結(jié)節(jié)病CT典型和不典型型表現(xiàn)課件1

Sarcoidosisisamultisystemdisorderthatischaracterizedbynoncaseousepithelioidcellgranulomas,whichmayaffectalmostanyorgan.結(jié)節(jié)病是一種以非干酪樣壞死的上皮細(xì)胞肉芽腫為特點的多系統(tǒng)疾病，幾乎可以累及所有器官。Sarcoidosismaybeasymptomaticorchronic.Itcommonlyimprovesorclearsupspontaneously（自愈或好轉(zhuǎn)）.Morethan2/3ofpeoplewithlungsarcoidosishavenosymptomsafter9years.About50%haverelapses.About10%developseriousdisability.

Sarcoidosisofthelungisprimarilyan

interstitiallungdiseaseinwhichtheinflammatoryprocessinvolvesthealveoli,smallbronchi,andsmallbloodvessels.TypicalandAtypicalFeaturesofPulmonarySarcoidosisatHigh-ResolutionCT

Typicalfeatures1Lymphadenopathy:hilar,mediastinal(rightparatracheal),bilateral,symmetric,andwelldefined

2Nodules:micronodules(2–4mmindiameter;welldefined,bilateral);macronodules(≥5mmindiameter,coalescing)

3Lymphangiticspread:peribronchovascular,subpleural,interlobularseptal

4Fibroticchanges:reticularopacities,architecturaldistortion,tractionbronchiectasis,bronchiolectasis,volumelossBilateralperihilaropacities

5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalities結(jié)節(jié)病原本是肺間質(zhì)性病變，累及肺泡，支氣管和小血管淋巴結(jié)增大，兩側(cè)對稱，境界清楚大小結(jié)節(jié)淋巴管播散，支氣管血管鞘，胸膜下，小葉間隔纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影中上肺為主典型特征

Atypicalfeatures1Lymphadenopathy:unilateral,isolated,anteriorandposteriormediastinal

2Airspaceconsolidation:masslikeopacities,conglomeratemasses,solitarypulmonarynodules,confluentalveolaropacities(alveolarsarcoidpattern)

3Ground-glassopacities

4Linearopacities:interlobularseptalthickening,intralobularlinearopacities

5Fibrocysticchanges:cysts,bullae,blebs,emphysema,honeycomb-likeopacitieswithupper-andmiddle-zonepredominance

單側(cè)孤立前后縱隔淋巴結(jié)增大肺泡實變：腫塊，實質(zhì)性結(jié)節(jié)，實變?nèi)诤厦Ａш幱熬€狀陰影小葉間隔增厚小葉年線狀陰影不典型表現(xiàn)囊性纖維化改變：囊，大泡，小泡，肺氣腫，蜂窩樣改變6Miliaryopacities

粟粒樣改變

7Airwayinvolvement:mosaicattenuationpattern,tracheobronchialabnormalities,atelectasis

氣道累及：馬賽克改變，氣管支氣管異常，肺不張8Pleuraldisease:effusion,chylothorax,hemothorax,pneumothorax,pleuralthickening,calcificationPleuralplaquelikeopacities

9Mycetoma,aspergilloma

霉菌球Duringthepastdecade,advanceshavebeenmadeinthestudyofsarcoidosis

TheMycobacteriumtuberculosiscatalase-peroxidase(mKatG)protein,apotentialantigen,hasbeenidentified,結(jié)核分枝桿菌過氧化氫酶過氧化物酶（mkatg）蛋白，作為一個潛在的抗原已被確定。PETscanninghasprovenvaluableinlocatingoccultsitesfordiagnosticbiopsy.PET掃描已被證明在定位活檢診斷隱匿性病灶的價值

Endobronchialultrasound-guidedtransbronchialneedleaspiration(EBUS-TBNA)ofmediastinallymphnodeshasfacilitateddiagnosis,ofteneliminatingtheneedformore-invasiveprocedures,suchasmediastinoscopy.支氣管內(nèi)超聲引導(dǎo)下經(jīng)支氣管針吸活檢（EBUS-TBNA）的縱隔淋巴結(jié)有利于診斷，往往避免更具侵襲性的操作，如縱隔鏡。Geneexpressionanalyseshavemoreclearlydefinedcytokinedysregulationinsarcoidosis

