胸部常见CT征象认读麻涌医院放射科卢劲松The Secondary Pulmonary Lobule肺小叶（直径肺小叶（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肺静脉常分成许多细小的分支, ,这些分支与主支构成直角。这些分支与主支构成直角。叶间裂（厚度小于叶间裂（厚度小于1mm1mm，边缘光滑，均一厚度），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。正常小叶间隔normalsepta正常小叶中心动脉正常小叶中心动脉centrilobularartery2肺静脉Pulmonaryveins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。Case1F/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。Case279岁、淋巴瘤病史小叶间隔增厚？(a)Yes(a)Yes(b)No(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(a)Yes(b)No(b)No增厚的支气管血管间质胸膜下间质增厚？(a)Yes(a)Yes(b)No(b)No斜裂增厚Whatisthemostlikelydiagnosis?n n最可能的诊断？最可能的诊断？(a)Pulmonaryedema(肺水肿）(b)Interstitialfibrosis（间质纤维化）(c)Lymphangiticspreadoflymphoma（癌性淋巴管炎）Diagnosis:Lymphangiticspreadoflymphoma,withinterlobularseptalthickening。n n癌性淋巴管炎（小叶间隔增厚）癌性淋巴管炎（小叶间隔增厚）lymphocyticinterstitialpneumonitis(LIP)淋淋巴巴间间质质局局限限性性肺肺炎炎Case358-year-oldmanwithheartdisease小叶间隔增厚？(a)Yes(a)Yes(b)No(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Istherethickeningofthesubpleuralinterstitium?(胸膜下间质增厚？)(a)Yes(b)NoNO!Whatisthemostlikelydiagnosis?(最可能的诊断？)(a)Pulmonaryedema肺水肿(b)Interstitialfibrosis间质纤维化(c)Lymphangiticspreadofcarcinoma癌性淋巴管炎(a)Pulmonaryedema肺水肿Correct.Becauseofthehistoryofheartdisease心脏病史,characteristicabnormalities典型的异常,ymmetry对称,andthepredominanceofseptalthickeningindependentlung,thisdiagnosismustbeconsidered考虑mostlikely.文献：间质性肺水肿（1 1）肺血重新分布）肺血重新分布）肺血重新分布）肺血重新分布：左心衰左心衰- -肺淤血。肺淤血。（2 2）支气管周围袖口症）支气管周围袖口症）支气管周围袖口症）支气管周围袖口症：正常厚度约正常厚度约1mm1mm结缔结缔组织内液体存积组织内液体存积增厚。增厚。X-X-肺纹理及肺门血管增粗、肺纹理及肺门血管增粗、模糊模糊. .（3 3）肺透过度下降）肺透过度下降）肺透过度下降）肺透过度下降：液体分布到支气管血管周围、：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、肺泡间隔小叶间隔、小叶内支气管血管周围、肺泡间隔透透过度下降。过度下降。（4 4）间隔线）间隔线）间隔线）间隔线：KerleyBKerleyB线线xx上与肋膈角处与胸膜上与肋膈角处与胸膜垂直。垂直。（5 5）胸膜增厚）胸膜增厚）胸膜增厚）胸膜增厚：液体液体入脏层胸膜下薄层结缔组入脏层胸膜下薄层结缔组织织胸膜下结缔组织水肿胸膜下结缔组织水肿- -水肿位于脏层胸膜与结水肿位于脏层胸膜与结体组织间，不随体位移动。体组织间，不随体位移动。（）胸腔积液（）胸腔积液（）胸腔积液（）胸腔积液：胸膜腔内液体来自壁层胸膜。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。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、水钠潴留、左心衰肺水肿上腔静脉、奇静脉增宽。奇静脉增宽。肺微血管损伤性肺水肿：除肺水肿外，还可见出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血及细胞渗出肺血分布正常、无袖口症、间隔肺血分布正常、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。原性肺水肿、复张性肺水肿。Case4a53-year-oldwomanwithandabnormalchesta53-year-oldwomanwithandabnormalchestradiographandmildshortnessradiographandmildshortness（短缺）（短缺）ofbreathofbreath（异常（异常胸片，气短）胸片，气短）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)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。Case5a42-year-oldmanwithmildshortnessofbreathforanumberofyears（气促多年）Isseptalthickeningvisible?