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1、孤立性肺结节的鉴别诊断，在临床中经常遇到。根据结节的良恶性差异，处理方法有很大差别。在这篇文章中，我们主要探讨CT和PET-CT的相关征象在孤立性肺结节良恶性鉴别诊断中的意义。n nThe differential diagnosis of a solitary pulmonary nodule is broad and The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is benign or malignant.man
2、agement depends on whether the lesion is benign or malignant.In this overview we will discuss some of the new features that can help to In this overview we will discuss some of the new features that can help to differentiate between benign and malignant nodules based upon CT and differentiate betwee
3、n benign and malignant nodules based upon CT and PET-CT findings PET-CT findings 9/11/20241孤立性肺结节PETCT良恶性鉴别诊疗孤立性肺结节的鉴别诊断，在临床中经常遇到。根据结节的良恶性差目录（contents）n nCTCT征象征象征象征象1.1.钙化钙化2.2.大小大小3.3.生长速度生长速度4.4.形状形状5.5.边界边界6.6.充气支气管征充气支气管征7.7.实性和磨玻璃成分实性和磨玻璃成分8.8.强化特征强化特征n nPET-CTPET-CT征象征象征象征象n n结论结论结论结论n nCT: b
4、enign versus CT: benign versus malignant malignant 1.1.CalcificationCalcification 2.2.Size Size 3.3.GrowthGrowth 4.4.ShapeShape 5.5.MarginMargin 6.6.Air Bronchogram signAir Bronchogram sign 7.7.Solid and Ground-glass Solid and Ground-glass componentscomponents 8.8.Contrast enhancementContrast enhanc
5、ement n nPET-CT: benign PET-CT: benign versus malignant versus malignant n nConclusionConclusion 9/11/20242孤立性肺结节PETCT良恶性鉴别诊疗目录（contents）CT征象CT: benign ver钙化良性钙化征象：良性钙化征象： 弥漫性弥漫性 中心性中心性 层状层状 爆米花样爆米花样n n弥漫性、中心性、层状及爆米花样钙化多见于良性结节。弥漫性、中心性、层状及爆米花样钙化多见于良性结节。主要见于肉芽肿性疾病和错构瘤。主要见于肉芽肿性疾病和错构瘤。n n其他类型钙化多见于恶性结节，不
6、应该认为属于良性表现。其他类型钙化多见于恶性结节，不应该认为属于良性表现。n n在已知有原发肿瘤存在的情况下，其钙化类型不一定适用在已知有原发肿瘤存在的情况下，其钙化类型不一定适用此结论。例如：骨肉瘤或软骨肉瘤的病人，其钙化多表现此结论。例如：骨肉瘤或软骨肉瘤的病人，其钙化多表现为弥漫性；同样的，中心性和爆米花样钙化也可见于胃肠为弥漫性；同样的，中心性和爆米花样钙化也可见于胃肠道肿瘤或接受过化疗的病人。道肿瘤或接受过化疗的病人。9/11/20243孤立性肺结节PETCT良恶性鉴别诊疗钙化良性钙化征象： 弥漫性 Calcificationn nDiffuse, central, laminate
7、d or popcorn Diffuse, central, laminated or popcorn calcifications are benign patterns of calcification.calcifications are benign patterns of calcification.These types of calcification are seen in These types of calcification are seen in granulomatous disease and hamartomas.granulomatous disease and
8、 hamartomas.All other patterns of calcification should not be All other patterns of calcification should not be regarded as a sign of benignity.regarded as a sign of benignity.n nThe exception to the rule above is when patients The exception to the rule above is when patients are known to have a pri
9、mary tumor.are known to have a primary tumor.For instance the diffuse calcification pattern can For instance the diffuse calcification pattern can be seen in patients with osteosarcoma or be seen in patients with osteosarcoma or chondrosarcoma.chondrosarcoma.Similarly the central and popcorn pattern
10、 can be Similarly the central and popcorn pattern can be seen in patients with GI-tumors and patients who seen in patients with GI-tumors and patients who previously had chemotherapy.previously had chemotherapy.9/11/20244孤立性肺结节PETCT良恶性鉴别诊疗CalcificationDiffuse, central,结节大小 结节大小与恶性可能性之间的关系结节大小与恶性可能性之
11、间的关系n n孤立性肺结节（孤立性肺结节（SPNSPN）定义：肺实质内小于等于）定义：肺实质内小于等于3cm3cm的病灶（需除外的病灶（需除外肺不张和肿大的淋巴结）。大于肺不张和肿大的淋巴结）。大于3cm3cm的病灶称为肿块（的病灶称为肿块（massmass）。）。n n之所以这样定义，是因为大于之所以这样定义，是因为大于3cm3cm的病灶多为恶性，而更小的病灶可的病灶多为恶性，而更小的病灶可能是良心或恶性。能是良心或恶性。n nSwensen. et al Swensen. et al 研究了研究了SPNSPN大小与恶性可能性之间的关系（上图），大小与恶性可能性之间的关系（上图），结论是小的
