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1、胸部常见CT征象认读,The Secondary Pulmonary Lobule肺小叶（直径1-2.5CM）,小叶支气管、终末细支气管,肺动脉pulmonary artery,小叶间隔interlobular septa,肺静脉pulmonary vein,腺泡pulmonary acini,正常HRCT.,中央肺动脉。,支气管与相邻肺动脉直径大致相等。,肺动脉常分为两个直径相当的分支。,肺静脉常分成许多细小的分支,这些分支与主支构成直角。,叶间裂（厚度小于1mm，边缘光滑，均一厚度）,常见伪影,双侧下肺近心脏处，肺血管脉动伪影。低密度区，可以错当作扩大的支气管。,常见伪影,主叶裂伪影。,常
2、见伪影,血管双重伪影。,正常小叶间隔normal septa,正常小叶中心动脉,正常小叶中心动脉centrilobular artery 2,肺静脉Pulmonary veins,肺间质病变,发生于：慢性间质性肺炎、弥漫性间质纤维化、结节病、癌性淋巴管炎、结缔组织病（红斑狼疮、类风湿性关节炎、硬皮病、皮肌炎）、尘肺（矽肺、煤矽肺、石棉肺）、组织细胞病、淋巴管平滑肌瘤病。：界面征、小叶间隔增厚、小叶中心结构增厚、胸膜下线、长疤痕线（扭曲肺结构）、蜂窝样改变、结节影、牵拉性支扩、磨玻璃样改变。,Case 1 F/60y 乳腺癌术后，现呼吸困难。,分析：（1）小叶间隔增厚,分析：（2）支气管血管周围
3、间质增厚,支气管袖口症：,分析：(3)斜裂增厚,分析：（4）大结节影,网状阴影：病理上主要为小叶间隔增厚、小叶内间隔增厚、小叶核心增厚、胸膜下线影、蜂窝肺和支气管血管周围间质增厚等改变。可见于特发性间质性肺炎、结节病、癌性淋巴管炎、特发性含铁血黄素沉积、感染性疾病等。双肺网状阴影多见与特发性间质性肺炎、结缔组织病肺浸润、结节病等。单侧以癌性淋巴管炎和放射性肺炎为主。,上病例为癌性淋巴管炎。,Case 2 79岁、淋巴瘤病史,小叶间隔增厚？,(a)Yes(b)No,双侧光滑增厚的小叶间隔,支气管血管间质是否增厚？,(a)Yes(b)No,增厚的支气管血管间质,胸膜下间质增厚？,(a)Yes(b)
4、No,斜裂增厚,What is the most likely diagnosis?最可能的诊断？(a)Pulmonary edema(肺水肿）(b)Interstitial fibrosis（间质纤维化）(c)Lymphangitic spread of lymphoma（癌性淋巴管炎）,Diagnosis:Lymphangitic spread of lymphoma,with interlobular septal thickening。癌性淋巴管炎（小叶间隔增厚）,lymphocytic interstitial pneumonitis(LIP),淋巴间质局限性肺炎,Case 3 58
5、-year-old man with heart disease,小叶间隔增厚？(a)Yes(b)No,双侧小叶间隔增厚,支气管血管间质增厚？(a)Yes(b)No,支气管血管间质增厚,Is there thickening of the subpleural interstitium?(胸膜下间质增厚？)(a)Yes(b)No,NO!,What is the most likely diagnosis?(最可能的诊断？)(a)Pulmonary edema肺水肿(b)Interstitial fibrosis间质纤维化(c)Lymphangitic spread of carcinoma癌性
6、淋巴管炎,(a)Pulmonary edema肺水肿Correct.Because of the history of heart disease心脏病史,characteristic abnormalities典型的异常,ymmetry对称,and the predominance of septal thickening in dependent lung,this diagnosis must be considered 考虑most likely.,文献：间质性肺水肿,（1）肺血重新分布：左心衰-肺淤血。（2）支气管周围袖口症：正常厚度约1mm结缔组织内液体存积增厚。X-肺纹理及肺门血
7、管增粗、模糊.（3）肺透过度下降：液体分布到支气管血管周围、小叶间隔、小叶内支气管血管周围、肺泡间隔透过度下降。（4）间隔线：Kerley B线x上与肋膈角处与胸膜垂直。（5）胸膜增厚：液体入脏层胸膜下薄层结缔组织胸膜下结缔组织水肿-水肿位于脏层胸膜与结体组织间，不随体位移动。（）胸腔积液：胸膜腔内液体来自壁层胸膜。,不同原因的肺水肿,心源性肺水肿：左心衰（见于心梗、二尖瓣病变。肾性肺水肿：急慢性肾功能衰竭，可合并尿毒症水钠潴留、左心衰肺水肿上腔静脉、奇静脉增宽。肺微血管损伤性肺水肿：除肺水肿外，还可见出血及细胞渗出 肺血分布正常、无袖口症、间隔线。肺泡实变斑片状，肺野外为分布。毒性气体吸入、
8、胃液吸入、药物、溺水、颅内压升高、高原性肺水肿、复张性肺水肿。,Case 4 a 53-year-old woman with and abnormal chest radiograph and mild shortness（短缺）of breath（异常胸片，气短）,Is septal thickening present?(a)Yes(b)No小叶间隔增厚吗？,增厚的小叶间隔,Are the septa smooth or nodular in appearance?(a)Smooth(b)Nodular小叶间隔增厚是结节状还是光滑增厚？,小叶间隔结节状增厚,胸膜下间质结节影,支气管袖口症