(a)Yes(b)NoNextPage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:n nEnd-stagesarcoidosiswithfibrosisandEnd-stagesarcoidosiswithfibrosisandinterlobularseptalthickening.interlobularseptalthickening.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：界面征：支气管血管间质增厚支气管血管间质增厚支气管血管束增支气管血管束增粗、支气管袖口症；液体粗、支气管袖口症；液体边缘光滑、肿瘤或肉边缘光滑、肿瘤或肉芽组织芽组织结节状界面。结节状界面。胸膜下线：胸膜下线：近胸膜面近胸膜面1cm1cm内弧线状影内弧线状影为肺纤维为肺纤维化征象。化征象。长疤痕线：长疤痕线：蜂窝肺：蜂窝肺：结节影：结节影：小结节小结节2-5mm2-5mm，肉芽、肿瘤、纤维组，肉芽、肿瘤、纤维组织。织。肺结构扭曲变形及牵拉支扩：肺结构扭曲变形及牵拉支扩：磨玻璃样改变：磨玻璃样改变：CaseCase66a68-year-oldwomanwithrheumatoidarthritisa68-year-oldwomanwithrheumatoidarthritis（风湿性（风湿性关节炎）关节炎）andprogressiveandprogressive累计累计shortnessshortness短缺短缺ofbreathovera2-ofbreathovera2-yearperiodyearperiodThepredominantabnormalfindingonthesescansis?(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。Case7a74-year-oldwomanwithprogressivea74-year-oldwomanwithprogressiveshortnessofbreathover6monthsshortnessofbreathover6monthsThemostsignificantabnormalfindinginthisstudyis:(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?n n(a)Idiopathicpulmonaryfibrosis(IPF)(a)Idiopathicpulmonaryfibrosis(IPF)特发性特发性肺间质纤维化肺间质纤维化n n(b)Autoimmunedisease(e.g.,rheumatoid(b)Autoimmunedisease(e.g.,rheumatoidlungdisease)lungdisease)自身免疫性疾病自身免疫性疾病n n(c)End-stagehypersensitivitypneumonitis(c)End-stagehypersensitivitypneumonitis过过敏性肺炎敏性肺炎n n(d)Asbestosis(d)Asbestosis石棉肺石棉肺n n(e)Drug-relatedlunginjury(e)Drug-relatedlunginjury麻醉药物肺损害麻醉药物肺损害n n(f)Sarcoidosis(f)Sarcoidosis结节病结节病最可能的诊断？IPF:特发性肺间质纤维化磨玻璃密度：肺野周围磨玻璃密度：肺野周围活动性肺泡炎症。活动性肺泡炎症。网状改变：小叶间隔、小叶中心结构增厚网状改变：小叶间隔、小叶中心结构增厚蜂窝状改蜂窝状改变的前期。变的前期。蜂窝状改变：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。间胸膜增厚。肺气肿：小叶中心型肺气肿。肺气肿：小叶中心型肺气肿。肺实变：肺实变：支扩：支扩：蜂窝肺牵拉性支扩小叶间隔增厚Case886-year-oldmanwithchronicmyelogenousleukemia86-year-oldmanwithchronicmyelogenousleukemia骨髓性的白血病骨髓性的白血病, ,treatedusingmethotrexatetreatedusingmethotrexate化疗化疗,nowcomplainsofshortnessofbreath,nowcomplainsofshortnessofbreath 气短气短. .DoesthismanshowevidenceoffibrosisandUIP?(a)Yes(b)Non n显示明显的纤维化和普通间质性肺炎？显示明显的纤维化和普通间质性肺炎？n n屑性间质性肺炎（屑性间质性肺炎（DIPDIP）、普通性间质性肺炎）、普通性间质性肺炎（UIPUIP） 。(a)YesCorrect.Findingsindicativeofusualinterstitialpneumonitis(UIP)visibleinthispatientinclude:n nhoneycombinghoneycombing; ;蜂窝肺蜂窝肺n nirregularfissuresirregularfissures; ;叶裂扭曲叶裂扭曲n nirregularinterlobularseptalthickeningirregularinterlobularseptalthickening; ;小叶间小叶间隔不规则增厚。隔不规则增厚。n ntractionbronchiectasistractionbronchiectasis. .牵拉性支扩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.ThepatternoffibrosisseeninthispatientisCorrect.Thepatternoffibrosisseeninthispatientisnonspecific,andcouldbecausedbyIPF.Therecenthistorynonspecific,andcouldbecausedbyIPF.Therecenthistoryoftreatmentwithmethotrexatemakesdrug-relatedfibrosisoftreatmentwithmethotrexatemakesdrug-relatedfibrosismostlikely.Lunginvolvementbyleukemiawouldlikelymostlikely.Lunginvolvementbyleukemiawouldlikelyresultinanappearancesimilartothatoflymphangiticresultinanappearancesimilartothatoflymphangiticspreadofcarcinomawithseptalthickeningbeingthespreadofcarcinomawithseptalthickeningbeingthepredominantfinding.predominantfinding.IPFIPF一可有同种表现，但患者有最近化疗史，白血病肺浸润小一可有同种表现，但患者有最近化疗史，白血病肺浸润小叶间隔增厚明显。叶间隔增厚明显。Case9ina63-year-oldmanwithahistoryofsclerodermaina63-year-oldmanwithahistoryofscleroderma硬皮病硬皮病andandprogressiveshortnessofbreathprogressiveshortnessofbreath进行性喘憋进行性喘憋Findingsinclude:interlobularseptalthickening;小叶间隔增厚。n ntractionbronchiectasistractionbronchiectasis; ;牵拉性支扩牵拉性支扩n nsubpleuralhoneycombingsubpleuralhoneycombing; ;胸膜下蜂窝肺胸膜下蜂窝肺n nirregularfissuresirregularfissures. .叶裂扭曲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,Diagnosis:Scleroderma,withlungfibrosis,honeycombing,andtractionbronchiectasishoneycombing,andtractionbronchiectasisn n硬皮病硬皮病肺纤维化：蜂窝肺、牵拉性支扩。肺纤维化：蜂窝肺、牵拉性支扩。n n结缔组织病及肺血管炎结缔组织病及肺血管炎主要为肺间质病变。主要为肺间质病变。肺内实变肺内实变肺泡内渗出、肉芽肿形成、肺泡内出肺泡内渗出、肉芽肿形成、肺泡内出血、水肿。血、水肿。肺内多发结节肺内多发结节肺内血管炎、肉芽肿、肺栓塞所肺内血管炎、肉芽肿、肺栓塞所形成。常见于：形成。常见于：wengnerwengner类风湿性关节炎。类风湿性关节炎。肺间质病变肺间质病变肺间质性肺炎、肺泡炎肺间质性肺炎、肺泡炎间质纤维间质纤维化、蜂窝肺。化、蜂窝肺。Case10ina61-year-oldwomanwithprogressiveina61-year-oldwomanwithprogressiveshortnessofbreathshortnessofbreath进行性喘憋进行性喘憋.Whichofthefollowingfindingsareshownonthisscan?n n上图包含症像上图包含症像: :(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?Whichofthefollowingismostlikelyinthiscase?n n最符合的诊断？最符合的诊断？(a)Idiopathicpulmonaryfibrosis(IPF)(a)Idiopathicpulmonaryfibrosis(IPF)n n特发性间质纤维化特发性间质纤维化(b)Autoimmunedisease(e.g.,rheumatoidlung(b)Autoimmunedisease(e.g.,rheumatoidlungdisease)disease)n n自身免疫性疾病自身免疫性疾病(c)End-stagehypersensitivityPneumonitis(c)End-stagehypersensitivityPneumonitisn n过敏性肺炎过敏性肺炎(d)Asbestosis(d)Asbestosis石棉肺石棉肺(e)Drug-relatedlunginjury(e)Drug-relatedlunginjury药物肺损害药物肺损害(f)Sarcoidosis(f)Sarcoidosis结节病结节病Idiopathicpulmonaryfibrosis(IPF)Correct.Idiopathicpulmonaryfibrosis(IPF).Intheabsenceahistorytosuggestoneofthespecificdiagnosesonthislist,IPFismostlikely.Itaccountsfor60%ofcaseshavingthisappearance.IPF在该病例无特异性，60%有该表现。Case11a34-year-oldmanwithprogressiveshortnessofbreath喘憋Thepredominantabnormalityinthiscaseis:n n明显的异常表现明显的异常表现(a)honeycombingn n蜂窝肺蜂窝肺(b)intralobularinterstitialthickeningn n小叶间质增厚小叶间质增厚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.Case12a71-year-oldmanwithprogressiveshortnessofbreathThepredominantabnormalityinthiscaseis:n n突出的表现突出的表现(a)honeycombingn n蜂窝肺蜂窝肺(b)intralobularinterstitialthickeningn