12、结节，良性可能性大。超过结论是小的结节，良性可能性大。超过20002000例小于例小于4mm4mm的结节，无的结节，无一例属于恶性。一例属于恶性。9/11/20245孤立性肺结节PETCT良恶性鉴别诊疗结节大小 Size n nA solitary pulmonary nodule (SPN) is defined as a single A solitary pulmonary nodule (SPN) is defined as a single intraparenchymal lesion less than 3 cm in size and not intraparenchymal
13、lesion less than 3 cm in size and not associated with atelectasis or lymphadenopathy.associated with atelectasis or lymphadenopathy.A lesion greater than 3 cm in diameter is called a mass.A lesion greater than 3 cm in diameter is called a mass.This distinction is made, because lesions greater than 3
14、 cm This distinction is made, because lesions greater than 3 cm are usually malignant, while smaller lesions can be either are usually malignant, while smaller lesions can be either benign or malignant.benign or malignant.n nSwensen et al studied the relationship between the size of a Swensen et al
15、studied the relationship between the size of a SPN and the chance of malignancy in a cohort at high risk SPN and the chance of malignancy in a cohort at high risk for lung cancer (1).for lung cancer (1).Their findings are listed in the table on the left.Their findings are listed in the table on the
16、left.They concluded that benign nodule detection rate is high, They concluded that benign nodule detection rate is high, especially if lesions are small.especially if lesions are small.Of the over 2000 nodules that were less than 4 mm in size, Of the over 2000 nodules that were less than 4 mm in siz
17、e, none was malignantnone was malignant9/11/20246孤立性肺结节PETCT良恶性鉴别诊疗Size A solitary pulmonary nodu生长速度n n与以前的CT片进行比较，在结节定性方面具有重要意义。超过2年无变化的结节多为良性。9/11/20247孤立性肺结节PETCT良恶性鉴别诊疗生长速度与以前的CT片进行比较，在结节定性方面具有重要意义。Growthn nComparison with prior imaging studies is often the most useful procedure to determine th
18、e importance of the finding of a SPN, since stability over 2 years is highly associated with benignity.9/11/20248孤立性肺结节PETCT良恶性鉴别诊疗GrowthComparison with prior im形状 左：横断图像；右：冠状重建图像。三维比值左：横断图像；右：冠状重建图像。三维比值=（最大）横径（最大）横径/ /长径长径n n日本的相关研究证实，多角形、三维比值大于日本的相关研究证实，多角形、三维比值大于1.781.78的结节，多为的结节，多为良性。在肺的外围、胸膜下的
19、结节也多为良性。良性。在肺的外围、胸膜下的结节也多为良性。n n三维比值三维比值=（最大）横径（最大）横径/ /长径。大的三维比值说明病灶的形状是长径。大的三维比值说明病灶的形状是扁平的（是扁平的（是“ “片片” ”不是不是“ “块块” ”），这是良性的特征。），这是良性的特征。9/11/20249孤立性肺结节PETCT良恶性鉴别诊疗形状 左：横断图像；右：冠状重建图Shapen nJapanese screening studies showed that a Japanese screening studies showed that a polygonal shape and a thr
20、ee-dimensional ratio polygonal shape and a three-dimensional ratio 1.78 was a sign of benignity (2,3).1.78 was a sign of benignity (2,3).A polygonal shape means that the lesion has A polygonal shape means that the lesion has multiple facets (multi-sided).multiple facets (multi-sided).A peripheral su
21、bpleural location was also a sign of A peripheral subpleural location was also a sign of benignity in this study.benignity in this study.n nThe three-dimensional ratio is measured by The three-dimensional ratio is measured by obtaining the maximal transverse dimension and obtaining the maximal trans