Currently,noreliableprognosticbiomarkershavebeenidentified.目前，還沒有可靠的預(yù)后標(biāo)志物已被確定。Thetumornecrosisfactor(TNF)inhibitors,arelativelynewclassofsteroid-sparingagents,havebeenusedinpatientswithrefractorydisease.Itisunclearwhethermedicationsusedtotreatpulmonaryarterialhypertensionaresafeandeffectiveforthetreatmentofsarcoidosis-associatedpulmonaryhypertension.腫瘤壞死因子（TNF）抑制劑，一個相對較新的類固醇保代理類藥品，已被用于治療難治性疾病。目前還不清楚是否用于治療肺動脈高壓的藥物治療結(jié)節(jié)病相關(guān)性肺動脈高壓是安全和有效的。PathologicCorrelation相關(guān)病理

Granulomasinthelungparenchymahaveacharacteristicdistributioninrelationtolymphaticsintheperibronchovascularinterstitialspace,subpleuralinterstitialspace,and,toalesserextent,theinterlobularsepta(ie,alymphangiticdistribution)

肺實質(zhì)肉芽腫分布與支氣管血管鞘，胸膜下結(jié)締組織，小葉間隔中淋巴管相關(guān).

ThickenedbronchovascularbundlesandsmallperivascularnodulesseenatCTcorrespondedtogranulomaswithintheconnectivetissuesheathsurroundingpulmonaryairwaysandvessels.PleuralorsubpleuralnoduleswerecorrelatedwithgranulomasadjacenttothevisceralpleuraCT上支氣管血管鞘增厚和小結(jié)節(jié)是與包繞氣道血管結(jié)締組織鞘中肉芽腫，胸膜和胸膜下結(jié)節(jié)與臟層胸膜旁肉芽腫相關(guān)。

Ground-glassopacitiesrepresentedanaccumulationofmanygranulomatouslesions,withorwithoutfibrosis,inthealveolarseptaandaroundthesmallvessels.Noalveolitiswasseen

肺泡間隔小血管周圍大量肉芽腫是毛玻璃陰影主要原因，可伴纖維化，但沒有肺泡炎。

Largeparenchymalnodules(>1cmindiameter)representedcoalescentgranulomas

大結(jié)節(jié)是肉芽腫病變的融合

AirbronchiologramswithinregionsofdenseconsolidationonCTimagescorrespondedtobronchiolardilatationwithsurroundingfibrosis

支氣管充氣癥是纖維化旁的支擴(kuò)honeycomb-likepatternofmicroscopiccystsseenatpathologicanalysis.

蜂窩樣改變在顯微鏡下就是很多的小囊pulmonarysarcoidosisshowsthetypicalperilymphaticdistributionofmicronodules(arrow).

（外周淋巴分布的微結(jié)節(jié)）

Photomicrographofalungbiopsyspecimendemonstratesnumerousepithelioidgranulomas(arrow)surroundingthebronchialwallsandimmediatelybeneaththenormalbronchialepithelium(arrowheads).CTscanshowsmultiplemicronoduleswithaperibronchovasculardistributioninbothlungs,predominantlyintheupperandmiddlelobes.Oneclusterofnodulesintheperipheryoftheleftupperlobe(arrow)hascoalescedtoformaconglomeratelesion(macronodule).

Coronalreformattedimagefromhigh-resolutionCTclearlyshowsupper-lobepredominanceofthemicronodules.

Low-magnificationphotomicrographslicefromthelowerpartoftherightupperlobeshowsmultipleconfluentgranulomasinfiltratingtheperibronchovascular(arrows)andsubpleural(arrowheads)interstitium.CTscanshowsmediastinallymphnodeenlargementandareticularpatternproducedbynodularityandthickeningofinterlobularsepta,pleuralsurfaces,andfissures,CT掃描顯示縱隔淋巴結(jié)腫大和形成網(wǎng)狀圖案的小葉間隔增厚，及胸膜表面，及產(chǎn)生的裂縫。

