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1、Solitary pulmonary nodule:benign versus malignant 孤立性肺结节：良性孤立性肺结节：良性(lin(lin xn xn)与与恶性对比恶性对比第一页，共三十一页。n nThe differential diagnosis of a solitary pulmonary nodule is The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is broad and manageme
2、nt depends on whether the lesion is benign or malignant.benign or malignant.n n孤立性肺结节的鉴别诊断是很多的，处理方法依赖于该病孤立性肺结节的鉴别诊断是很多的，处理方法依赖于该病变是良性还是恶性变是良性还是恶性In this overview we will discuss some of the new features that In this overview we will discuss some of the new features that can help to differentiate bet
3、ween benign and malignant nodules can help to differentiate between benign and malignant nodules based upon CT and PET-CT findings.based upon CT and PET-CT findings.n n在此篇文章，我们着重讨论在此篇文章，我们着重讨论(t(t oln)oln)下一些有助于鉴别良恶下一些有助于鉴别良恶性结节的新特征，此特征是基于性结节的新特征，此特征是基于CTCT与与PET-CTPET-CT的检查结果的检查结果第二页，共三十一页。CT:benign
4、 versus malignantn nCalcificationCalcification n nSize Size n nGrowthGrowth n nShape n nMargin n nAir Bronchogram signAir Bronchogram sign n nSolid and Ground-glass componentsSolid and Ground-glass components n nContrast enhancementContrast enhancement 第三页，共三十一页。CT:良性良性(lin(lin xn xn)与恶性与恶性n n钙化n n大
5、小n n生长速度n n形状(xngzhun)(xngzhun)n n边缘n n支气管含气征n n实性或磨玻璃样n n增强特征第四页，共三十一页。Calcification 钙化钙化(gihu)(gihu)n nDiffuse,central,laminated or popcorn calcifications are benign patterns of calcification.n n弥漫性，中心(zhngxn)(zhngxn)性，分层，爆米花钙化是良性钙化，第五页，共三十一页。n nThese types of calcification are seen in granulomato
6、us disease and hamartomasn n这些(zhxi)(zhxi)形式的钙化最常见于错构瘤、肉芽肿性病变第六页，共三十一页。n nThe 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 pa
7、ttern can be seen in patients with GI-tumors and patients who previously had chemotherapy.n n一些病人一些病人(bngrn)(bngrn)有原发肿瘤病史，可以表现为良性钙化有原发肿瘤病史，可以表现为良性钙化n n例如骨肉瘤、软骨肉瘤可以表现弥漫性钙化。n n胃肠间质瘤的病人化疗后可以表现为中心性或苞米花钙化。第七页，共三十一页。Size 大小大小(dxi(dxi o)o)n nA solitary pulmonary nodule(SPN)is defined as a single A solitar
8、y pulmonary nodule(SPN)is defined as a single intraparenchymal lesion less than 3 cm in size and not associated intraparenchymal lesion less than 3 cm in size and not associated with atelectasis or lymphadenopathy.with atelectasis or lymphadenopathy.A lesion greater than 3 cm in diameter is called a
9、 mass.A lesion greater than 3 cm in diameter is called a mass.孤立性结节定义孤立性结节定义(dngy)(dngy)为小于为小于3cm3cm，不伴有肺不张、淋巴结，不伴有肺不张、淋巴结转移，大于转移，大于3cm3cm的为肿块的为肿块n nThis distinction is made,because lesions greater than 3 cm are This distinction is made,because lesions greater than 3 cm are usually malignant,while s
10、maller lesions can be either benign or usually malignant,while smaller lesions can be either benign or malignant.malignant.n n以3cm为界，因为大于3cm的通常是恶性的，而小于3cm的可能是良性或恶性。第八页，共三十一页。Relationship between SPN-size and chance of malignancy in patients with high risk for lung cancer结节结节(ji ji)(ji ji)大小与恶性度具有密切相
11、关大小与恶性度具有密切相关性性第九页，共三十一页。Growth 生长(shngzh(shngzh ng)ng)速度n nComparison 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.n n与前次影像结果相比是鉴别孤立性结节良恶性的一个非常有用(y(y u ynu yn)的方法。如果
12、超过2年以上保持不变，这个结节就是良性结节第十页，共三十一页。Shape 形态(xngti)(xngti)n nJapanese screening studies showed that a polygonal shape Japanese screening studies showed that a polygonal shape and a three-dimensional ratio 1.78 was a sign of benignity and a three-dimensional ratio 1.78 was a sign of benignity(2,3).(2,3).日
13、本日本(r bn)(r bn)的一项研究表明，多变形和三维立体比率大的一项研究表明，多变形和三维立体比率大于于1.781.78是良性结节的标志是良性结节的标志n nA polygonal shape means that the lesion has multiple facets A polygonal shape means that the lesion has multiple facets(multi-sided).(multi-sided).多边形意味这个病灶具有多个面多边形意味这个病灶具有多个面A peripheral subpleural A peripheral subple
