高分辨率肺部CT(珍藏版)

高分辨率肺部CTHRCT扫描技术 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。常见伪影 血管双重伪影。TheSecondaryPulmonaryLobule肺小叶（直径1-2.5CM）小叶支气管、终末细支气管肺动脉pulmonaryartery小叶间隔interlobularsepta肺静脉pulmonaryvein腺泡pulmonaryacini正常小叶间隔normalsepta正常小叶中心动脉centrilobularartery2肺静脉PulmonaryveinsRETICULAROPACITIES网状结构肺间质病变 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Ｘ、淋巴管平滑肌瘤病。 ＣＴ：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。网状结构reticularopacities F/60y 乳腺癌术后，现呼吸困难。分析：（1）小叶间隔增厚thickeningofinterlobularsepta分析：（2）支气管血管周围间质增厚thickeningoftheperibronchovascularinterstitium 支气管袖口症："peribronchialcuffing"分析：(3)斜裂增厚thickeningofthemajorfissure分析：（3）大结节影Largenodules上病例为癌性淋巴管炎。 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。测试：M/73y，咳嗽、喘憋Isseptalthickeningapredominantfinding? Isseptalthickeningapredominantfinding? (a)Yes (b)No 小叶间隔增厚？右侧肺小叶间隔增厚。 Aretheseptasmoothornodularinappearance? (a)Smooth. (b)Nodular 小叶间隔光滑增厚还是结节状增厚？smooth光滑增厚支气管血管间质Istherethickeningoftheperibronchovascularinterstitium? (a)Yes (b)No 支气管血管间质是增厚的？支气管袖口症peribronchialcuffing胸膜下间质Istherethickeningofthesubpleuralinterstitium? (a)Yes (b)No 胸膜下间质是增厚的？斜裂增厚thickeningofthemajorfissureWhatisthemostlikelydiagnosis?可能的诊断？ (a)Pulmonaryedema 肺水肿 (b)Interstitialfibrosis 间质纤维化 (c)Lymphangiticspreadofcarcinoma 癌性淋巴管炎右肺门肿块，纵隔淋巴结肿大。 PLCresultsfromhematogenousspreadtolung,withsubsequentinterstitialandlymphaticinvasion,or,asinthiscase,directlymphaticspreadoftumorfromhilarormediastinallymphnodes. 癌性淋巴管炎—血性播散到肺淋巴系统。淋巴播散图表79-year-oldmanwithknownlymphoma79岁、淋巴瘤病史AreHRCTfindingsofinterlobularseptalseptalthickeningvisible? (a)Yes (b)No 小叶间隔增厚？？？双侧光滑增厚的小叶间隔 Allscansshowmarkedsmooththickeningofinterlobularseptainvolvingbothlungsinasymmetricalfashion.Istherethickeningoftheperibronchovascularinterstitium? (a)Yes (b)No 支气管血管间质是否增厚？？？增厚的支气管血管间质Istherethickeningofthesubpleuralinterstitium? (a)Yes (b)No 胸膜下间质增厚？斜裂增厚 Whatisthemostlikelydiagnosis? 最可能的诊断？？？ (a)Pulmonaryedema (b)Interstitialfibrosis (c)Lymphangiticspreadoflymphoma Diagnosis:Lymphangiticspreadoflymphoma,withinterlobularseptalthickening。 癌性淋巴管炎（小叶间隔增厚）lymphocyticinterstitialpneumonitis(LIP) 淋巴间质局限性肺炎58-year-oldmanwithheartdisease DoHRCTfindingsincludeinterlobularseptalthickening? (a)Yes (b)No 小叶间隔增厚？？？双侧小叶间隔增厚 Istherethickeningoftheperibronchovascularinterstitium? (a)Yes (b)No 支气管血管间质增厚？？？支气管血管间质增厚 Istherethickeningofthesubpleuralinterstitium? (a)Yes (b)No 胸膜下间质增厚？？？ NO!!! Whatisthemostlikelydiagnosis? (a)Pulmonaryedema肺水肿 (b)Interstitialfibrosis间质纤维化 (c)Lymphangiticspreadofcarcinoma癌性淋巴管炎 最可能的诊断？ (a)Pulmonaryedema肺水肿Correct.Becauseofthehistoryofheartdisease心脏病史,characteristicabnormalities典型的异常,symmetry对称,andthepredominanceofseptalthickeningindependentlung,thisdiagnosismustbeconsidered考虑mostlikely.