肺毛玻璃樣病變

1、肺毛玻璃樣病變GGO(ground-glass opacity,GGO)，肺毛玻璃樣病變，是周圍型肺癌最早期的CT表現(xiàn)容易被我們無視或者被認(rèn)為是正常的CT圖像隨著CT技術(shù)的開展及人們安康意識(shí)的增強(qiáng)，我們將面臨越來越多這種的病人一、GGO的病理解讀這是什么？abGGO的定義GGO定義 ：在高分辨率CT(HRCT) 上表現(xiàn)為密度輕度增加,但其內(nèi)的支氣管血管束仍可顯示的病變,縱隔窗上病灶往往不能顯示或僅能顯示磨玻璃樣病灶中的實(shí)性成分GGO的病理解讀GGO 病理：由于肺泡內(nèi)氣體減少、細(xì)胞數(shù)量相對(duì)增多、肺泡上皮細(xì)胞增生、肺泡間隔增厚及終末氣道局部充填等因素所致的病理變化。Pathology: Groun

2、d-glass opacity may be caused by partial airspace filling; interstitial thickening with inflammation, edema, fibrosis, or neoplastic proliferation; or interstitial thickening with partial airspace filling. a.Transverse lung-window thin-section (1.25-mm-thick) CT scan shows8-mm round, well-defined GG

3、O nodule (arrow) in left upper lobe.b. Photomicrograph shows columnar tumor cells growing along thickened alveolar walls (lepidic growth).abAAH in 55-year-old man. a.Transverse lung-window thin-section (2.5-mm-thick) CT scan shows 12-mm round, well-defined GGO nodule (arrow) in left upper lobe. b.sh

4、ows alveolar wall thickening and increased numbers of alveolar lining cells with minimal wall thickening.abGGO演變?yōu)橹車头伟┑倪^程肺泡上皮不典型樣增生AAH原位癌AIS進(jìn)展期肺癌肺癌前病變演化成原位癌的病理變化過程基內(nèi)幕胞增生輕度不典型增生中度不典型增生重度不典型增生原位癌肺泡上皮不典型樣增生AAH原位癌AIS肺腺癌病變病理衍化過程圖腺癌 侵襲性AISAAH二、高分辨率CT對(duì)GGO的評(píng)價(jià)肺良好的自然比照，是CT成像的有利條件；多排螺旋CT，主要是指16排以上螺旋CT，具有高時(shí)間、高空

5、間、高密度辨分率以及高信噪比的成像特點(diǎn)；任意層厚重建，能檢出1mm的小病灶；高分辨率CT(HRCT)對(duì)肺內(nèi)小病灶細(xì)節(jié)的顯示優(yōu)于常規(guī)CT，能檢出0.5mm的小病灶，是評(píng)價(jià)GGO最正確的無創(chuàng)性方法。肺多排螺旋CT掃描技術(shù)參數(shù)層厚(任意層厚重建）0.3-1mm重建算法高分辨率算法矩陣512512掃描時(shí)間0.5sPicth1mm曝光量（盡量低毫安）KV/mAS ：120-140/50-80窗寬窗位肺 窗：+700 -700Hu縱隔窗： 50 300Hu靶重建FOV20-50cm容積掃描準(zhǔn)備各向同性成像圖像處理多層、無間隔、連續(xù)的圖像薄層，小FOV，多發(fā)方位重建第一種分型第二種分型局限性GGO的CT分型

6、單純型GGO(pure GGO，pGGO) : 整個(gè)病灶密度淺淡, 內(nèi)見血管或支氣管壁, 完全無實(shí)性組織成分, 只能在肺窗下看到 混合型GGO (mixed GGO,mGGO): 病灶內(nèi)部見局部實(shí)性組織, 相應(yīng)局部血管被遮蓋, 實(shí)性病變局部可在縱隔窗下看到第一種分型:單純磨玻璃樣影:密度不均的磨玻璃樣影 :中央高密度,外圍淡薄模糊磨玻璃樣影 :單純結(jié)節(jié)影第二種分型GGO分型和腫瘤發(fā)生及CT表現(xiàn) 型：純磨玻璃樣結(jié)節(jié),病理改變?yōu)槟[瘤細(xì)胞沿肺泡壁生長,無肺泡塌陷,腫瘤內(nèi)彈性纖維輕度增生 型：低密度不均勻結(jié)節(jié),病理為腫瘤細(xì)胞沿肺泡壁生長,伴有散在肺泡塌陷,腫瘤內(nèi)彈性纖維、重度增生,但其網(wǎng)狀構(gòu)造仍保存