(b)Photomicrographofaspecimenfromfine-needleaspirationbiopsyofanenlargedrightparatracheallymphnodeshowsagroupofhistiocytesagainstalymphocyticbackground,acytologicstructurecharacteristicofsarcoidgranuloma.(c)Photomicrographofalungbiopsyspecimenfromanotherpatientshowsprogressivethickeningoftheinterlobularseptum(*)becauseoftheaccumulationofnumeroussarcoidgranulomas(arrowheads),anappearancethatcorrelateswellwiththeCTfeaturesseenina.從擴(kuò)大的右氣管旁淋巴結(jié)細(xì)針穿刺活檢標(biāo)本顯微鏡下顯示一組以淋巴細(xì)胞的背景的組織細(xì)胞，具有結(jié)節(jié)病肉芽腫細(xì)胞的結(jié)構(gòu)特征。（C）從另一個病人的肺活檢標(biāo)本的顯微照片顯示小葉間隔增厚（*），大量積累的肉芽腫結(jié)節(jié)（箭頭）。expiratoryCTscanobtainedinapatientwithpulmonarysarcoidosisshowsamosaicpatternconsistingofmultipleareasoflowattenuation(arrows)interspersedwithlargerareasofnormallungparenchyma.Thisappearanceisproducedbyairtrapping.Photomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).呼氣相CT掃描在肺結(jié)節(jié)病患者顯示馬賽克征，由低密度的多個區(qū)域（箭頭）穿插著大面積的正常肺實質(zhì)。這種現(xiàn)象是由空氣滯留產(chǎn)生。一經(jīng)支氣管鏡肺活檢標(biāo)本顯示的積累結(jié)節(jié)病肉芽腫的顯微照片（×）在粘膜和粘膜下的細(xì)支氣管上皮層（箭頭B）。5Fibrocysticchanges:cysts,bullae,blebs,emphysema,honeycomb-likeopacitieswithupper-andmiddle-zonepredominance這種現(xiàn)象是由空氣滯留產(chǎn)生。Low-magnificationphotomicrograph肺實質(zhì)肉芽腫分布與支氣管血管鞘，胸膜下結(jié)締組織，小葉間隔中淋巴管相關(guān)Avideo-assistedthoracoscopicsurgicalbiopsywasperformed.PathologicCorrelation相關(guān)病理(b)Low-powerphotomicrograph(originalmagnification,×10;H-Estain)obtainedathistopathologicanalysisshowsasubpleuralnodulethatisdarkerincolorbecauseofanthracosis（塵肺）.5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalitiesAlveolarsarcoid多房型肉瘤patternofairspaceconsolidationinpulmonarysarcoidosis.Typicalfeatures呼氣相CT掃描在肺結(jié)節(jié)病患者顯示馬賽克征，由低密度的多個區(qū)域（箭頭）穿插著大面積的正常肺實質(zhì)。Mildbilateralhilarlymphadenopathyandmarkedsub-carinallymphadenopathyalsoareseen.一經(jīng)支氣管鏡肺活檢標(biāo)本顯示的積累結(jié)節(jié)病肉芽腫的顯微照片（×）在粘膜和粘膜下的細(xì)支氣管上皮層（箭頭B）。Photomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).A,High-resolutionCTscanoflungsrevealsill-definedsmallnodularopacitiesinperibronchovascularandissuraldistribution.Characteristicfeaturesofchronicdiseasearedepicted,includingtractionbronchiectasis牽拉性支氣管擴(kuò)張,severearchitecturaldistortion,volumeloss,andinterlobularseptalthickening.CT掃描顯示彌漫性磨玻璃影，由多個融合的結(jié)節(jié)產(chǎn)生，伴支氣管擴(kuò)張(11b)Magnifiedaxialhigh-resolutionCTscanoftherightlungclearlydepictsseparatenodulesinasubpleural(blackarrow)andfissural(whitearrow)distributionandalongthebronchovascularbundles(arrowheads)放大的軸位高分辨率CT掃描清楚顯示右肺胸膜下區(qū)分胸膜下的結(jié)節(jié)（黑色箭頭）和沿支氣管血管束分布的“裂”（白色箭頭）.蜂窩樣改變在顯微鏡下就是很多的小囊纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影