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：KerleyB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。 （６）胸腔积液：胸膜腔内液体来自壁层胸膜。不同原因的肺水肿 （１）心源性肺水肿：左心衰（见于心梗、二尖瓣病变。 （２）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（血管蒂增宽。 （3）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、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。9.a53-year-oldwomanwithandabnormalchestradiographandmildshortness（短缺）ofbreath Isseptalthickeningpresent? (a)Yes (b)No 小叶间隔增厚吗？增厚的小叶间隔 Aretheseptasmoothornodularinappearance? (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 Possiblediagnosesinclude: (a)pulmonaryedema肺水肿 (b)interstitialfibrosis间质纤维化 (c)lymphangiticspreadoflymphoma (d)sarcoidosis结节病 最可能的诊断？ sarcoidosis结节病Correct.Nodularthickeningofinterlobularseptaandfissurescanbeseeninthisdiseaseandlymphangiticspreadofcarcinoma.（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断。Case10ina42-year-oldmanwithmildshortness（短缺）ofbreathforanumberofyears Isseptalthickeningvisible? (a)Yes (b)No  NextPage  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-stagesarcoidosiswithfibrosisandinterlobularseptalthickening. 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：Case11ina68-year-oldwomanwithrheumatoidarthritis（风湿性关节炎）andprogressive累计shortness短缺ofbreathovera2-yearperiod Thepredominantabnormalfindingonthesescansis? (a)interlobularseptalthickening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 Whatdoeshoneycombingreflecthistologically? (a)Interstitialedema肺间质水肿 (b)Interstitialinfiltration渗透bycells (c)Interstitialfibrosis 蜂窝肺的组织学—肺间质纤维化的后期表现。 Diagnosis: Rheumatoidlungdisease,withfibrosisandhoneycombing.风湿性肺疾病，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。Case12ina74-year-oldwomanwithprogressiveshortnessofbreathover6months Themostsignificantabnormalfindinginthisstudyis: (a)interlobularseptalthickening小叶间隔增厚 (b)honeycombing蜂窝肺 (c)subpleuralemphysema胸膜下肺气肿 主要的异常表现？蜂窝肺 Whatisthemostlikelydiagnosis? (a)Idiopathicpulmonaryfibrosis(IPF)特发性肺间质纤维化 (b)Autoimmunedisease(e.g.,rheumatoidlungdisease)自身免疫性疾病 (c)End-stagehypersensitivitypneumonitis过敏性肺炎 (d)Asbestosis石棉肺 (e)Drug-relatedlunginjury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Case1386-year-oldmanwithchronicmyelogenousleukemia骨髓性的白血病,treatedusingmethotrexate化疗,nowcomplainsofshortnessofbreath气短. DoesthismanshowevidenceoffibrosisandUIP? (a)Yes (b)No 显示明显的纤维化和普通间质性肺炎？？ 屑性间质性肺炎（DIP）、普通性间质性肺炎（UIP）。 (a)YesCorrect.Findingsindicativeofusualinterstitialpneumonitis(UIP)visibleinthispatientinclude: honeycombing;蜂窝肺 irregularfissures;叶裂扭曲 irregularinterlobularseptalthickening;小叶间隔不规则增厚。 tractionbronchiectasis.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 Themostlikelydiagnosisis:可能的诊断？ (a)idiopathicpulmonaryfibrosis(IPF) (b)lunginvolvementbyleukemia白血病肺浸润。 (c)drug-relatedlunginjury化疗药物肺损害。 (c)drug-relatedlunginjuryCorrect.Thepatternoffibrosisseeninthispatientisnonspecific,andcouldbecausedbyIPF.Therecenthistoryoftreatmentwithmethotrexatemakesdrug-relatedfibrosismostlikely.Lunginvolvementbyleukemiawouldlikelyresultinanappearancesimilartothatoflymphangiticspreadofcarcinomawithseptalthickeningbeingthepredominantfinding. 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。Case14ina63-year-oldmanwithahistoryofscleroderma硬皮病andprogressiveshortnessofbreath进行性喘憋 Findingsinclude:interlobularseptalthickening;小叶间隔增厚。 tractionbronchiectasis;牵拉性支扩 subpleuralhoneycombing;胸膜下蜂窝肺 irregularfissures.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 Canyoubeconfidentthatlungfibrosisispresent? (a)Yes (b)No 你能确定肺纤维化存在？ YesCorrect.Thepresenceofhoneycombingisdiagnosticoffibrosis.Tractionbronchiectasisisalsostronglysuggestiveoffibrosis.Interlobularseptalthickeningandirregularfissuresarenonspecific,andcannotbereliedupontodiagnosefibrosis. 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,withlungfibrosis,honeycombing,andtractionbronchiectasis 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。Case15ina61-year-oldwomanwithprogressiveshortnessofbreath进行性喘憋. Whichofthefollowingfindingsareshownonthisscan? 上图包含症像: (a)Honeycombing蜂窝肺 (b)Asubpleuralline胸膜下线 (c)Aperipheralandsubpleuraldistribution外围胸膜下分布 (d)Alloftheabove以上全包括 AlloftheaboveCorrect.Smallsubpleuralcystsarepresenttypicalofmildhoneycombing.轻度的蜂窝肺Anirregularlineparallelsthepleuralsurface,termedasubpleuralline.胸膜下线 Whichofthefollowingismostlikelyinthiscase? 最符合的诊断？ (a)Idiopathicpulmonaryfibrosis(IPF) 特发性间质纤维化 (b)Autoimmunedisease(e.g.,rheumatoidlungdisease) 自身免疫性疾病 (c)End-stagehypersensitivityPneumonitis 过敏性肺炎 (d)Asbestosis石棉肺 (e)Drug-relatedlunginjury药物肺损害 (f)Sarcoidosis结节病 Idiopathicpulmonaryfibrosis(IPF)Correct.Idiopathicpulmonaryfibrosis(IPF).Intheabsenceahistorytosuggestoneofthespecificdiagnosesonthislist,IPFismostlikely.Itaccountsfor60%ofcaseshavingthisappearance. IPF在该病例无特异性，60%有该表现。Case16ina34-year-oldmanwithprogressiveshortnessofbreath喘憋 Thepredominantabnormalityinthiscaseis: 明显的异常表现 (a)honeycombing 蜂窝肺 (b)intralobularinterstitialthickening 小叶间质增厚 intralobularinterstitialthickeningCorrect.Honeycombingisnotvisibleinthispatient.Afineirregularreticular不规则的网状改变patternispresentinthelungperiphery,representingintralobularinterstitialthickening.小叶间质增厚Insomepatientswithpulmonaryfibrosis,thisfindingwillpredominate.Otherfindingsoffibrosisinthispatientincludetractionbronchiectasis.牵拉性支扩Thedifferentialdiagnosisofthisappearanceisidenticalasthatforhoneycombing.