7、型：中心高密度伴周邊磨玻璃樣結(jié)節(jié),病理為肺泡塌陷,瘤體中心彈性纖維增生,伴彈性纖維網(wǎng)狀構(gòu)造斷裂,周邊區(qū)腫瘤細(xì)胞伏壁生長 型：均勻軟組織密度結(jié)節(jié),病理上腫瘤呈實(shí)體生長,無含氣肺泡組織,腫瘤內(nèi)彈性纖維增生,網(wǎng)狀構(gòu)造中斷、破壞型:單純磨玻璃樣陰影GGO開展成肺癌的動(dòng)態(tài)演變過程型:密度不均的磨玻璃樣陰影型:中央高密度,外圍淡薄模糊的磨玻璃樣陰影 型:單純結(jié)節(jié)影GGO開展成肺癌CT表現(xiàn)的四步曲pGGO：pure GGO 純毛玻璃樣病變mGGO: mixed GGO混合型毛玻璃樣病變SOLID SPN(3cm，腫塊，實(shí)體瘤，進(jìn)展期肺癌)肺腺癌的演變過程是和CT的表現(xiàn)相對(duì)應(yīng)的pGGO：AAHmGGO：AIS

8、MASS:腺癌從病理學(xué)角度看肺癌的CT圖像的演變過程Illustration of the relationship between the Noguchi histologic classification of adenocarcinoma of the lung (Noguchi types A though F) and corresponding CT appearances of these lesions. Persistent nodular ground-glass opacity in an 80-year-old man with adenocarcinoma. Aden

9、ocarcinoma was found at histopathologic analysis of an excised specimen.a. Initial thick-section CT image obtained at the level of the right inferior pulmonary vein shows a subtle nodule (arrow) in the middle lobe of the right lung. b.Follow-up CT image obtained 12 months later shows an increase in

10、the lesion size and an additional subtle internal solid component (arrow). c.Follow-up thin-section CT image obtained at 16 months shows an increase in the size of the solid component within the lesion (arrow). abcBAC. Sequential magnified 1-mm CT sections through the right upper lobe show minimal i

11、ncrease in size of a nodule with GGO over a 3-year period. The central area of higher attenuation represents a vessel bifurcation and not a solid component, which was better characterized on sequential images.一肺惡性GGO的CT評(píng)價(jià)GGO和AAHAtypical adenomatous hyperplasia in a 53-year-old woman.a.Thin-section C

12、T image of the right lung shows an 11-mm well-defined nodular ground-glass opacity without a solid component in the lower lobe. b. photomicrograph shows thickened alveolar walls lined by an intermittent single layer of atypical cuboidal pneumocytes.ab Concurrent atypical adenomatous hyperplasia and

13、adenocarcinoma in a 71-year-old woman. Thin-section CT image at the level of the carina shows an 18-mm-diameter mixed nodular ground-glass opacity with a solid component in the upper lobe of the right lung and a 10-mm pure nodular ground-glass opacity in the lower lobe of the left lung. AAHcarcinoma

14、 of the bronchioloalveolar Multiple AAHs in a 42-year-oldwoman. CT scans show round well-defined, pure GGO nodules (arrow).Photomicrograph of the nodule in the left upper lobe show AAH.abcbronchioloalveolar carcinoma in a 63-year-old woman.a.the right upper anterior segmental bronchus shows a 10-mm

15、well-defined nodular ground-glass opacity without a solid component in the lower lobe of the right lung. Note the presence of pulmonary vessels in the lesion. b. Photomicrograph specimen shows replacement of the alveolar lining by neoplastic columnar epithelium, without evidence of stromal invasion.

16、 GGO 和 BAC (AIS)abbronchioloalveolar carcinoma in a 49-year-old woman. a.The level of the right bronchus intermedius shows a 14-mm well-defined nodular ground-glass opacity with a solid component (arrow) in the lower lobe of the right lung, abutting the vertebral body. b. Photomicrograph shows BAC (

17、AIS)ab Adenocarcinoma with mixed acinar and bronchioloalveolar carcinoma in a 50-year-old woman. a. Thin-section CT image shows a 28-mm well-defined mixed ground-glass opacity lesion with peripheral ground-glass opacity in the upper lobe of the left lung. The mass abuts the pleura.b. Photomicrograph

