fig,)MorphologicCharacterizationThisincludesassessinganumberofcharacteristicsincludingwhethernodulesareasfollows:uniformorvariableinsizesharplyorpoorlymarginated–solidorsubsolidindensity(socalledgroundglassopacities)Figorhaveasocalledtreeinbudappearance(Fig)Additionally,nodulesmayeitherbecalcified,asoccursinfungaldisease,orcavitary,asisseen,forexample,inpatientswithsepticemboli,metastaticdisease,orLangerhanscellhistiocytosis(LCH)ItshouldbeemphasizedthatmanyofthesecharacteristicsarebestevaluatedonhighresolutionCTscanimagesWiththeintroductionofmultidetectorCTscanners,itisnowpossibletoroutinely,prospectivelyreconstructboththickandthinsectionsthroughthelungsafterasinglebreathhold,providedthattheinitialdataareacquiredusingappropriatelythincollimationThisapproachalsoenablestheuseofhighdefinition,multiplanarreconstructions,theuseofwhichmaybeofvalueinfurthercharacterizinglungnodulesMultinodularHRCTAlgorithm:AStepWiseApproachTheuseofthisalgorithmbeginsbydividingCTscansintotwobroadarmsbasedonthepresence(group)orabsence(group)ofpleuralorperifissuralinvolvement(Table)StepGroup:Thosecasesinwhichastrikingproportionofnodulesdemonstratepleuralorperifissuralinvolvementcharacterizenodulesaspredominantlyperilymphaticorlymphohematogenousinorigin,constitutingaseparatearmofthealgorithm(Table)TheexplanationforthispatternliesinthegreaterdensityoflymphaticchannelsseenintheinterlobuFigureSecondarylobularanatomyAsidebysidediagrammaticrepresentationoftwonormalsecondarypulmonarylobulesSecondarylobulesrepresentfundamentalanatomicunitsofthelungandaredefinedbycentrilobularstructures,includingpulmonaryarteriesarteriolesandtheiraccompanyingbronchibronchioles,andperipheralstructures,includingthepulmonaryveinsandlymphaticswithintheinterlobularseptaeAsshown,mostofthesestructuresare�mminsizeandtherefore,withtheexceptionofthecentrilobulararteries,liebelowtheresolutionofevenHRCTscansMostimportantly,notethatcentrilobularstructuresdonotextendtothepleuralorinterlobularseptalsurfacesAswillbeillustrated,knowledgeofbasiclobularanatomyisthekeytodifferentiatingbetweendifferentetiologiesofdiffusepulmonarynodulesFigurePerilymphaticdiseaseAdiagrammaticrepresentationofthecharacteristicdistributionoflungnodulesinpatientswithperilymphaticdiseaseNotethatnodulesarepreferentiallysubpleural,peribronchovascularwithintheaxialinterstitium,oralonglobularseptaeWhilethisappearanceisespeciallycharacteristicofnodularsarcoidosis,lesscommonlyasimilarpatternmayalsobeseeninpatientswithsilicosisorcoalworkerspneumoconiosisChestImagingforCliniciansbyKimYongMionSeptember,wwwchestjournalorgDownloadedfromlarseptaandsubpleuralregions,includingalongthefissuresStepOncenodulesarecharacterizedaspredominantlyperilymphaticorlymphohematogenousinorigin,furtherassessmentrequiresdeterminingwhetherornotnodulesaredistributeddiffuselyorarepatchyorclustered,withparticularattentionpaidtothepresenceorabsenceoftheextentofaxialinterstitialinvolvementItisrecalledthattheaxialinterstitiumenvelopsthemainpulmonaryvesselsandbronchiextendingfromthehilumoutwardtowardthelungperipheryStepIfnodulesprovetobeclusteredinapredominantlysubpleuralaxialdistribution,theyaredeemedtobeperilymphaticindistribution(Fig)Inthiscategory,themaindiseasetobeconsideredissarcoidosis(Fig,),,Thisdiagnosisisfurthersuggestedbynodulesthataretypicallyilldefined,frequentlymeasuringonlyafewmillimetersinsizeClustersofthesenodulesoftenhavea“grainy”appearanceandwhensufficientlyprofusemayresultinanappearanceofpoorlydefinednodulesormassesoncorrespondingchestradiographs(soFigureBronchiolardiseaseAdiagrammaticrepresentationofthetypicalappearanceofbronchiolarinflammationresultinginsocalledtreeinbudopacitiesThesecharacteristicallyresultinclustersofilldefinednodules“attached”toadjacentbranchingortubularstructuresduetoextensivebronchiolarmucoidimpactionMostimportantly,notethat,unlikethesituationinpatientswitheitherperilymphaticdiseaseorrandomnodules,mucoidimpactedbronchiolesdonotextendtothepleural,fissural,orseptalsurfaceThispatternisnearlyalwaysduetoinfectedsecretionsresultingfromvirtuallyanycauseofacuteorsubacutebronchiolarinfectionFigureRandomnodulesAdiagrammaticrepresentationofthecharacteristicdistributionofrandomlydistributednodulesinpatientswithlymphohematogenousdiseaseNotethatindistinctionwithpatientshavingpredominantlyperilymphaticdisease,randomnodulesmaybeenseenadjacenttoallsecondarylobularstructuresSomenodulesmayalsoappeartobeattachedtopulmonaryarterialbranches(socalledfeedingvessels)Randomnodulesaremostcommonlyduetometastaticdisease,andmayvaryconsiderablyinsizeandedgecharacteristicsThedifferentialdiagnosismostimportantlyincludesmiliaryinfectionLymphangiticcarcinomatosis,whilehematogenousinorigin,iseasilydistinguishedfromrandommetastaticnodulesbythepresenceofcharacteristicallythickenedinterlobularseptae,preferentiallyinvolvingthelungbases,andusuallyassociatedwithasymmetrichilaradenopathyandpleuraleffusionsFigureCentrilobulardiseaseAdiagrammaticrepresentationofthedistributionofdiseasesthatpredominantlyaffectthecentrilobularportionofsecondarylobules,excludingthosediseasesthatresultinpredominantlymucoidimpactionduetoinfectedsecretionsThemostcommoncauseofdiffusecentrilobulardiseaseissubacuteHPThischaracteristicallyresultsinpoorlydefined,poorlymarginatedgroundglassopacitiesSimilartotreeinbudopacities,theserarelyinvolvethepleuralorfissuralsurfacesWhileanumberofdifferententitiesmayresultinpredominantlycentrilobularopacities,thedifferentialdiagnosismostoftenincludesRBRBILDIndistinctionwithsubacuteHP,RBinparticularislessextensive,typicallyupperlobeindistribution,andalmostalwaysoccursinsmokerswwwchestjournalorgCHESTMARCH,byKimYongMionSeptember,wwwchestjournalorgDownloadedfromcalledalveolarsarcoid)Whencoalescent,thesemaysimulateprogressivemassivefibrosisAncillaryfindingsincludeapredominantupperlobedistribution,focalairtrappingduetobronchiolarobstruction,anddiffuseadenopathy,oftencalcifiedCalcifiednodulesmayalsobepresentinlaterstagesofthediseaseThemostimportantdifferentialdiagnosesforthispatternofdiseasearesilicosisandcoalworkerpneumoconiosis,Inbothoftheseoccupationaldiseases,perilymphaticnodulesaretheprimaryabnormality,typicallyinvolvingthemidandupperlungfieldsWhiletheseentitiesmaysimulatetheappearanceofsarcoidosis,theyareusuallyeasilydiagnosedwhencorrelatedwithclinicalhistoryThisincludesotherrareoccupationallungdisease,forexample,siderosis,thatmayalsosimulatetheappearanceofsarcoidosisWhilelymphangiticcarcinomatosismayresultinperilymphaticnodules,infact,CTscanfindingsaremostoftencharacterizedbymarkedlythickenednodularinterlobularseptaeusuallyasymmetricallyinvolvingthelowerlobesandusuallyassociatedwithadenopathyandeffusionsNodules,whenpresent,tendmoreoftentobewelldefinedandareoftenassociatedwithdiscretefeedingvessels,furtheridentifyingthemashematogenousinoriginLymphangiticcarcinomatosisrarelymimicsfindingsthatarecharacteristicofsarcoidosisStepIfnodulesprovetobediffuseinsteadofclustered,theyareproperlyconsideredtoberandomindistribution(Table)Bydefinition,truerandomdistributionwillleadtonodulesbeingidentifiedalongpleuralandfissuralsurfacesaswellasalongtheaxialFigurePerilymphaticdisease:sarcoidosisAnHRCTscanofammsectionatthelevelofthecarinashowsinnumerableilldefinedsmallnodulesclusteredinthemidportionsofbothlungswithrelativesparingoftheanterioraspectsofbothupperlobesNotethatthesepreferentiallyinvolvetheleftmajorfissure(arrowonleftlung)aswellasthewallsoftheperipheralairways(curvedarrowonrightlung)TableHRCTAlgorithmforMultinodularDisease**CWP�coalworkerspneumoconiosisMAI�MaviumintracellulareMTB�MtuberculosisPMF�progressivemassivefibrosisChestImagingforCliniciansbyKimYongMionSeptember,wwwchestjournalorgDownloadedfrominterstitiumHowever,indistinctionfromprimarilyperilymphaticdisease,randomnodulesmayalsobeidentifiedinevengreaternumberswhendispersedrandomlythroughoutthelungsIncludedinthiscategorymostimportantlyarehematogenousmetastasesUnlikenodulesinpatientswithsarcoidosis,metastaticnodulestendtobesmooth,welldefinedlesions(Fig,)However,awidevarietyofmorphologicappearanceshasbeennotedInastudycomparingtheHRCTscanfeaturesofpulmonarymetastaticlesionswithautopsyfindings,whilenodulesmostoftenprovedtohavewelldefinedmargins(ofcases),noduleswithwelldefinedirregularmargins,poorlydefinedsmoothmargins,andpoorlydefinedirregularmarginscouldbeidentifiedin,,andofcases,respectivelyWhilenodulesrangefromafewmillimetersto�cm,theyarefrequentlysimilarinsizeAbasilarpredominanceistypicallynotedduetopreferentialbloodflowtothelungbasesIndividualnodulesmayhave“feedingvessels”consistentwiththeirhematogenousoriginOnHRCTscans,aconnectionbetweennodulesandtheadjacentpulmonaryvessels(ie,themassvesselsign)maybeseeninapproximatelyofcasesNodulesmayalsobeeithercavitaryorsurroundedbya“halo”ofgroundglassattenuation,whichistypicalofhemorrhagicmetastasessuchasthoseduetochoriocarcinomaFeaturesoflymphangiticcancermayalsobepresent,whichagainisconsistentwithahematogenousoriginofdiseaseItshouldbenotedthatthereportedincidenceofmalignantdiseaseasacauseofmultiplepulmonarynoduleshasbeenshowntovarygreatly,fromaslowastoashighasinsomesurgicalseriesInpatientswithaknownmalignancywhounderwentvideoassistedthoracoscopyformultiplepulmonarynodules,provedtohaveatleastonemalignantnoduleAnumberofmalignanciescanresultinamiliarypattern,renderingdifferentialdiagnosismoreproblematicThisincludestumors,suchasrenalcellcarcinoma,headandneckcancers,andtesticulartumors,thathavetheirprimaryvenousdrainageinthelungsThedifferentialdiagnosisincludesanumberofadditionalentitiesthatresultinrandomnodulesThemostimportantoftheseismiliaryinfection(Fig),Infact,whiledifferentiationbetweenmiliaryinfectionandamiliarytumormaybeimpossibletodeterminebyimagingfeaturesalone,ingeneral,closecorrelationwiththeclinicalhistoryrendersthesediagnosesrelativelystraightforwardMiliarymetastasesarefrequentlyduetometastaticthyroidcancer,renalcancer,andmelanoma,amongothercancers,whilelargerlessprofusemetastasestendtobeadenocarcinomasinadults,typicallyoriginatingfromthelung,breast,ortheGItract,Lesscommonly,diffusenodulesmaybeidentifiedinpatientswithsepticemboli,invasivefungalinfections,andpulmonaryvasculitidesTheseentitiesfrequentlyresultincavitarynodules,somewithadistinct“halo”ofgroundglassattenuation,andhaveevenbeendescribedinpatientswithorganizingpneumoniaDespitesimilaritiesbetweentheseentitiesandroutinemetastaticdisease,itshouldbeemphasizedthatthenumbersofnodulesidentifiedinthesecasesusuallyfailtomeetthecriterionof“toomanynodulestocount,”withthedifferentialdiagnosisagainfurtheraidedbycloseclinicalcorrelationStepGroup:Indistinctionwiththepatternsdescribedinpatientsingroup,groupincludesthoseFigurePerilymphaticdisease:sarcoidosisAnHRCTscanofammsectionthroughtherightmidlunginadifferentpatientthantheoneinFigureshowsevidenceofinnumerableilldefinedsmallnodulesNotethatthesetendtobeclusteredwithrelativesparingoftherightupperlobeanteriorlyandclearlypreferentiallylieadjacenttotherightmajorfissure(arrow),alongpleuralsurfaces,andalongcentralvascularstructures(arrowheads)ThisdistributionofnodulesisrarelyseeninanyotherdiseasewwwchestjournalorgCHESTMARCH,byKimYongMionSeptember,wwwchestjournalorgDownloadedfrompatientsinwhomnoorveryfewnodulesareperifissuralorsubpleuralindistributionAnatomically,thesenodulesaregroupedtogetherasbeingcentrilobularindistributionBydefinition,theseentitiesprimarilyinvolvecentrilobularbronchiolesandortheiraccompanyingpulmonaryarterybranchesAnatomically,thesestructurestaperperipherally,stoppingtommshortofthepleuralorinterlobularseptalsurfacesandconsequentlyfailtoinvolvepleuralandfissuralsurfaces(Table)Aswillbediscussed,thesenodulestypicallyfallintothefollowingtwobroadcategories:thosewitha“treeinbud”configurationandthosethatappearasamorphous“groundglass”nodulesStepOncenodulesarecharacterizedasbeingprimarilycentrilobularindistribution,furtherassessmentrequiresdeterminingwhetherornotthesehaveatreeinbudconfigurationTreeinbudopacitiesarecharacterizedbytheappearanceofcentrilobularmicronodularbranchingstructuresthatendseveralmillimete

用户评价(0)

关闭

新课改视野下建构高中语文教学实验成果报告(32KB)

抱歉,积分不足下载失败,请稍后再试!

提示

试读已结束,如需要继续阅读或者下载,敬请购买!

文档小程序码

使用微信“扫一扫”扫码寻找文档

1

打开微信

2

扫描小程序码

3

发布寻找信息

4

等待寻找结果

我知道了
评分:

/13

肺内多发小结节鉴别

VIP

在线
客服

免费
邮箱

爱问共享资料服务号

扫描关注领取更多福利