.(11a)CTscanshowsadiffuseground-glasspatternproducedbymultipleconfluentmicronodules,withassociatedbronchiectasis.CT掃描顯示彌漫性磨玻璃影，由多個融合的結(jié)節(jié)產(chǎn)生，伴支氣管擴(kuò)張(11b)Magnifiedaxialhigh-resolutionCTscanoftherightlungclearlydepictsseparatenodulesinasubpleural(blackarrow)andfissural(whitearrow)distributionandalongthebronchovascularbundles(arrowheads)放大的軸位高分辨率CT掃描清楚顯示右肺胸膜下區(qū)分胸膜下的結(jié)節(jié)（黑色箭頭）和沿支氣管血管束分布的“裂”（白色箭頭）.(11c)High-powerphotomicrographshowsanaccumulationofinterstitialgranulomas(white*),whichcausesathickenedappearanceoftheinteralveolarsepta,andacinargranulomas(black*),whichformintheinterstitiumofthealveolarwallandprotrudeintothealveoli(arrowheads).高倍鏡下涂片顯示間質(zhì)肉芽腫集聚（白*），使肺小泡壁的增厚，和腺泡肉芽腫（黑色），形成在肺泡壁的間質(zhì)和伸入肺泡（箭頭）。SarcoidosisinapatientwithahistoryofstageIIIprimarycutaneousmalignantmelanoma.結(jié)節(jié)病III期原發(fā)性皮膚惡性黑色素瘤病史。(a)Contrast-enhancedCTscansshowpulmonarynodules(arrow)insubpleural(right)andfissural(left)regions.Avideo-assistedthoracoscopicsurgicalbiopsywasperformed.(b)Low-powerphotomicrograph(originalmagnification,×10;H-Estain)obtainedathistopathologicanalysisshowsasubpleuralnodulethatisdarkerincolorbecauseofanthracosis（塵肺）.(c)Photo-micrographobtainedathigherpower(originalmagnification,×100;H-Estain)showsmultiplenonnecroticgranulomas（壞死性肉芽腫）(arrows)expandingtheinterstitiumthatsurroundsthesubpleuralnoduleinb.Typical(a,b)andatypical(c,d)radiologicfindingsoflymphadenopathyinfourpatientswithsarcoidosis四例結(jié)節(jié)病淋巴結(jié)病變的影像學(xué)表現(xiàn).(a)Axialcontrastmaterial–enhancedCTscan(mediastinalwindow)showstypicalbilateralandsymmetrichilar(ar-rows)andsubcarinal(*)lymphadenopathy.CT增強(qiáng)掃描（縱隔窗）顯示了典型的雙側(cè)對稱性肺門（箭頭）及隆突下淋巴結(jié)腫大（*）(b)AxialunenhancedCTscan(mediastinalwindow)obtainedattheleveloftheleftpulmonaryarteryshowsenlargementofrightparatrachealandlefthilarlymphnodes(arrows)右氣管旁和左肺門淋巴結(jié)腫大.Althoughtherighthilumisnotshown,ittoowasaffected.(c)AxialunenhancedCTscan(mediastinalwindow)showspunctatecal-cificationsofhilarlymphnodes(arrows),apatternthatalsooccursinotherchronicgranulomatousdiseases.(d)Axialcontrast-enhancedCTscanshowsbilateraleggshell-likecalcificationsofhilarandmediastinallymphnodes雙側(cè)縱隔、肺門淋巴結(jié)蛋殼樣鈣化(arrows),findingsthatwarranttheinclusionofsilicosis矽肺inthedifferentialdiagnosisinthiscase.Axialhigh-resolutionCTscansobtainedattheleveloftheupperlobes(a)andcarina(b)inapatientwithpulmonarysarcoidosisshowafibrotic-cicatricialpatternofdisease,withmultiplelesionsinaperibronchovasculardistribution.Characteristicfeaturesofchronicdiseasearedepicted,includingtractionbronchiectasis牽拉性支氣管擴(kuò)張,severearchitecturaldistortion,volumeloss,andinterlobularseptalthickening.Coales-centirregularmasslikeopacities(whitearrows)andacalcifiedrightlowerparatra-chealnode(blackarrowinb)alsoareseen.Mosaicattenuation,whichismostvisibleina,presumablyresultsfromairwaydistor-tionduetofibrosis.Axialhigh-resolutionCTscanshowsseverallarge,ill-definednodulesandareasofcon-solidationresultingfromtheconfluenceofmultipleparenchymalmicronodulescomposedofnumeroustinygranulomasinbothlungs.Finenodularopacitiesareseenaroundthelargenodules(whitearrows),andsmalllow-attenuationspotsthatcorrespondtothespacesbetweenpartiallycoalescentsmallnod-ulesarevisibleperipherally.Thisappearancehasbeentermedthesarcoid“galaxysign”小結(jié)節(jié)環(huán)繞大結(jié)節(jié)——銀河征.Distortionoftherightmajorfissureisalsoseen扭曲的葉間胸膜(blackarrow).Alveolarsarcoid多房型肉瘤patternofairspaceconsolidationinpulmonarysarcoidosis.Axialhigh-resolutionCTscanshowsalveolarconsolidationintheleftupperlobeandpatchysubpleuralalveolaropacitiesintherightupperlobe.Architecturaldistortionandtractionbronchiectasis,signsoffibrosis,alsoarevisible,mainlyintherightupperlobe.Axialunenhancedhigh-resolutionCTscanshowsasymmetricsubpleuralhoneycomb-likecysts不對稱胸膜下蜂窩樣囊腫(ar-rowheads)andarchitecturaldistortionassociatedwithleftfissurenodularity(arrow).Althoughthesefeaturesalsoarecharacteristicofidiopathicpulmonaryfibrosis特發(fā)性肺纖維化,theupper-lobepredominanceofhoneycomb-likecystsandtheperibronchovascularandfissuraldistributionofmicronodulesinthiscaseweremoresuggestiveofsarcoidosis.以上葉為主的蜂窩狀囊，沿支氣管血管束周圍分布并且更提示結(jié)節(jié)病。Miliaryopacitiesinsarcoidosis.粟粒樣結(jié)節(jié)病Axialun-enhancedhigh-resolutionCTscanshowscountlesstinymicronodulesrepresentingmultipleanddiffusegranulomasinarandomdistribution,withbronchialwallthickening.Whenthispatternisseen,thedifferentialdiagnosisshouldincludemiliarytuberculosis,pneumo-coniosis,andmetastaticlesions.無數(shù)的小結(jié)節(jié)表現(xiàn)為隨機(jī)分布的多發(fā)彌漫性肉芽腫，支氣管壁增厚。鑒別診斷應(yīng)包括粟粒性肺結(jié)核，塵肺，和轉(zhuǎn)移性病變。A,High-resolutionCTscanoflungsrevealsill-definedsmallnodularopacitiesinperibronchovascularandissuraldistribution.Smallamountofinterlobularseptalthickening少量的小葉間隔增厚(arrow)isseen.