n小叶间质增厚小叶间质增厚intralobularinterstitialthickeningintralobularinterstitialthickeningCorrect.HoneycombingisnotclearlyseeninCorrect.Honeycombingisnotclearlyseeninthispatient.Afinebutirregularreticularpatternthispatient.Afinebutirregularreticularpattern不规则的网状改变不规则的网状改变 ispresentinthelungispresentinthelungperipheryperiphery外围外围,representing,representingintralobularintralobularinterstitialthickeninginterstitialthickening小叶间质增厚小叶间质增厚.Insome.Insomepatientswithpulmonaryfibrosis,thisfindingwillpatientswithpulmonaryfibrosis,thisfindingwillpredominate.Otherfindingspredominate.Otherfindings其他征象其他征象offibrosisoffibrosisinthispatientincludeinthispatientincludetractionbronchiectasistractionbronchiectasis牵拉牵拉性支扩性支扩,and,andirregularinterlobularseptalirregularinterlobularseptalthickeningthickening不规则小叶间隔增厚不规则小叶间隔增厚.Thedifferential.Thedifferentialdiagnosisofthisappearanceisidenticaltothatdiagnosisofthisappearanceisidenticaltothatforhoneycombing.forhoneycombing.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.Case1334-year-oldwomanwithlupuserytematosus狼疮红斑Canyoudiagnosefibrosis?n n能诊断纤维化？能诊断纤维化？(a)Yes(b)NoYesYesCorrect.HRCTobtainedinthesupineandproneCorrect.HRCTobtainedinthesupineandpronepositionspositions仰卧和俯卧位仰卧和俯卧位showsanumberofshowsanumberoffindingsindicatingfibrosisfindingsindicatingfibrosis指示指示,including:,including:honeycombingwhichismildindegreehoneycombingwhichismildindegree; ;轻度蜂窝轻度蜂窝肺肺tractionbronchiectasistractionbronchiectasis; ;牵拉性支扩牵拉性支扩intralobularinterstitialthickeningintralobularinterstitialthickening; ;小叶间质增厚小叶间质增厚interlobularseptalthickeninginterlobularseptalthickening小叶间隔增厚小叶间隔增厚;and;andasubpleuraldistribution.asubpleuraldistribution.胸膜下分布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.Case14a65-year-oldwomanwithrheumatoidarthritisa65-year-oldwomanwithrheumatoidarthritis风湿风湿性关节炎性关节炎andmilddyspneaandmilddyspnea轻度呼吸困难轻度呼吸困难Canyoudiagnosefibrosis?n n能诊断纤维化？能诊断纤维化？(a)Yes(b)NoCorrectnincluding: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.Case15a26-year-oldwomanwithmixedconnectivea26-year-oldwomanwithmixedconnectivetissuediseasetissuedisease混合结缔组织病混合结缔组织病,basilarcracklesonphysical,basilarcracklesonphysicalexaminationexamination双肺底水泡音双肺底水泡音,andrestrictivediseaseonpulmonary,andrestrictivediseaseonpulmonaryfunctiontestsfunctiontests肺功能受限肺功能受限Canyoudiagnosefibrosis?n n能诊断纤维化？能诊断纤维化？(a)Yes(b)NoYesCorrect.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,andintralobularinterstitialthickeningCase16a81-year-oldmanwithsignificanta81-year-oldmanwithsignificantoccupationalexposuretoasbestosoccupationalexposuretoasbestos石棉职业史Ispulmonaryfibrosispresent?n n肺纤维化存在？肺纤维化存在？(a)Yes(b)NoYesCorrect.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、钙化椎旁区域椎旁区域横膈胸膜肥厚钙化横膈胸膜肥厚钙化Case17a58-year-oldmanwithahistoryofasbestosa58-year-oldmanwithahistoryofasbestosexposureexposure石棉史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)NoNoCorrect.