18、 of a histologic specimen shows BAC (AIS).ab BAC and AAH in a 63-year-old woman. a. lung-window CT scan shows a 19-mm ovoid, well-defined, pure GGO nodule in the left lower lobe. This lesion was confirmed as BAC after basal segmentectomy.b. lung-window thin-section CT scan shows a 9-mm round, well-d

19、efined, pure GGO nodule (arrow) in the left upper lobe. This lesion was confirmed as AAH after wedge resection. c. Nodule in the left lower lobe shows columnar or cuboidal cell lining thickened alveolar walls without evidence of stromal, vascular, or pleural invasion.abca. Transverse lung-window thi

20、n-section (1-mm-thick) CT scan shows a 22-mm irregular GGO nodule with bubble-lucency in the left lower lobe. This lesion was confirmed as adenocarcinoma with a predominant BAC component after lobectomy.b. Transverse lung-window thin-section (1-mm) CT scan shows a 12- mm round, well-defined pure GGO

21、 nodule in the right upper lobe. This lesion was confirmed as BAC. AAdenocarcinoma with a predominant BAC component and BAC in a 48-year old woman. ab 65-year-old-woman with multiple pure ground-glass opacities (PGGOs)a. Multiple small PGGOs were found in all lobes of lung. Computed tomographic slic

22、e reveals three PGGOs (arrows) in the right upper lobe. The lobe, including the maximal PGGO (10 mm in diameter), was removed. b. Comprehensive histologic examination of resected specimens demonstrated existence of many smaller lesions revealing bronchioloalveolar carcinoma or atypical adenomatous h

23、yperplasia. During 37 months of postoperative follow-up, only a slight increase in size or density was recognized in some residual PGGOs scattered in all lobes.ab Adenocarcinoma in a 56-year-old man.a.Thin-section CT image obtained shows a 14-mm nodular ground-glass opacity with no solid component i

24、n the upper lobe of the right lung.b.Photomicrograph of a histologic specimen shows adenocarcinoma with dense sclerosis.GGO與腺癌abCT scan (1-mm section) of mixed subtype adenocarcinoma with BAC component (Noguchi type C lesion) shows a nodule with pure GGO, demonstrating that although nonsolid nodules

25、 are likely to represent AAH or BAC, an invasive component may rarely be present as in this case.CT scan in a 64-year-old man shows an oval 2.1-cm left lower lobe nonsolid nodule (arrow). FNAB revealed adenocarcinoma.支氣管充氣造影征軸位示：左上肺毛玻璃陰影分葉征冠狀位毛刺征矢狀位BACCT:左上肺毛玻璃陰影短毛刺征冠狀位重建矢狀位重建典型胸膜凹陷征BAC冠狀位重建：局灶性純磨玻璃

26、密度影(Focal pure groundglass opacity，pGGO矢狀位局部放大BAC峰值時(shí)間后移F， 68，腺鱗癌,HRCT動(dòng)態(tài)增強(qiáng)特征二肺良性GGO的CT評(píng)價(jià)肺局灶性間質(zhì)纖維化與GGO Focal interstitial fibrosis in a 40-year-old womana.Thin-section CT image shows a 25-mm well-defined nodular ground-glass opacity with no solid component in the lower lobe of the left lung. b.Photomi

27、crograph of a histologic shows the lesion (arrow) with alveolar septal thickening and fibrosis and with intraalveolar infiltration by inflammatory cells.ab A 36-year-old woman with two nodular GGOsa.Transverse thin-section CT scan shows a 5.1-mm well defined round pure GGO nodule in the right middle

28、 lobe. focal interstitial fibrosis. b.The other 9-mm mixed GGO nodule containing a central solid portion is shown in the right lower lobe. bronchioloalveolar carcinoma abFocal nonspecific interstitial pneumonia. a, b.Thin-section CT scans at the level of the left pulmonary artery and aortic arch, re

29、spectively, show three foci of persistent GGO. c.Histologic specimen shows thickening of the alveolar wall with chronic inflammatory infiltrates. No tumor was identified.abcA 34-year-old woman with focal interstitial fibrosis showing a round pure GGO lesion a.Transverse thin-section CT scan shows an

30、 8.5-mm well-defined round nodule with pure GGO. There was no evidence of spiculation or vascular convergence around the lesion. b.Photomicrograph of resection specimen shows alveolar interstitial thickening with fibrosis and type II pneumocyte proliferationab A 50-year-old woman with focal intersti

31、tial fibrosis appearing as mixed GGO with a spiculated margin and pleural traction. a.Transverse thin-section CT scan shows a mixed GGO nodule in the left upper lobe. Note the spiculated margin and pleural retraction. b.This follow-up thin-section CT taken 2 months later shows a similar appearance.