B,Photomicrographofhistopathologicspecimenshowsnoncaseating？tightlyformedgranulomasandepithelioidhistiocytesandlymphocytes.Perilymphaticdistributionofgranulomasisevident.Normallungparenchymaandsmallregionoffibroticinterlobularseptalthickening(arrow)areseen.組織病理標(biāo)本的顯微照片顯示緊密的肉芽腫和上皮樣細(xì)胞和淋巴細(xì)胞。肉芽腫淋巴分布是顯而易見的。正常肺組織纖維化和小葉間隔增厚（箭頭）。Tracheobronchialandpulmonaryinvolvementofsarcoidosis主支氣管及肺實質(zhì)受侵

(a)Axialcontrast-enhancedCTscanobtainedatthesubcarinallevelshowsasoft-tissuemasswithpunctatecalcificationsthatfillsthelumenoftherightintermediatebronchus(arrow),causingpartialatelectasisoftherightmiddleandrightlowerlobes.Mildbilateralhilarlymphadenopathyandmarkedsub-carinallymphadenopathyalsoareseen.造成右中、右下葉肺不張的部分。雙側(cè)肺門淋巴結(jié)腫大和標(biāo)記隆突淋巴結(jié)腫大也看到。(b)Axialcontrast-enhancedCTscanshowsthatpartofthemassencasesandoccupiestherightlowerlobebronchi,causingpartialatelectasis.Atdiagnosticthoracotomy,sarcoidosiswithtracheobronchialandpulmonaryinvolvementwasfound.開胸活檢示，支氣管及肺實質(zhì)受累Sarcoidosisisamultisystemdisorderthatischaracterizedbynoncaseousepithelioidcellgranulomas,whichmayaffectalmostanyorgan.結(jié)節(jié)病是一種以非干酪樣壞死的上皮細(xì)胞肉芽腫為特點的多系統(tǒng)疾病，幾乎可以累及所有器官。Sarcoidosismaybeasymptomaticorchronic.Itcommonlyimprovesorclearsupspontaneously（自愈或好轉(zhuǎn)）.Morethan2/3ofpeoplewithlungsarcoidosishavenosymptomsafter9years.About50%haverelapses.About10%developseriousdisability.支氣管內(nèi)超聲引導(dǎo)下經(jīng)支氣管針吸活檢（EBUS-TBNA）的腫瘤壞死因子（TNF）抑制劑，一個相對較新的類固醇保代理類藥品，已被用于治療難治性疾病。纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影粟粒樣結(jié)節(jié)病Axialun-enhancedhigh-resolutionCTscanshowscountlesstinymicronodulesrepresentingmultipleanddiffusegranulomasinarandomdistribution,withbronchialwallthickening.6MiliaryopacitiesLow-magnificationphotomicrograph2Nodules:micronodules(2–4mmindiameter;welldefined,bilateral);macronodules(≥5mmindiameter,coalescing)無數(shù)的小結(jié)節(jié)表現(xiàn)為隨機(jī)分布的多發(fā)彌漫性肉芽腫，支氣管壁增厚。5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalitiesPhotomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).8Pleuraldisease:effusion,chylothorax,hemothorax,pneumothorax,pleuralthickening,calcificationPleuralplaquelikeopacities（外周淋巴分布的微結(jié)節(jié)）Architecturaldistortionandtractionbronchiectasis,signsoffibrosis,alsoarevisible,mainlyintherightupperlobe.從擴(kuò)大的右氣管旁淋巴結(jié)細(xì)針穿刺活檢標(biāo)本顯微鏡下顯示一組以淋巴細(xì)胞的背景的組織細(xì)胞，具有結(jié)節(jié)病肉芽腫細(xì)胞的結(jié)構(gòu)特征。PathologicCorrelation相關(guān)病理Mildbilateralhilarlymphadenopathyandmarkedsub-carinallymphadenopathyalsoareseen.2Nodules:micronodules(2–4mmindiameter;welldefined,bilateral);macronodules(≥5mmindiameter,coalescing)Typicalfeatures(c)AxialunenhancedCTscan(mediastinalwindow)showspunctatecal-cificationsofhilarlymphnodes(arrows),apatternthatalsooccursinotherchronicgranulomatousdiseases.目前還不清楚是否用于治療肺動脈高壓的藥物治療結(jié)節(jié)病相關(guān)性肺動脈高壓是安全和有效的。