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。Case18a67-year-oldmanwithahistoryofa67-year-oldmanwithahistoryofasbestosexposureasbestosexposure石棉史NoNoCorrect.HRCTatlungwindowsshowsirregularCorrect.HRCTatlungwindowsshowsirregularlinearopacitieslinearopacities不规则的线状影不规则的线状影 ( (“crowsfeet”“crowsfeet”乌乌鸦脚鸦脚),withoutevidenceofhoneycombing),withoutevidenceofhoneycombing无蜂窝无蜂窝肺肺,intralobularinterstitialthickening,intralobularinterstitialthickening小叶间质增小叶间质增厚厚,ortractionbronchiectasis,ortractionbronchiectasis牵拉性支扩牵拉性支扩.This.Thisappearancedoesnotindicateasbestosisappearancedoesnotindicateasbestosis无石棉无石棉特征特征.Linearopacities,asseeninthiscase.Linearopacities,asseeninthiscase(parenchymalbands(parenchymalbands肺实质带肺实质带)arecommonin)arecommoninpatientswithpleuralthickeningrelatedtopatientswithpleuralthickeningrelatedtoasbestosexposure,butarenotnecessarilyasbestosexposure,butarenotnecessarilyassociatedwithlungfibrosisassociatedwithlungfibrosis不必须考虑肺纤维不必须考虑肺纤维化化.Theyrepresentfocalareasofatelectasis.Theyrepresentfocalareasofatelectasis焦焦点为肺膨胀不全点为肺膨胀不全,associated,associated联系联系withthepleuralwiththepleuralthickening,orfocalareasofscarringthickening,orfocalareasofscarring焦点区疤痕焦点区疤痕. .乌鸦脚（crowsfeet),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Case19a56-year-oldmanwithsignificanta56-year-oldmanwithsignificantoccupationalexposuretoasbestosoccupationalexposuretoasbestos石棉史Istherepleuralthickening胸膜增厚youwouldconsider考虑likely可能duetoasbestosexposure石棉?(a)Yes(b)NoYescorrect.Afocalcorrect.Afocal焦点焦点, ,calcifiedpleuralplaquecalcifiedpleuralplaque胸膜钙胸膜钙斑斑 isvisibleanteriorly,typicalofasbestosexposureisvisibleanteriorly,typicalofasbestosexposure石棉肺典型表现石棉肺典型表现.Althoughplaquesaremorelikely.Althoughplaquesaremorelikelyposteriorinlocationposteriorinlocation常见后胸膜常见后胸膜,thisappearanceis,thisappearanceishighlysuggestivehighlysuggestive高度提示高度提示. .Canadefinitediagnosisofpulmonaryfibrosisonthepronelungwindowscansbemade?肺窗能明确诊断肺纤维化吗？(a)Yes(b)NoNoNoCorrect.ThereismildseptalthickeningCorrect.Thereismildseptalthickening轻度间轻度间隔增厚隔增厚andandreticulationreticulation 网状网状intheposteriorintheposteriorsubpleuralregionsubpleuralregion后胸膜下后胸膜下 ontheright.Thisisontheright.Thisisunassociatedunassociated无联系无联系withadjacentwithadjacent临近临近 pleuralpleuralthickening.Thisisaverysubtleabnormalitythickening.Thisisaverysubtleabnormality轻微轻微的异常的异常 whichcouldrepresenttheearlieststagewhichcouldrepresenttheearlieststageofasbestosisofasbestosis石棉肺早期表现石棉肺早期表现.However,inthe.However,intheabsenceofamoredefiniteabnormalityabsenceofamoredefiniteabnormality明确的异明确的异常常 orsimilarorsimilar类似类似findingsontheleft,itwouldbefindingsontheleft,itwouldbedifficultdifficult困难困难tomakeadefinitediagnosisoftomakeadefinitediagnosisoffibrosisfibrosis石棉肺或肺纤维化的诊断石棉肺或肺纤维化的诊断 orasbestosis.