32、The lesion was resected under the impression of primary lung cancer. The pathologic diagnosis was of focal interstitial fibrosis without evidence of malignancyabA 66-year-old man with focal interstitial fibrosis with a polygonal shape and peri-lobular linear density. Transverse thinsection CT scan s

33、hows a nodular GGO lesion with peri-lobular linear opacities (arrow) around the lesion in the right upper lobe. Note the pleural traction around the lesionNodular fibrosis with concave margins in 67-year-old man. Both reviewers interpreted lesion as having concave margins (arrow), air bronchograms (

34、arrowheads), and predominantly ground-glass appearance on transverse high-resolution CT images. Lesion size was measured 8 mm by reviewer 1 and 8.5 mm by reviewer 2. Pathologic diagnosis was nodular fibrosis.Nodular fibrosis with polygonal shape in 72-year-old man. Both reviewers interpreted lesion

35、(arrow ) as having coarse spiculation, pleural tag, and polygonal shape, and as being predominantly solid on transverse high resolution CT images. Lesion size was measured as 8 mm by reviewer 1 and 9 mm by reviewer 2. Pathologic diagnosis was nodular fibrosis.Intrapulmonary lymph nodethat showed per

36、ipheral subpleurallesion in 53-year-old woman.Both reviewers regarded lesion(arrow ) as predominantly solid lesion attached to major fissure on transverse high-resolution CT images. Lesion size was measured 9 mm by both reviewers. Pathologic diagnosis wasintrapulmonary lymph node.肺內(nèi)淋巴結(jié)與GGOCT scan in

37、 a 90-year-old woman with chronic congestive heart failure shows a tiny nodule adjacent to the right major fissure that is likely to represent a congested intrapulmonary lymph node (arrow). GGO與霉菌灶Thin-section CT image at the level of the main pulmonary artery shows a 23-mm poorly defined nodular gr

38、ound-glass opacity in the upper lobe of the left lung. The lesion includes several peripheral solid portions (arrows) and a subtle groundglass opacity (arrowhead). Eosinophilic pneumonia in a 36-year-old man with peripheral blood eosinophilia. a.Thin-section CT image at the level of the aortic arch

39、shows an ill-defined area of nodular ground-glass opacity in the upper lobe of the right lung. b.Thin-section CT image at the level of the upper lobar bronchus in the left lung shows a similar nodular ground-glass opacity.abGGO與結(jié)核灶False positive PET in patient with tuberculosis. a.Thin-section axial

40、 CT scan through the upper lobes at lung windows shows a left upper lobe nodule with irregular margins. b.Fused image from PET-CT shows increased metabolic activity within the nodule. Surgical resection revealed a granuloma with cultures positive for Mycobacterium tuberculosis.ab三GGO的CT處理原那么和步驟CT隨訪G

41、GO變化的重要性體積不變體積變大體積變小密度變實(shí)代謝較低1、體積不變Persistent nodular ground-glass opacity in a 69-year-old man.a.Thin-section CT image obtained at the level of the left brachiocephalic vein shows a 14-mm poorly defined round nodular ground-glass opacity in the upper lobe of the left lung. b.Follow-up thin-section C

42、T image obtained 4 months later shows the persistence and stable appearance of the lesion. The pathologic diagnosis, obtained after a wedge resection, was focal interstitial fibrosis.abPure nodular ground-glass opacity confirmed as focal interstitial fibrosis A.Thin-section CT shows 30 mm pure nodul

43、ar ground-glass opacity in the right upper lobe.B.On follow-up CT scan after seven months, an interval change was not noted. abPure nodular ground-glass opacity confirmed as atypical adenomatous hyperplasia in a 58-year-old man. A.Initial thin-section CT shows a 15 mm pure nodular ground-glass opaci

44、ty B.On thin-section CT after 2 months, an interval change was not noted. All lesions were pathologically confirmed as atypical adenomatous hyperplasia by multifocal wedge resection.abPure nodular ground-glass opacity confirmed as atypical adenomatous hyperplasia a. Initial CT shows 8 mm pure nodula

45、r ground-glass opacity in the right upper lobe.b. Thin-section CT after 10 months shows persistent pure nodular ground glass opacity with the same size. ab2、體積變大體積變大一般為惡性病變 Small adenocarcinoma detected on screening CT.Initial axial thin section CT at the level of the right upper lobe bronchus shows