小叶间质增厚牵拉性支扩 Diagnosis: Idiopathicpulmonaryfibrosis特发性间质纤维化,withintralobularinterstitialthickening.Case17ina71-year-oldmanwithprogressiveshortnessofbreath Thepredominantabnormalityinthiscaseis: 突出的表现 (a)honeycombing 蜂窝肺 (b)intralobularinterstitialthickening 小叶间质增厚 intralobularinterstitialthickeningCorrect.Honeycombingisnotclearlyseeninthispatient.Afinebutirregularreticularpattern不规则的网状改变ispresentinthelungperiphery外围,representingintralobularinterstitialthickening小叶间质增厚.Insomepatientswithpulmonaryfibrosis,thisfindingwillpredominate.Otherfindings其他征象offibrosisinthispatientincludetractionbronchiectasis牵拉性支扩,andirregularinterlobularseptalthickening不规则小叶间隔增厚.Thedifferentialdiagnosisofthisappearanceisidenticaltothatforhoneycombing.小叶间质增厚牵拉性支扩不规则小叶间隔增厚 Diagnosis: Idiopathicpulmonaryfibrosis特发性间质纤维化,withintralobularinterstitialthickening.Case18,ina55-year-oldsalamimanufacturer腊肠制造商withprogressiveshortnessofbreath Themostlikelydiagnosisinthiscaseis: 最可能的诊断 (a)Idiopathicpulmonaryfibrosis(IPF) 特发性间质纤维化 (b)Autoimmunedisease(e.g.,rheumatoidlungdisease)自身免疫系统疾病 (c)End-stagehypersensitivitypneumonitis过敏性肺炎 (d)Asbestosis石棉肺 (e)Drug-relatedlunginjury药物肺损害 (f)Sarcoidosis结节病 Anydiagnosisispossible. 任何诊断都是可能的。Case19in34-year-oldwomanwithlupuserytematosus狼疮红斑 Canyoudiagnosefibrosis? 能诊断纤维化？ (a)Yes (b)No YesCorrect.HRCTobtainedinthesupineandpronepositions仰卧和俯卧位showsanumberoffindingsindicatingfibrosis指示,including: honeycombingwhichismildindegree;轻度蜂窝肺 tractionbronchiectasis;牵拉性支扩 intralobularinterstitialthickening;小叶间质增厚 interlobularseptalthickening小叶间隔增厚;and asubpleuraldistribution.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: Systemiclupuserythematosus（SLE系统性红斑狼疮肺部表现—肺结缔组织病,withfibrosisandhoneycombing.Case20ina65-year-oldwomanwithrheumatoidarthritis风湿性关节炎andmilddyspnea轻度呼吸困难 Canyoudiagnosefibrosis? 能诊断纤维化？ (a)Yes (b)No Correct including: tractionbronchiectasis;牵拉性支扩 intralobularinterstitialthickening;小叶间质增厚 asubpleuralline.胸膜下线牵拉性支扩小叶间质增厚胸膜下线 Diagnosis: Rheumatoidlungdisease肺结缔组织病,withmildpulmonaryfibrosis轻度肺纤维化andintralobularinterstitialthickening小叶间质增厚.Case21ina26-year-oldwomanwithmixedconnectivetissuedisease混合结缔组织病,basilarcracklesonphysicalexamination双肺底水泡音,andrestrictivediseaseonpulmonaryfunctiontests肺功能受限 Canyoudiagnosefibrosis? 能诊断纤维化？ (a)Yes (b)No YesCorrect. Including: tractionbronchiectasis;牵拉性支扩 intralobularinterstitialthickening小叶间质增厚; asubpleuraldistribution胸膜下分布牵拉性支扩小叶间质增厚 Diagnosis:Mixedconnectivetissuedisease混合结缔组织病,withpulmonaryfibrosis,andintralobularinterstitialthickeningCase22,ina81-year-oldmanwithsignificantoccupationalexposuretoasbestos石棉职业史 Ispulmonaryfibrosispresent? 肺纤维化存在？ (a)Yes (b)No YesCorrect.Findingsoffibrosisinclude: tractionbronchiectasis;牵拉性支扩 intralobularinterstitialthickening;小叶间质增厚 asubpleuraldistribution.