9、,Possible diagnoses include:(a)pulmonary edema肺水肿(b)interstitial fibrosis间质纤维化(c)sarcoidosis结节病最可能的诊断？,sarcoidosis结节病Correct.Nodular thickening of interlobular septa and fissures can be seen in this disease and lymphangitic spread of carcinoma.（小叶间隔结节状改变可见于结节病、癌性淋巴管炎、尘肺）。支气管血管间质、胸膜下间质结节状改变对结节病有特征性的诊
10、断。,Case 5 a 42-year-old man with mild shortness of breath for a number of years（气促多年）,Is septal thickening visible?(a)Yes(b)NoNext Page 小叶间隔增厚吗？,增厚的小叶间隔,扭曲的肺结构,叶间裂的扭曲,Diagnosis:End-stage sarcoidosis with fibrosis and interlobular septal thickening.结节病伴随征象：肺结构扭曲、小叶间隔结节状增厚、牵拉性支扩、蜂窝肺等。,文献：肺间质病变,界面征：支气管
11、血管间质增厚支气管血管束增粗、支气管袖口症；液体边缘光滑、肿瘤或肉芽组织结节状界面。胸膜下线：近胸膜面1cm内弧线状影为肺纤维化征象。长疤痕线：蜂窝肺：结节影：小结节2-5mm，肉芽、肿瘤、纤维组织。肺结构扭曲变形及牵拉支扩：磨玻璃样改变：,Case 6 a 68-year-old woman with rheumatoid arthritis（风湿性关节炎）and progressive 累计shortness 短缺of breath over a 2-year period,The predominant abnormal finding on these scans is?(a)inte
12、rlobular septal thickening小叶间隔增厚。(b)honeycombing蜂窝肺主要的异常表现？,蜂窝肺,部分层面小叶间隔增厚,What does honeycombing reflect histologically?(a)Interstitial edema肺间质水肿(b)Interstitial infiltration 渗透by cells(c)Interstitial fibrosis蜂窝肺的组织学肺间质纤维化的后期表现。,Diagnosis:Rheumatoid lung disease,with fibrosis and honeycombing.风湿性肺疾
13、病，肺纤维化、蜂窝肺。壁厚0.8-1MM，胸膜下3-4cm范围内或近叶裂处；早期囊腔小而少；囊壁为折叠破坏的肺泡壁及气道壁。,Case 7 a 74-year-old woman with progressive shortness of breath over 6 months,The most significant abnormal finding in this study is:(a)interlobular septal thickening小叶间隔增厚(b)honeycombing蜂窝肺(c)subpleural emphysema胸膜下肺气肿主要的异常表现？,蜂窝肺,What
14、is the most likely diagnosis?(a)Idiopathic pulmonary fibrosis(IPF)特发性肺间质纤维化(b)Autoimmune disease(e.g.,rheumatoid lung disease)自身免疫性疾病(c)End-stage hypersensitivity pneumonitis过敏性肺炎(d)Asbestosis石棉肺(e)Drug-related lung injury麻醉药物肺损害(f)Sarcoidosis结节病最可能的诊断？,IPF:特发性肺间质纤维化,磨玻璃密度：肺野周围活动性肺泡炎症。网状改变：小叶间隔、小叶中心
15、结构增厚蜂窝状改变的前期。蜂窝状改变：胸膜下间质纤维化：胸膜下弧线状影、脏层胸膜及叶间胸膜增厚。肺气肿：小叶中心型肺气肿。肺实变：支扩：,蜂窝肺,牵拉性支扩,小叶间隔增厚,Case 8 86-year-old man with chronic myelogenous leukemia骨髓性的白血病,treated using methotrexate化疗,now complains of shortness of breath 气短.,Does this man show evidence of fibrosis and UIP?(a)Yes(b)No显示明显的纤维化和普通间质性肺炎？屑性间质
16、性肺炎（DIP）、普通性间质性肺炎（UIP）。,(a)YesCorrect.Findings indicative of usual interstitial pneumonitis(UIP)visible in this patient include:honeycombing;蜂窝肺irregular fissures;叶裂扭曲irregular interlobular septal thickening;小叶间隔不规则增厚。traction bronchiectasis.牵拉性支扩,蜂窝肺,叶裂扭曲,不规则小叶间隔增厚,牵拉性支扩,The most likely diagnosis i
17、s:可能的诊断？(a)idiopathic pulmonary fibrosis(IPF)(b)lung involvement by leukemia白血病肺浸润。(c)drug-related lung injury化疗药物肺损害。,(c)drug-related lung injuryCorrect.The pattern of fibrosis seen in this patient is nonspecific,and could be caused by IPF.The recent history of treatment with methotrexate makes dru