Sarcoidosisofthelungisprimarilyan

interstitiallungdiseaseinwhichtheinflammatoryprocessinvolvesthealveoli,smallbronchi,andsmallbloodvessels.TypicalandAtypicalFeaturesofPulmonarySarcoidosisatHigh-ResolutionCT

Typicalfeatures1Lymphadenopathy:hilar,mediastinal(rightparatracheal),bilateral,symmetric,andwelldefined

2Nodules:micronodules(2–4mmindiameter;welldefined,bilateral);macronodules(≥5mmindiameter,coalescing)

3Lymphangiticspread:peribronchovascular,subpleural,interlobularseptal

4Fibroticchanges:reticularopacities,architecturaldistortion,tractionbronchiectasis,bronchiolectasis,volumelossBilateralperihilaropacities

5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalities結(jié)節(jié)病原本是肺間質(zhì)性病變，累及肺泡，支氣管和小血管淋巴結(jié)增大，兩側(cè)對稱，境界清楚大小結(jié)節(jié)淋巴管播散，支氣管血管鞘，胸膜下，小葉間隔纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影中上肺為主典型特征CTscanshowsmediastinallymphnodeenlargementandareticularpatternproducedbynodularityandthickeningofinterlobularsepta,pleuralsurfaces,andfissures,CT掃描顯示縱隔淋巴結(jié)腫大和形成網(wǎng)狀圖案的小葉間隔增厚，及胸膜表面，及產(chǎn)生的裂縫。