14、ural location was also a sign of benignity in this study location was also a sign of benignity in this study n n在这项研究中，周围的胸膜下的病变也是良性结节的一在这项研究中，周围的胸膜下的病变也是良性结节的一个标志个标志第十一页，共三十一页。n nThe three-dimensional ratio is measured by obtaining the maximal transverse dimension and dividing it by the maximal ver
15、tical dimension.A large three-dimensional ratio indicates that the lesion is relatively flat,which is a benign sign.第十二页，共三十一页。Margin 边缘(binyun)(binyun)n nCorona radiata sign-highly associated with malignancy(figure)放射(fngsh)(fngsh)冠征n nLobulated or scalloped margins-intermediate probability 分叶征和锯齿征
16、第十三页，共三十一页。n nSmooth margins-more likely benign unless metastatic in origin n n边缘光滑见于良性(lin(lin xn xn)结节，除外转移瘤第十四页，共三十一页。Air Bronchogram sign空气(kngq)(kngq)支气管征n nRecent studies have showed that an air bronchogram is more commonly seen in malignant pulmonary nodules.It is most commonly seen in BAC(br
17、onchoalveolar cell carcinoma)and adenocarcinoma.n n最近一项研究表明，在恶性结节中经常看见(kn jin)(kn jin)空气支气管征，主要见于支气管肺泡癌或腺癌第十五页，共三十一页。n nThe 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.第十六页，共三
18、十一页。n nOn the left two solitary pulmonary nodules.Based upon the morphology,which lesion has the most malignant features?n n下列两个结节有哪些恶性(xng)(xng)特征呢第十七页，共三十一页。n nThe lesion on the far left has a spicuated margin and has The lesion on the far left has a spicuated margin and has lucencies within it.lu
19、cencies within it.The lesion next to it is lobulated in contour and has some The lesion next to it is lobulated in contour and has some spicules radiating to the pleura.spicules radiating to the pleura.It is however homogeneous in attenuation.It is however homogeneous in attenuation.Based on these f
20、indings we should be most concerned that Based on these findings we should be most concerned that the lesion on the far left is malignant.the lesion on the far left is malignant.It proved to be an adenocarninoma,while the other one It proved to be an adenocarninoma,while the other one was a fungal i
21、nfection.was a fungal infection.The lucencies and frank air bronchograms should not The lucencies and frank air bronchograms should not mislead you in thinking that it probably is infection.mislead you in thinking that it probably is infection.第十八页，共三十一页。Solid and Ground-glass components实性与磨玻璃(b l)(
22、b l)样n nAnother result from screening studies is that nodules containing a Another result from screening studies is that nodules containing a ground-glass component are more likely to be malignant(5).ground-glass component are more likely to be malignant(5).n n另一项研究表明，含有磨玻璃样密度的结节很可能是恶性结节。另一项研究表明，含有磨
23、玻璃样密度的结节很可能是恶性结节。n nPartly solid lesions with ground-glass components had a malignancy Partly solid lesions with ground-glass components had a malignancy rate of 63%.rate of 63%.部分部分(b fen)(b fen)实性和磨玻璃样密度是恶性结节的可能性实性和磨玻璃样密度是恶性结节的可能性事事63%63%n nNonsolid-only ground-glass lesions had a malignancy rate
24、of 18%.Nonsolid-only ground-glass lesions had a malignancy rate of 18%.完全磨完全磨玻璃样密度结节玻璃样密度结节16%16%是恶性结节是恶性结节n nOnly solid lesions had a malignancy rate of only 7%.Only solid lesions had a malignancy rate of only 7%.完全实性结节完全实性结节是仅是仅7%7%是恶性结节是恶性结节第十九页，共三十一页。n nPartly solid nodule containing ground-glas
25、s component most likely to be malignant第二十页，共三十一页。n nOn 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-gla