18、g-related fibrosis most likely.Lung involvement by leukemia would likely result in an appearance similar to that of lymphangitic spread of carcinoma with septal thickening being the predominant finding.IPF一可有同种表现，但患者有最近化疗史，白血病肺浸润小叶间隔增厚明显。,Case 9 in a 63-year-old man with a history of scleroderma硬皮病
19、and progressive shortness of breath进行性喘憋,Findings include:interlobular septal thickening;小叶间隔增厚。traction bronchiectasis;牵拉性支扩subpleural honeycombing;胸膜下蜂窝肺irregular fissures.叶裂扭曲,小叶间隔增厚,牵拉性支扩,胸膜下蜂窝肺,斜裂扭曲,Can you be confident that lung fibrosis is present?(a)Yes(b)No你能确定肺纤维化存在？,YesCorrect.The presenc
20、e of honeycombing is diagnostic of fibrosis.Traction bronchiectasis is also strongly suggestive of fibrosis.Interlobular septal thickening and irregular fissures are nonspecific,and cannot be relied upon to diagnose fibrosis.蜂窝肺、牵拉性支扩肺纤维化存在。小叶间隔增厚、斜裂扭曲对肺纤维化的诊断意义不大。,Diagnosis:Scleroderma,with lung fi
21、brosis,honeycombing,and traction bronchiectasis 硬皮病肺纤维化：蜂窝肺、牵拉性支扩。结缔组织病及肺血管炎主要为肺间质病变。肺内实变肺泡内渗出、肉芽肿形成、肺泡内出血、水肿。肺内多发结节肺内血管炎、肉芽肿、肺栓塞所形成。常见于：wengner类风湿性关节炎。肺间质病变肺间质性肺炎、肺泡炎间质纤维化、蜂窝肺。,Case 10 in a 61-year-old woman with progressive shortness of breath进行性喘憋.,Which of the following findings are shown on thi
22、s scan?上图包含症像:(a)Honeycombing蜂窝肺(b)A subpleural line胸膜下线(c)A peripheral and subpleural distribution外围胸膜下分布(d)All of the above以上全包括,All of the aboveCorrect.Small subpleural cysts are present typical of mild honeycombing.轻度的蜂窝肺An irregular line parallels the pleural surface,termed a subpleural line.胸膜
23、下线,Which of the following is most likely in this case?最符合的诊断？(a)Idiopathic pulmonary fibrosis(IPF)特发性间质纤维化(b)Autoimmune disease(e.g.,rheumatoid lung disease)自身免疫性疾病(c)End-stage hypersensitivity Pneumonitis过敏性肺炎(d)Asbestosis石棉肺(e)Drug-related lung injury药物肺损害(f)Sarcoidosis结节病,Idiopathic pulmonary fib
24、rosis(IPF)Correct.Idiopathic pulmonary fibrosis(IPF).In the absence a history to suggest one of the specific diagnoses on this list,IPF is most likely.It accounts for 60%of cases having this appearance.IPF在该病例无特异性，60%有该表现。,Case 11 a 34-year-old man with progressive shortness of breath喘憋,The predomin
25、ant abnormality in this case is:明显的异常表现(a)honeycombing蜂窝肺(b)intralobular interstitial thickening小叶间质增厚,intralobular interstitial thickeningCorrect.Honeycombing is not visible in this patient.A fine irregular reticular不规则的网状改变pattern is present in the lung periphery,representing intralobular intersti