22、verse dimension and dividing it by the maximal vertical dimension.dividing it by the maximal vertical dimension.A large three-dimensional ratio indicates that the A large three-dimensional ratio indicates that the lesion is relatively flat, which is a benign sign.lesion is relatively flat, which is
23、a benign sign.9/11/202410孤立性肺结节PETCT良恶性鉴别诊疗Shape10/2/202210孤立性肺结节PETCT良恶性边缘n n辐射冠征辐射冠征辐射冠征辐射冠征：绝大多数都为恶性（上图：恶性病灶：绝大多数都为恶性（上图：恶性病灶周围的辐射冠征周围的辐射冠征-毛刺）。毛刺）。n n病灶边缘呈病灶边缘呈分叶状分叶状分叶状分叶状的，可以是良性或恶性的，可以是良性或恶性n n边缘边缘光滑光滑光滑光滑，多为良性。，多为良性。9/11/202411孤立性肺结节PETCT良恶性鉴别诊疗边缘辐射冠征：绝大多数都为恶性（上图：恶性病灶周围的辐射冠征Marginn nCorona ra
24、diata sign - highly associated with malignancy (figure) n nLobulated or scalloped margins - intermediate probability n nSmooth margins - more likely benign unless metastatic in origin 9/11/202412孤立性肺结节PETCT良恶性鉴别诊疗MarginCorona radiata sign - hi充气支气管征n n最新研究表明，有充气支气管征的结节多为恶性。最新研究表明，有充气支气管征的结节多为恶性。主要见于
25、主要见于BACBAC（细支气管肺泡癌）和腺癌。（细支气管肺泡癌）和腺癌。n n上图显示充气的支气管呈线样（粗箭）或囊状上图显示充气的支气管呈线样（粗箭）或囊状（细箭）透亮区，这是支气管走向不同造成的。（细箭）透亮区，这是支气管走向不同造成的。9/11/202413孤立性肺结节PETCT良恶性鉴别诊疗充气支气管征最新研究表明，有充气支气管征的结节多为恶性。主要Air Bronchogram signn nRecent studies have showed that an air Recent studies have showed that an air bronchogram is more
26、 commonly seen in bronchogram is more commonly seen in malignant pulmonary nodules.malignant pulmonary nodules.It is most commonly seen in BAC It is most commonly seen in BAC (bronchoalveolar cell carcinoma) and (bronchoalveolar cell carcinoma) and adenocarcinoma.adenocarcinoma.n nThe case on the le
27、ft shows an The case on the left shows an airbronchogram seen as a linear lucency airbronchogram seen as a linear lucency (broad arrow) and as a more cystic (broad arrow) and as a more cystic lucency (small arrow) due to the fact that lucency (small arrow) due to the fact that the bronchus is seen e
28、n face.the bronchus is seen en face.9/11/202414孤立性肺结节PETCT良恶性鉴别诊疗Air Bronchogram sign10/2/20221n n图中两个图中两个SPNSPN，根据形态表现，哪个更像恶性的？，根据形态表现，哪个更像恶性的？n n左边的结节边缘呈毛刺状，内部有透亮区；右侧者呈分叶左边的结节边缘呈毛刺状，内部有透亮区；右侧者呈分叶状，边缘毛刺并与胸膜粘连，但是内部均质。状，边缘毛刺并与胸膜粘连，但是内部均质。n n基于上面的表现，我们认为左侧者更像恶性的。最终证实，基于上面的表现，我们认为左侧者更像恶性的。最终证实，左侧者为腺癌，右
29、侧为真菌感染。左侧者为腺癌，右侧为真菌感染。9/11/202415孤立性肺结节PETCT良恶性鉴别诊疗图中两个SPN，根据形态表现，哪个更像恶性的？10/2/20n nOn the left two solitary pulmonary nodules.On the left two solitary pulmonary nodules.Based upon the morphology, which lesion has the Based upon the morphology, which lesion has the most malignant features?most malig
30、nant features?n nThe lesion on the far left has a spicuated margin The lesion on the far left has a spicuated margin and has lucencies within it. and has lucencies within it. The lesion next to it is lobulated in contour and The lesion next to it is lobulated in contour and has some spicules radiati
31、ng to the pleura.has some spicules radiating to the pleura.It is however homogeneous in attenuation.It is however homogeneous in attenuation.Based on these findings we should be most Based on these findings we should be most concerned that the lesion on the far left is concerned that the lesion on t
32、he far left is malignant.malignant.It proved to be an adenocarcinoma, while the It proved to be an adenocarcinoma, while the other one was a fungal infection.other one was a fungal infection.The lucencies and frank air bronchograms should The lucencies and frank air bronchograms should not mislead y