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n n11胸膜改变胸膜改变：胸膜斑、弥漫性胸膜增厚、胸腔：胸膜斑、弥漫性胸膜增厚、胸腔积液。积液。n n22肺改变肺改变：弥漫性肺间质纤维化：弥漫性肺间质纤维化HRCTHRCT胸膜胸膜下弧线、胸膜下点状致密影、肺实质带、蜂窝下弧线、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增厚）；圆形肺不张（支气管血管结构进入- -彗彗星尾征）。星尾征）。 Case20a57-year-oldwomanwithyearsofa57-year-oldwomanwithyearsofprogressivedyspneaprogressivedyspnea多年呼吸困难Ispulmonaryfibrosispresent?n n肺纤维化存在吗？肺纤维化存在吗？(a)Yes(b)NoYesCorrect.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;andHoneycombingatthelungbases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)NoNoCorrect.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.DISCUSSIONDISCUSSIONInpatientswithsarcoidosisInpatientswithsarcoidosis结节病结节病,progressivefibrosis,progressivefibrosisoftenleadsoftenleads累计纤维化常导致累计纤维化常导致toperibronchovasculartoperibronchovascularconglomeratemassesoffibroustissueconglomeratemassesoffibroustissue支气管血管束聚集支气管血管束聚集成纤维块成纤维块,typicallymostmarkedintheupperlobes,typicallymostmarkedintheupperlobes上叶显上叶显著著.Bronchiandvesselsareclusteredtogetherbecauseof.Bronchiandvesselsareclusteredtogetherbecauseofretraction,andbronchiappeardilated(i.e.tractionretraction,andbronchiappeardilated(i.e.tractionbronchiectasis);theonlyotherdiseasesthatcommonlybronchiectasis);theonlyotherdiseasesthatcommonlyresultinthisappearancearesilicosis,tuberculosis,andresultinthisappearancearesilicosis,tuberculosis,andtalcosis.talcosis.PosteriordisplacementoftheupperlobebronchiPosteriordisplacementoftheupperlobebronchi indicatingvolumelossintheposteriorsegmentsoftheindicatingvolumelossintheposteriorsegmentsoftheupperlobesisacommonearlyfinding.upperlobesisacommonearlyfinding.HoneycombingHoneycombingorlungcystscanbepresentinpatientsorlungcystscanbepresentinpatientswithsarcoidosis,butthisfindingislesscommonthaninwithsarcoidosis,butthisfindingislesscommonthaninotherfibroticlungdiseasessuchasidiopathicpulmonaryotherfibroticlungdiseasessuchasidiopathicpulmonaryfibrosis.Honeycombingisusuallylimitedtopatientswithfibrosis.Honeycombingisusuallylimitedtopatientswithseverefibrosisandcentralconglomerationofbronchi.severefibrosisandcentralconglomerationofbronchi.ThehoneycombingseeninpatientswithsarcoidosisThehoneycombingseeninpatientswithsarcoidosisinvolvesmainlythemiddleandupperlungzones,withinvolvesmainlythemiddleandupperlungzones,withrelativesparingofthelungbases.However,inanrelativesparingofthelungbases.However,inanoccasionalcase,findingscanmimicIPF.occasionalcase,findingscanmimicIPF.支气管血管束聚集成纤维块谢谢！