胸膜下分布 irregularinterlobularseptalthickening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Asbestosiswithtractionbronchiectasis牵拉性支扩andintralobularinterstitialthickening小叶间质纤维化.纵隔窗pleuralthickeningandcalcification胸膜增厚、钙化 椎旁区域 横膈胸膜肥厚钙化Case24ina58-year-oldmanwithahistoryofasbestosexposure石棉史可见椎旁胸膜增厚、不规则线状影 Thepleuralthickeningistypicalofasbestosexposure胸膜增厚是典型的石棉肺表现.Wouldyoudiagnoseasbestosis诊断石棉肺吗? (a)Yes (b)No NoCorrect.Linearopacities线状影asseeninthiscase(termedparenchymalbands肺实质带)arecommoninpatientswithpleuralthickening胸膜增厚,butarenotnecessarilyassociated不必须考虑withlungfibrosis肺纤维化.肺实质带parenchymalbands 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Asbestosexposurewithpleuraldiseaseandparenchymalbands石棉至椎旁胸膜增厚、肺实质带。Case25ina67-year-oldmanwithahistoryofasbestosexposure石棉史 NoCorrect.HRCTatlungwindowsshowsirregularlinearopacities不规则的线状影(“crow‘sfeet”乌鸦脚),withoutevidenceofhoneycombing无蜂窝肺,intralobularinterstitialthickening小叶间质增厚,ortractionbronchiectasis牵拉性支扩.Thisappearancedoesnotindicateasbestosis无石棉特征.Linearopacities,asseeninthiscase(parenchymalbands肺实质带)arecommoninpatientswithpleuralthickeningrelatedtoasbestosexposure,butarenotnecessarilyassociatedwithlungfibrosis不必须考虑肺纤维化.Theyrepresentfocalareasofatelectasis焦点为肺膨胀不全,associated联系withthepleuralthickening,orfocalareasofscarring焦点区疤痕.乌鸦脚（"crow'sfeet"),即 尽管如此，结合病史考虑Asbestosexposurewithpleuraldiseaseandparenchymalbands。 另一病例：胸膜下线 椎旁胸膜增厚Case26ina56-year-oldmanwithsignificantoccupationalexposuretoasbestos石棉史 Istherepleuralthickening胸膜增厚youwouldconsider考虑likely可能duetoasbestosexposure石棉? (a)Yes (b)No Yescorrect.Afocal焦点,calcifiedpleuralplaque胸膜钙斑isvisibleanteriorly,typicalofasbestosexposure石棉肺典型表现.Althoughplaquesaremorelikelyposteriorinlocation常见后胸膜,thisappearanceishighlysuggestive高度提示. Canadefinitediagnosisofpulmonaryfibrosisonthepronelungwindowscansbemade?肺窗能明确诊断肺纤维化吗？ (a)Yes (b)No NoCorrect.Thereismildseptalthickening轻度间隔增厚andreticulation网状intheposteriorsubpleuralregion后胸膜下ontheright.Thisisunassociated无联系withadjacent临近pleuralthickening.Thisisaverysubtleabnormality轻微的异常whichcouldrepresenttheearlieststageofasbestosis石棉肺早期表现.However,intheabsenceofamoredefiniteabnormality明确的异常orsimilar类似findingsontheleft,itwouldbedifficult困难tomakeadefinitediagnosisoffibrosis石棉肺或肺纤维化的诊断orasbestosis.小叶间质增厚—轻度网状改变 Diagnosis: Asbestosisexposure石棉肺.Possiblefibrosis可能纤维化. 文献：石棉肺 [1]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）。Case27ina57-year-oldwomanwithyearsofprogressivedyspnea多年呼吸困难 Ispulmonaryfibrosispresent? 肺纤维化存在吗？ (a)Yes (b)No YesCorrect.Thispatientshowsanumberof许多findingsindicativeofpulmonaryfibrosis肺纤维化征象.Theseinclude: Extensive广泛的tractionbronchiectasis牵拉性支扩involvingbothupperlobes双上叶; Irregularreticularopacities不规则的网状anddistortionoflungarchitecture肺结构扭曲associatedwithtractionbronchiectasis;and Honeycombingatthelungbases下肺蜂窝状改变。