(b)Photomicrographofaspecimenfromfine-needleaspirationbiopsyofanenlargedrightparatracheallymphnodeshowsagroupofhistiocytesagainstalymphocyticbackground,acytologicstructurecharacteristicofsarcoidgranuloma.(c)Photomicrographofalungbiopsyspecimenfromanotherpatientshowsprogressivethickeningoftheinterlobularseptum(*)becauseoftheaccumulationofnumeroussarcoidgranulomas(arrowheads),anappearancethatcorrelateswellwiththeCTfeaturesseenina.從擴(kuò)大的右氣管旁淋巴結(jié)細(xì)針穿刺活檢標(biāo)本顯微鏡下顯示一組以淋巴細(xì)胞的背景的組織細(xì)胞，具有結(jié)節(jié)病肉芽腫細(xì)胞的結(jié)構(gòu)特征。（C）從另一個病人的肺活檢標(biāo)本的顯微照片顯示小葉間隔增厚（*），大量積累的肉芽腫結(jié)節(jié)（箭頭）。expiratoryCTscanobtainedinapatientwithpulmonarysarcoidosisshowsamosaicpatternconsistingofmultipleareasoflowattenuation(arrows)interspersedwithlargerareasofnormallungparenchyma.Thisappearanceisproducedbyairtrapping.Photomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).呼氣相CT掃描在肺結(jié)節(jié)病患者顯示馬賽克征，由低密度的多個區(qū)域（箭頭）穿插著大面積的正常肺實質(zhì)。這種現(xiàn)象是由空氣滯留產(chǎn)生。一經(jīng)支氣管鏡肺活檢標(biāo)本顯示的積累結(jié)節(jié)病肉芽腫的顯微照片（×）在粘膜和粘膜下的細(xì)支氣管上皮層（箭頭B）。Axialhigh-resolutionCTscanshowsseverallarge,ill-definednodulesandareasofcon-solidationresultingfromtheconfluenceofmultipleparenchymalmicronodulescomposedofnumeroustinygranulomasinbothlungs.Finenodularopacitiesareseenaroundthelargenodules(whitearrows),andsmalllow-attenuationspotsthatcorrespondtothespacesbetweenpartiallycoalescentsmallnod-ulesarevisibleperipherally.Thisappearancehasbeentermedthesarcoid“galaxysign”小結(jié)節(jié)環(huán)繞大結(jié)節(jié)——銀河征.Distortionoftherightmajorfissureisalsoseen扭曲的葉間胸膜(blackarrow).5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalities5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalitiesCT增強(qiáng)掃描（縱隔窗）顯示了典型的雙側(cè)對稱性肺門（箭頭）及隆突下淋巴結(jié)腫大（*）(b)AxialunenhancedCTscan(mediastinalwindow)obtainedattheleveloftheleftpulmonaryarteryshowsenlargementofrightparatrachealandlefthilarlymphnodes(arrows)右氣管旁和左肺門淋巴結(jié)腫大.肺實質(zhì)肉芽腫分布與支氣管血管鞘，胸膜下結(jié)締組織，小葉間隔中淋巴管相關(guān)粟粒樣結(jié)節(jié)病Axialun-enhancedhigh-resolutionCTscanshowscountlesstinymicronodulesrepresentingmultipleanddiffusegranulomasinarandomdistribution,withbronchialwallthickening.Whenthispatternisseen,thedifferentialdiagnosisshouldincludemiliarytuberculosis,pneumo-coniosis,andmetastaticlesions.Low-magnificationphotomicrograph(b)Photomicrographofaspecimenfromfine-needleaspirationbiopsyofanenlargedrightparatracheallymphnodeshowsagroupofhistiocytesagainstalymphocyticbackground,acytologicstructurecharacteristicofsarcoidgranuloma.4Linearopacities:interlobularseptalthickening,intralobularlinearopacities（外周淋巴分布的微結(jié)節(jié)）Coronalreformattedimagefromhigh-resolutionCTclearlyshowsupper-lobepredominanceofthemicronodules.Atdiagnosticthoracotomy,sarcoidosiswithtracheobronchialandpulmonaryinvolvementwasfound.Axialhigh-resolutionCTscanshowsalveolarconsolidationintheleftupperlobeandpatchysubpleuralalveolaropacitiesintherightupperlobe.Photomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).Thisappearancehasbeentermedthesarcoid“galaxysign”小結(jié)節(jié)環(huán)繞大結(jié)節(jié)——銀河征.從擴(kuò)大的右氣管旁淋巴結(jié)細(xì)針穿刺活檢標(biāo)本顯微鏡下顯示一組以淋巴細(xì)胞的背景的組織細(xì)胞，具有結(jié)節(jié)病肉芽腫細(xì)胞的結(jié)構(gòu)特征。一經(jīng)支氣管鏡肺活檢標(biāo)本顯示的積累結(jié)節(jié)病肉芽腫的顯微照片（×）在粘膜和粘膜下的細(xì)支氣管上皮層（箭頭B）。CT上支氣管血管鞘增厚和小結(jié)節(jié)是與包繞氣道血管結(jié)締組織鞘中肉芽腫，胸膜和胸膜下結(jié)節(jié)與Endobronchialultrasound-guidedtransbronchialneedleaspiration(EBUS-TBNA)of大結(jié)節(jié)是肉芽腫病變的融合Smallamountofinterlobularseptalthickening少量的小葉間隔增厚(arrow)isseen.mediastinallymphnodeshasfacilitateddiagnosis,ofteneliminatingtheneedformore-invasiveprocedures,suchasmediastinoscopy.Coronalreformattedimagefromhigh-resolutionCTclearlyshowsupper-lobepredominanceofthemicronodules.Avideo-assistedthoracoscopicsurgicalbiopsywasperformed.