26、tial thickening.小叶间质增厚 In some patients with pulmonary fibrosis,this finding will predominate.Other findings of fibrosis in this patient include traction bronchiectasis.牵拉性支扩 The differential diagnosis of this appearance is identical as that for honeycombing.,小叶间质增厚,牵拉性支扩,Diagnosis:Idiopathic pulmon
27、ary fibrosis特发性间质纤维化,with intralobular interstitial thickening.,Case 12 a 71-year-old man with progressive shortness of breath,The predominant abnormality in this case is:突出的表现(a)honeycombing蜂窝肺(b)intralobular interstitial thickening小叶间质增厚,intralobular interstitial thickeningCorrect.Honeycombing is
28、not clearly seen in this patient.A fine but irregular reticular pattern不规则的网状改变 is present in the lung periphery外围,representing intralobular interstitial thickening小叶间质增厚.In some patients with pulmonary fibrosis,this finding will predominate.Other findings 其他征象of fibrosis in this patient include tra
29、ction bronchiectasis牵拉性支扩,and irregular interlobular septal thickening不规则小叶间隔增厚.The differential diagnosis of this appearance is identical to that for honeycombing.,小叶间质增厚,牵拉性支扩,不规则小叶间隔增厚,Diagnosis:Idiopathic pulmonary fibrosis特发性间质纤维化,with intralobular interstitial thickening.,Case 13 34-year-old w
30、oman with lupus erytematosus 狼疮红斑,Can you diagnose fibrosis?能诊断纤维化？(a)Yes(b)No,YesCorrect.HRCT obtained in the supine and prone positions 仰卧和俯卧位shows a number of findings indicating fibrosis指示,including:honeycombing which is mild in degree;轻度蜂窝肺traction bronchiectasis;牵拉性支扩intralobular interstitial
31、thickening;小叶间质增厚interlobular septal thickening小叶间隔增厚;and a subpleural distribution.胸膜下分布,轻度蜂窝肺,牵拉性支扩,小叶间质增厚,小叶间隔增厚,Diagnosis:Systemic lupus erythematosus（SLE系统性红斑狼疮肺部表现肺结缔组织病,with fibrosis and honeycombing.,Case 14 a 65-year-old woman with rheumatoid arthritis风湿性关节炎 and mild dyspnea 轻度呼吸困难,Can you
32、diagnose fibrosis?能诊断纤维化？(a)Yes(b)No,Correct including:traction bronchiectasis;牵拉性支扩 intralobular interstitial thickening;小叶间质增厚 a subpleural line.胸膜下线,牵拉性支扩,小叶间质增厚,胸膜下线,Diagnosis:Rheumatoid lung disease肺结缔组织病,with mild pulmonary fibrosis轻度肺纤维化 and intralobular interstitial thickening小叶间质增厚.,Case 15
33、 a 26-year-old woman with mixed connective tissue disease混合结缔组织病,basilar crackles on physical examination双肺底水泡音,and restrictive disease on pulmonary function tests 肺功能受限,Can you diagnose fibrosis?能诊断纤维化？(a)Yes(b)No,YesCorrect.Including:traction bronchiectasis;牵拉性支扩intralobular interstitial thickenin