牵拉性支扩扭曲的肺结构蜂窝肺 Isthedistributionofabnormalitiestypicalofidiopathicpulmonaryfibrosis?特发性间质纤维化的异常类型？ (a)Yes (b)No NoCorrect.Withexceptionoftheposteriorhoneycombing后部蜂窝肺,thefindingsoffibrosisinthispatientlacktheperipheral不在外围,lowerlobe,andsubpleuralpredominance胸膜下ofIPF.Thesefindingsaretypical典型ofend-stagesarcoidosis. Diagnosis: End-stagesarcoidosis结节病,withtractionbronchiectasis牵拉性支扩andhoneycombing蜂窝肺. DISCUSSION Inpatientswithsarcoidosis结节病,progressivefibrosisoftenleads累计纤维化常导致toperibronchovascularconglomeratemassesoffibroustissue支气管血管束聚集成纤维块,typicallymostmarkedintheupperlobes上叶显著.Bronchiandvesselsareclusteredtogetherbecauseofretraction,andbronchiappeardilated(i.e.tractionbronchiectasis);theonlyotherdiseasesthatcommonlyresultinthisappearancearesilicosis,tuberculosis,andtalcosis.Posteriordisplacementoftheupperlobebronchiindicatingvolumelossintheposteriorsegmentsoftheupperlobesisacommonearlyfinding. Honeycombingorlungcystscanbepresentinpatientswithsarcoidosis,butthisfindingislesscommonthaninotherfibroticlungdiseasessuchasidiopathicpulmonaryfibrosis.Honeycombingisusuallylimitedtopatientswithseverefibrosisandcentralconglomerationofbronchi.Thehoneycombingseeninpatientswithsarcoidosisinvolvesmainlythemiddleandupperlungzones,withrelativesparingofthelungbases.However,inanoccasionalcase,findingscanmimicIPF.支气管血管束聚集成纤维块Case28ina46-year-oldmanhistoryofshortnessofbreath喘憋andhemoptysis咳血 Ispulmonaryfibrosispresent? 肺纤维化？ (a)Yes (b)No YesCorrect.Thispatientshowsanumberof许多的findingsindicativeofpulmonaryfibrosis肺纤维化征象。 Arethefindingsweseetypicalofidiopathicpulmonaryfibrosis? 能否诊断特发性间质纤维化？ (a)Yes (b)No NoCorrect.Typicalsubpleuralhoneycombingorreticulation,withabasal,subpleural,andposteriorpredominanceisabsentI特发间质纤维化肺的外围和肺底部网状、蜂窝状，向心性减轻.Findingsoffibrosisinthispatientinclude: tractionbronchiectasis牵拉性支扩inassociationwithcentral,peribronchovascularmassesoffibroustissueshownonlungwindowsandsofttissuewindows软组织窗支气管血管束纤维块; irregularinterlobularseptalthickening;不规则小叶间隔增厚 distortionoffissures;叶裂扭曲 lungcystsorbullae肺大泡sometimestermed"paracicatricialemphysema;"and anupperlobepredominance,withsparingofthelungbases(Figure5).牵拉性支扩支气管血管束纤维块不规则的小叶间隔增厚叶裂扭曲肺大泡 Whatisthemostlikelydiagnosis?最可能的诊断？ (a)Idiopathicpulmonaryfibrosis特发性间质纤维化 (b)Sarcoidosis结节病 (c)Asbestosis石棉肺 (d)Hypersensitivitypneumonitis过敏性肺炎 (e)Tuberculosis肺结核 SarcoidosisCorrect.Thesefindingsaretypicalofend-stagesarcoidosis. Animportantadditionalfinding额外的征象ispresent.Thismostlikelyrepresents可能是？