(b)Photomicrographofaspecimenfromfine-needleaspirationbiopsyofanenlargedrightparatracheallymphnodeshowsagroupofhistiocytesagainstalymphocyticbackground,acytologicstructurecharacteristicofsarcoidgranuloma.expiratoryCTscanobtainedinapatientwithpulmonarysarcoidosisshowsamosaicpatternconsistingofmultipleareasoflowattenuation(arrows)interspersedwithlargerareasofnormallungparenchyma.肺實質(zhì)肉芽腫分布與支氣管血管鞘，胸膜下結(jié)締組織，小葉間隔中淋巴管相關(guān)(c)AxialunenhancedCTscan(mediastinalwindow)showspunctatecal-cificationsofhilarlymphnodes(arrows),apatternthatalsooccursinotherchronicgranulomatousdiseases.支氣管內(nèi)超聲引導(dǎo)下經(jīng)支氣管針吸活檢（EBUS-TBNA）的Sarcoidosisisamultisystemdisorderthatischaracterizedbynoncaseousepithelioidcellgranulomas,whichmayaffectalmostanyorgan.Oneclusterofnodulesintheperipheryoftheleftupperlobe(arrow)hascoalescedtoformaconglomeratelesion(macronodule).(a)Axialcontrast-enhancedCTscanobtainedatthesubcarinallevelshowsasoft-tissuemasswithpunctatecalcificationsthatfillsthelumenoftherightintermediatebronchus(arrow),causingpartialatelectasisoftherightmiddleandrightlowerlobes.TypicalfeaturesAirbronchiologramswithinregionsofdenseconsolidationonCTimagescorrespondedtobronchiolardilatationwithsurroundingfibrosis支氣管充氣癥是纖維化旁的支擴(kuò)Itcommonlyimprovesorclearsupspontaneously（自愈或好轉(zhuǎn)）.(b)Low-powerphotomicrograph(originalmagnification,×10;H-Estain)obtainedathistopathologicanalysisshowsasubpleuralnodulethatisdarkerincolorbecauseofanthracosis（塵肺）.Mildbilateralhilarlymphadenopathyandmarkedsub-carinallymphadenopathyalsoareseen.About50%haverelapses.Smallamountofinterlobularseptalthickening少量的小葉間隔增厚(arrow)isseen.Axialunenhancedhigh-resolutionCTscanshowsasymmetricsubpleuralhoneycomb-likecysts不對稱胸膜下蜂窩樣囊腫(ar-rowheads)andarchitecturaldistortionassociatedwithleftfissurenodularity(arrow).纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影(c)AxialunenhancedCTscan(mediastinalwindow)showspunctatecal-cificationsofhilarlymphnodes(arrows),apatternthatalsooccursinotherchronicgranulomatousdiseases.(a)Axialcontrastmaterial–enhancedCTscan(mediastinalwindow)showstypicalbilateralandsymmetrichilar(ar-rows)andsubcarinal(*)lymphadenopathy.（外周淋巴分布的微結(jié)節(jié)）這種現(xiàn)象是由空氣滯留產(chǎn)生。纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影Alveolarsarcoid多房型肉瘤patternofairspaceconsolidationinpulmonarysarcoidosis.5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalitiesPhotomicrographsofatransbronchiallungbiopsyspecimenshowaccumulationsofsarcoidgranulomas(*)inthemucosalandsubmucosallayersofbronchiolarepithelium(arrowsinb).TypicalandAtypicalFeaturesofPulmonarySarcoidosisatHigh-ResolutionCTCharacteristicfeaturesofchronicdiseasearedepicted,includingtractionbronchiectasis牽拉性支氣管擴(kuò)張,severearchitecturaldistortion,volumeloss,andinterlobularseptalthickening.Alveolarsarcoid多房型肉瘤patternofairspaceconsolidationinpulmonarysarcoidosis.這種現(xiàn)象是由空氣滯留產(chǎn)生。雙側(cè)肺門淋巴結(jié)腫大和標(biāo)記隆突淋巴結(jié)腫大也看到。結(jié)節(jié)病III期原發(fā)性皮膚惡性黑色素瘤病史。大結(jié)節(jié)是肉芽腫病變的融合Miliaryopacitiesinsarcoidosis.粟粒樣結(jié)節(jié)病Axialun-enhancedhigh-resolutionCTscanshowscountlesstinymicronodulesrepresentingmultipleanddiffusegranulomasinarandomdistribution,withbronchialwallthickening.腫瘤壞死因子（TNF）抑制劑，一個相對較新的類固醇保代理類藥品，已被用于治療難治性疾病。纖維化改變，網(wǎng)狀陰影，肺結(jié)構(gòu)扭曲，牽拉性支擴(kuò)，肺容積縮小，兩肺門旁致密影這種現(xiàn)象是由空氣滯留產(chǎn)生。Axialunenhancedhigh-resolutionCTscanshowsasymmetricsubpleuralhoneycomb-likecysts不對稱胸膜下蜂窩樣囊腫(ar-rowheads)andarchitecturaldistortionassociatedwithleftfissurenodularity(arrow).Alveolarsarcoid多房型肉瘤patternofairspaceconsolidationinpulmonarysarcoidosis.Architecturaldistortionandtractionbronchiectasis,signsoffibrosis,alsoarevisible,mainlyintherightupperlobe.5Predominantupper-andmiddle-zonelocationsofparenchymalabnormalitiesslicefromthelowerpartoftherightupperlobeshowsmultipleconfluentgranulomasinfiltratingtheperibronchovascular(arrows)andsubpleural(arrowheads)interstitium.Endobronchialultrasound-guidedtransbronchialneedleaspiration(EBUS-TBNA)of肺實質(zhì)肉芽腫分布與支氣管血管鞘，胸膜下結(jié)締組織，小葉間隔中淋巴管相關(guān)Coronal