46、 a 4 mm nodule in the right upper lobe. .Repeat CT scan 3 months later at the same level shows slight enlargement of the nodule. Biopsy revealed adenocarcinoma.abGrowth of small nodule on follow up CT. (adenocarcinoma).Initial thin-section axial CT coned to the left lung shows a small left upper lob

47、e nodule measuring approximately 4 mm in diameter. . Repeat scan 6 months later shows interval growth of the lesion . An invasive adenocarcinoma was found at surgery.ab BAC. Sequential magnified 1-mm CT sections through the right upper lobe show minimal increase in size of a nodule with GGO over a 3

48、-year period. The central area of higher attenuation represents a vessel bifurcation and not a solid component, which was better characterized on sequential images.Sequential magnified 5-mm CT sections through the left upper lobe show GGOinitially measuring 8mm in size over a 3-year period. Histolog

49、ic analysis showed mixed subtype adenocarcinoma composed of acinar adenocarcinoma (40%) and BAC (60%). Computed tomogram from 57-year-old man (patient 1) with long-term follow-up of pure ground-glass opacity (PGGO) for more than 10 years. Patient had undergone operation for adenocarcinoma originatin

50、g in right upper lobe 10 years previously. .Small PGGO in left upper lobe (arrow) was pointed out as a function of the retrospective review of conventional CT taken at that operation. .On follow-up 124 months later, high-resolution computed tomography shows enlargement of PGGO from 8 mm (A) to 25 mm

51、 in diameter. . Most of the resected specimen reveals bronchioloalveolar carcinomaabc Mixed subtype adenocarcinoma, progression of GGO to a nodule with mixed solid component and GGO. a.Magnified 1-mm CT section shows a discrete GGO (arrows). b.Follow-up CT scan obtained 1 year later shows clear prog

52、ression of the disease, with the development of a central solid component, although there is no appreciable enlargement of the lesion (arrows).ab Mixed subtype adenocarcinoma.a Magnified 1-mm CT section through the left lower lobe shows a nodule with mixed solid component and GGO.b Follow-up CT scan

53、 obtained 6 months later shows increase in the extent of the solid component within the nodule.ab Persistent nodular ground-glass opacity in an 80-year-old man with adenocarcinoma. Initial thick-section CT image obtained at the level of the right inferior pulmonary vein shows a subtle nodule (arrow)

54、 in the middle lobe of the right lung. Follow-up CT image obtained 12 months later shows an increase in the lesion size and an additional subtle internal solid component (arrow).Follow-up thin-section CT imageobtained at 16 months shows an increase in the size of the solid component within the lesio

55、n (arrow). Adenocarcinoma was found at histopathologic analysis of an excised specimen.abc a.Transverse CT scan in a 75-year-old man shows a 2.0-cm-diameter nonsolid left upper lobe nodule. FNAB revealed no malignant cells. b.The lesion was followed up with serial CT; 25 months later, the nodule was

56、 slightly increased in size and had converted to a partly solid attenuation lesion with air bronchograms. Volumetric measurement showed the doubling time of the opacity to be 1375 days. Repeat FNAB showed bronchioloalveolar cell carcinoma.ab、體積變小體積變小一般為良性病變 Resolution of nodular ground-glass opacity

57、 over time helps determine the benignity of a lesion in a 50-year-old man. Initial thin-section CT image at the level of the inferior pulmonary vein shows a 12-mm poorly defined nodular ground-glass opacity in the right lower lobe. Follow-up CT image obtained approximately 2 months later shows that

58、the lesion in a has resolved.abFocal inflammation mimicking adenocarcinoma. a.Magnified 1-mm CT section through the right upper lobe shows nodules with GGO initially diagnosed as probable BAC. b. Follow-up CT scan obtained 3 months later shows near complete resolution of the lesion (arrow),(focal no

59、nspecific inflammation).abTransverse thin-section CT scans show transient PSN with multiplicity in a 43-year-old man.a.Scan shows a 16-mm PSN (arrow) in the left upper lobe. This patient had eosinophilia (eosinophil count, 574 per microliter). b. Follow-up scan obtained 1 month later shows disappear

60、ance of the PSN.abTransverse thin-section CT scans show transient PSN with ill-defi ned border in 37-year-old man.a.Scan shows a 27-mm PSN (arrow) with an ill-defi ned border in the right upper lobe. This patient had blood eosinophilia (eosinophil count, 1577 per microliter). b.At follow-up CT perfo