: (a)anaspergilloma曲霉菌球 (b)alargesarcoidgranuloma大结节肉芽肿 (c)lungcancer肺癌 (d)tractionbronchiectaiswithamucousplug牵拉支扩粘液栓 anaspergilloma曲菌球Correct.Thisistypicalofanaspergillomaarisinginapreexisting先前存在cyst囊orcavity洞 .Diagnosis:End-stagesarcoidosis,withtractionbronchiectasis牵拉性支扩andcysts,complicatedbyanaspergilloma曲菌球. In20-25%ofpatientswithsarcoidosis,fibrosisresultsfromhealingofgranulomas20-25%结节病纤维化来源于肉芽肿的治疗.Asfibrosisdevelops,irregularreticularopacities,includingirregularseptalthickening,oftenbecomeaprominentfeature纤维化进一步呈网状、小叶间隔增厚. Progressivefibrosisleadstoabnormalcentralconglomerationofparahilarbronchiandvessels,associatedwithmassesoffibroustissue肺门支气管血管纤维块,typicallymostmarkedintheupperlobes上叶多见.Thisfindingisfrequentlyassociatedwithbronchialdilation(i.e.tractionbronchiectasis);theonlyotherdiseasesthatcommonlyresultinthisappearancearesilicosis,tuberculosis,andtalcosis.Posteriordisplacementofthemainandupperlobebronchiindicatingvolumelossintheposteriorsegmentsoftheupperlobesiscommonlypresent.Findingsoffibrosisinpatientswithend-stagesarcoidosislackthetypicalsubpleural,posterior,lowerlobepredominanceseeninpatientswithidiopathicpulmonaryfibrosis.Acentralandupperlobepredominanceoffibrosissuggestssarcoidosis上叶中心纤维化支持结节病.上叶中心：支气管血管纤维块 Hemoptysis咳血,presentinthispatient,isacommonmanifestationofmycetoma肺霉菌常见表现。Case29ina74-yearold-manwithprogressiveshortnessofbreathforoneyear喘憋一年. Findingsoffibrosisinthispatientinclude:纤维化包括： intralobularinterstitialthickeningresultinginirregularreticularopacities;小叶间质增厚-网状改变 tractionbronchiectasis牵拉性支扩resultinginirregularreticularopacities;and interlobularseptalthickening.不规则小叶间隔增厚网状改变—小叶间质增厚牵拉性支扩小叶间隔不规则增厚 Isthedistributionofabnormaltitiesweseetypicalofidiopathicpulmonaryfibrosis?所见的异常分布为IPF？ (a)Yes (b)No NoCorrect.Typicalsubpleuralhoneycombingorreticulation,withabasal,subpleural,andposteriorpredominanceisabsent典型的肺外围、肺底呈向心性网状、蜂窝状改变缺乏.Anupperlobepredominance上叶优势(Figure1)ispresent,withrelativesparingofthelungbases下叶少(Figure4).ThisdistributionsuggestsadiagnosisotherthanIPF不支持.Also,asupleuralpredominance,typicalofIPF,isalsolackinginthispatient(Figure1).Sarcoidosiswouldbeapossibility结节病很像.Additionalhistoryrevealedalongexposuretopetbirds长养鸟史. Diagnosis:End-stagehypersensitivitypneumonitiswithfibrosis 过敏性肺炎伴纤维化.Case30ina59-year-oldmanwithmarkeddyspnea明显的呼吸困难 Themostlikelydiagnosisinthispatientis: 最可能的诊断？ (a)idiopathicpulmonaryfibrosis特发性间质纤维化 (b)autoimmunedisease自身免疫系统疾病 (c)asbestosis石棉肺 (d)sarcoidosis结节病 idiopathicpulmonaryfibrosisCorrect.Idiopathicpulmonaryfibrosisismostlikelybecauseoftypicalposterior,lowerlobe,andsubpleuralhoneycombing后胸膜下、肺底蜂窝状改变.肺大泡、结节影 Diagnosis: Idiopathicpulmonaryfibrosiswithhoneycombing,complicated复杂的、难解的bylungcancer.结节状阴影结节状影（1） 腺泡结节状影：1cm以下（4-7mm），边清、梅花瓣状、无融合趋向，为肉芽肿、肿瘤、血管炎及其周围炎、渗出、出血、水肿。中上肺野-多见结核的增殖性病变、慢性炎症；弥散—细菌性真菌性肺炎、肺泡蛋白沉积症、支原体肺炎、肺出血、肺水肿。结节状影（2） 粟粒状结节影：４ｍｍ以下，弥散分布，多由间质病变引起，见粟粒型肺结核、癌性淋巴管炎、结节病、特发性肺含铁血黄素沉着、急性细支气管炎、组织细胞病x。 较大-转移瘤、肺泡癌、支气管播散型肺结核；较小—肺泡微石症。 粟粒型肺结核—大小一致、分布均匀；癌性淋巴管炎—沿肺纹理分布。 短期增大为癌肿所致。肿块影直径2cm以上。