34、g小叶间质增厚;a subpleural distribution胸膜下分布,牵拉性支扩,小叶间质增厚,Diagnosis:Mixed connective tissue disease混合结缔组织病,with pulmonary fibrosis,and intralobular interstitial thickening,Case 16 a 81-year-old man with significant occupational exposure to asbestos 石棉职业史,Is pulmonary fibrosis present?肺纤维化存在？(a)Yes(b)No,Ye
35、sCorrect.Findings of fibrosis include:traction bronchiectasis;牵拉性支扩intralobular interstitial thickening;小叶间质增厚a subpleural distribution.胸膜下分布irregular interlobular septal thickening不规则的小叶间隔增厚,牵拉性支扩,小叶间质增厚,胸膜下分布,小叶间隔增厚,Diagnosis:石棉肺Asbestosis with traction bronchiectasis 牵拉性支扩and intralobular interst
36、itial thickening小叶间质纤维化.,纵隔窗,pleural thickening and calcification 胸膜增厚、钙化,椎旁区域,横膈胸膜肥厚钙化,Case 17 a 58-year-old man with a history of asbestos exposure石棉史,可见椎旁胸膜增厚、不规则线状影,The pleural thickening is typical of asbestos exposure胸膜增厚是典型的石棉肺表现.Would you diagnose asbestosis诊断石棉肺吗?(a)Yes(b)No,NoCorrect.Linea
37、r opacities线状影 as seen in this case(termed parenchymal bands肺实质带)are common in patients with pleural thickening胸膜增厚,but are not necessarily associated不必须考虑 with lung fibrosis肺纤维化.,肺实质带parenchymal bands,位于下肺部，肺内条状影；肺实质内的纤维化。,尽管如此，结合病史，考虑Asbestos exposure with pleural disease and parenchymal bands 石棉至
38、椎旁胸膜增厚、肺实质带。,Case 18 a 67-year-old man with a history of asbestos exposure 石棉史,NoCorrect.HRCT at lung windows shows irregular linear opacities不规则的线状影(“crows feet”乌鸦脚),without evidence of honeycombing无蜂窝肺,intralobular interstitial thickening小叶间质增厚,or traction bronchiectasis牵拉性支扩.This appearance does
39、not indicate asbestosis无石棉特征.Linear opacities,as seen in this case(parenchymal bands肺实质带)are common in patients with pleural thickening related to asbestos exposure,but are not necessarily associated with lung fibrosis不必须考虑肺纤维化.They represent focal areas of atelectasis焦点为肺膨胀不全,associated 联系with the
40、pleural thickening,or focal areas of scarring焦点区疤痕.,乌鸦脚（crows feet),即,尽管如此，结合病史考虑Asbestos exposure with pleural disease and parenchymal bands。另一病例：胸膜下线椎旁胸膜增厚,Case 19 a 56-year-old man with significant occupational exposure to asbestos 石棉史,Is there pleural thickening 胸膜增厚you would consider考虑 likely 可
41、能due to asbestos exposure石棉?(a)Yes(b)No,Yescorrect.A focal焦点,calcified pleural plaque胸膜钙斑 is visible anteriorly,typical of asbestos exposure石棉肺典型表现.Although plaques are more likely posterior in location常见后胸膜,this appearance is highly suggestive高度提示.,Can a definite diagnosis of pulmonary fibrosis on
42、the prone lung window scans be made?肺窗能明确诊断肺纤维化吗？(a)Yes(b)No,NoCorrect.There is mild septal thickening 轻度间隔增厚and reticulation 网状in the posterior subpleural region后胸膜下 on the right.This is unassociated 无联系with adjacent临近 pleural thickening.This is a very subtle abnormality轻微的异常 which could represent