26、ss and solid components.第二十一页，共三十一页。n nLEFT:1 in 5 malignant左边(zu(zu bian)bian)图是5个病灶1个为恶性结节n nRIGHT:2 in 3 malignantn n右边图是3个病灶2个为恶性结节第二十二页，共三十一页。Contrast enhancement对比(dub(dub)增强n nContrast enhancement less than 15 HU has a very high predictive value for benignity(99%).After a baseline scan,4 cons
27、ecutive scans at 1 minute interval are performed.对比增强(zngqing)(zngqing)小于15HU是良性病变的可能性（99%）第二十三页，共三十一页。n nThis applies only for nodules with the following selection criteria:n nNodule 5mm 结节大于5mmn nRelatively spherical 相对圆形n nHomogeneous,no necrosis,fat or calcificationn n均匀，无坏死(hui s(hui s)、钙化 n nN
28、o motion or beam hardening artifacts n n没有运动、硬射线伪影第二十四页，共三十一页。PET-CT:benign versus malignantn n PET-CT plays an increasingly important role in the evaluation of solitary nodules.n nPET-CT在肺结节的评价(pngji)(pngji)中起着很重要作用第二十五页，共三十一页。n nPET has a very high sensitivity 95%,but a lesser specificity PET has
29、a very high sensitivity 95%,but a lesser specificity of only 81%of only 81%n nPETPET有很高的敏感性有很高的敏感性95%95%，但特异性仅为，但特异性仅为81%81%n nPET is false positive in granulomatous disease PET is false positive in granulomatous disease n nPETPET是假阳性在炎症性疾病中国是假阳性在炎症性疾病中国n nPET is usually false negative in size 10 mm
30、 and low-grade PET is usually false negative in size 10 mm and low-grade malignancy including bronchoalveolar carcinoma and malignancy including bronchoalveolar carcinoma and carcinoid carcinoid n n当病变小于19 mm时或低度恶性时，PET表现为假阴性(ynxng)(ynxng)，包括支气管肺泡癌和类癌第二十六页，共三十一页。False negative PET in a patient with
31、adenocarcinoma.Activity is not sufficient for the diagnosis malignancy.第二十七页，共三十一页。Conclusion结论(jiln)(jiln)n nIn 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-gla
32、ss opacity,air bronchograms or cavities and the three-dimensional ratios of a lesion.n n在肺结节的鉴别(jinbi)(jinbi)诊断中，一些征象将被增加，包括磨玻璃密度、空气支气管征、空洞及三维立体比率第二十八页，共三十一页。n nWith 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 prevalenc
33、e of infectious and non-infectious granulomatous disease in the area that we practice.n n我们应该充分意识到PET-CT的重要性，在实践诊断(zhndun)(zhndun)中应该注意感染性与 非感染性疾病的流行情况第二十九页，共三十一页。Referencesn nCT Screening for Lung Cancer:Five-year Prospective ExperienceCT Screening for Lung Cancer:Five-year Prospective Experience S
34、tephen J.Swensen et al Stephen J.Swensen et al Radiology 2005;235:259-265.Radiology 2005;235:259-265.n nIndeterminate Solitary Pulmonary Nodules Revealed at Population-Based CT Screening of Indeterminate Solitary Pulmonary Nodules Revealed at Population-Based CT Screening of the Lung:Using First Fol
35、low-Up Diagnostic CT to Differentiate Benign and Malignant the Lung:Using First Follow-Up Diagnostic CT to Differentiate Benign and Malignant LesionsLesions Shodayu Takashima et al.Shodayu Takashima et al.AJR 2003;180:1255-1263 AJR 2003;180:1255-1263 n nSmall Solitary Pulmonary Nodules(1 cm)Detected
36、 at Population-Based CT Screening for Lung Small Solitary Pulmonary Nodules(1 cm)Detected at Population-Based CT Screening for Lung Cancer:Reliable High-Resolution CT Features of Benign LesionsCancer:Reliable High-Resolution CT Features of Benign Lesions Shodayu Takashima et al.Shodayu Takashima et
37、al.AJR 2003;180:955-964 AJR 2003;180:955-964 n nCT Screening for Lung Cancer Frequency and Significance of Part-Solid and Nonsolid NodulesCT Screening for Lung Cancer Frequency and Significance of Part-Solid and Nonsolid Nodules Claudia I.Henschke et alClaudia I.Henschke et alAJR 2002;178:1053-1057 AJR 2002;178:1053-1057 第三十页，共三十一页。内容(nirng)总结Solitary pulmonary nodule:benign versus malignant 孤立性肺结节(ji ji)：良性与恶性对比。右边图是3个病灶2个为恶性结节(ji ji)。178:1053-1057第三十一页，共三十一页。