43、the earliest stage of asbestosis石棉肺早期表现.However,in the absence of a more definite abnormality明确的异常 or similar 类似findings on the left,it would be difficult 困难to make a definite diagnosis of fibrosis石棉肺或肺纤维化的诊断 or asbestosis.,小叶间质增厚轻度网状改变,Diagnosis:Asbestosis exposure石棉肺.Possible fibrosis可能纤维化.文献：石棉肺1
44、胸膜改变：胸膜斑、弥漫性胸膜增厚、胸腔积液。2肺改变：弥漫性肺间质纤维化HRCT胸膜下弧线、胸膜下点状致密影、肺实质带、蜂窝状改变、胸膜下磨玻璃表现（肺泡壁小叶间隔增厚）；圆形肺不张（支气管血管结构进入-彗星尾征）。,Case 20 a 57-year-old woman with years of progressive dyspnea 多年呼吸困难,Is pulmonary fibrosis present?肺纤维化存在吗？(a)Yes(b)No,YesCorrect.This patient shows a number of许多 findings indicative of pulmo
45、nary fibrosis肺纤维化征象.These include:Extensive 广泛的traction bronchiectasis 牵拉性支扩involving both upper lobes双上叶;Irregular reticular opacities不规则的网状 and distortion of lung architecture肺结构扭曲 associated with traction bronchiectasis;and Honeycombing at the lung bases下肺蜂窝状改变。,牵拉性支扩,扭曲的肺结构,蜂窝肺,Is the distributi
46、on of abnormalities typical of idiopathic pulmonary fibrosis?特发性间质纤维化的异常类型？(a)Yes(b)No,NoCorrect.With exception of the posterior honeycombing后部蜂窝肺,the findings of fibrosis in this patient lack the peripheral不在外围,lower lobe,and subpleural predominance 胸膜下of IPF.These findings are typical 典型of end-sta
47、ge sarcoidosis.,Diagnosis:End-stage sarcoidosis结节病,with traction bronchiectasis 牵拉性支扩and honeycombing蜂窝肺.,DISCUSSIONIn patients with sarcoidosis结节病,progressive fibrosis often leads 累计纤维化常导致to peribronchovascular conglomerate masses of fibrous tissue支气管血管束聚集成纤维块,typically most marked in the upper lob
48、es上叶显著.Bronchi and vessels are clustered together because of retraction,and bronchi appear dilated(i.e.traction bronchiectasis);the only other diseases that commonly result in this appearance are silicosis,tuberculosis,and talcosis.Posterior displacement of the upper lobe bronchi indicating volume l
49、oss in the posterior segments of the upper lobes is a common early finding.Honeycombing or lung cysts can be present in patients with sarcoidosis,but this finding is less common than in other fibrotic lung diseases such as idiopathic pulmonary fibrosis.Honeycombing is usually limited to patients with severe fibrosis and central conglomeration of bronchi.The honeycombing seen in patients with sarcoidosis involves mainly the middle and upper lung zones,with relative sparing of the lung bases.However,in an occasional case,findings can mimic IPF.,支气管血管束聚集成纤维块,