33、ou in thinking that it probably is not mislead you in thinking that it probably is infection. infection. 9/11/202416孤立性肺结节PETCT良恶性鉴别诊疗On the left two solitary pulmo实性和磨玻璃成分一项研究表明：结节内含有磨玻璃样成分的，更倾向于属于恶性。结节内既含有部分实性成分，又含有磨玻璃成结节内既含有部分实性成分，又含有磨玻璃成分的，为恶性的可能性为分的，为恶性的可能性为63%63%。没有实性成分，只有磨玻璃成分的，恶性可能没有实性成分，只有磨
34、玻璃成分的，恶性可能性有性有18%18%。全部为实性成分的，恶性可能性为全部为实性成分的，恶性可能性为7%7%。9/11/202417孤立性肺结节PETCT良恶性鉴别诊疗实性和磨玻璃成分一项研究表明：结节内含有磨玻璃样成分的，更倾Solid and Ground-glass componentsAnother result from screening studies is that Another result from screening studies is that nodules containing a ground-glass nodules containing a groun
35、d-glass component are more likely to be component are more likely to be malignant.malignant. Partly solid lesions with ground-glass Partly solid lesions with ground-glass components had a malignancy rate of 63%. components had a malignancy rate of 63%. Nonsolid - only ground-glass lesions had a Nons
36、olid - only ground-glass lesions had a malignancy rate of 18%. malignancy rate of 18%. Only solid lesions had a malignancy rate of Only solid lesions had a malignancy rate of only 7%.only 7%.9/11/202418孤立性肺结节PETCT良恶性鉴别诊疗Solid and Ground-glass componen n左侧者只有磨玻璃成分；右侧者既有磨玻璃成分左侧者只有磨玻璃成分；右侧者既有磨玻璃成分又含有实性
37、成分。又含有实性成分。n n左侧者恶性可能性为左侧者恶性可能性为1/5;1/5;右侧者恶性可能性为右侧者恶性可能性为2/3.2/3.9/11/202419孤立性肺结节PETCT良恶性鉴别诊疗左侧者只有磨玻璃成分；右侧者既有磨玻璃成分又含有实性成分。1n nOn the far left a lesion that only has a ground-glass appearance and next to it a lesion that has both ground-glass and solid components.The likelihood of malignancy is 1:5
38、 for the lesion on the far left and 2:3 for the lesion with both ground-glass and solid components.9/11/202420孤立性肺结节PETCT良恶性鉴别诊疗On the far left a lesion that 强化特征n n增强扫描强化程度小于增强扫描强化程度小于15HU15HU的，有的，有99%99%的可能性为良性。的可能性为良性。平扫后增强扫描，每一分钟扫描一次，连续平扫后增强扫描，每一分钟扫描一次，连续4 4次。次。n n结节满足以下条件者，才能采用这种方法评价：结节满足以下条件者，
39、才能采用这种方法评价： 结节结节5mm5mm 相对呈球形相对呈球形 内部均质，没有坏死、脂肪和钙化内部均质，没有坏死、脂肪和钙化 图像无明显伪影图像无明显伪影9/11/202421孤立性肺结节PETCT良恶性鉴别诊疗强化特征增强扫描强化程度小于15HU的，有99%的可能性为良Contrast enhancement n nContrast enhancement less than 15 HU Contrast enhancement less than 15 HU has a very high predictive value for has a very high predictive
40、value for benignity (99%).benignity (99%).After a baseline scan, 4 consecutive scans After a baseline scan, 4 consecutive scans at 1 minute interval are performed.at 1 minute interval are performed.This applies only for nodules with the This applies only for nodules with the following selection crit
41、eria: following selection criteria: Nodule 5mm Nodule 5mm Relatively spherical Relatively spherical Homogeneous, no necrosis, fat or calcification Homogeneous, no necrosis, fat or calcification No motion or beam hardening artifacts No motion or beam hardening artifacts 9/11/202422孤立性肺结节PETCT良恶性鉴别诊疗C
42、ontrast enhancement Contrast PET-CTn nPET-CTPET-CT在实性结节评价方面起着越来越重要的作用。在实性结节评价方面起着越来越重要的作用。n n在进行在进行PET-CTPET-CT检查时，你必须意识到：检查时，你必须意识到： PET-CTPET-CT敏感性高达敏感性高达95%95%，但特异性只有，但特异性只有81%81%； 肉芽肿性疾病可以呈假阳性；肉芽肿性疾病可以呈假阳性； 小于小于10mm10mm的结节、良性肿瘤以及低度恶性的结节包括支气管肺的结节、良性肿瘤以及低度恶性的结节包括支气管肺泡癌可以呈假阴性。泡癌可以呈假阴性。n n上图为一例腺癌病人，
43、结节并不显示为高代谢状态，所以上图为一例腺癌病人，结节并不显示为高代谢状态，所以呈假阴性。呈假阴性。9/11/202423孤立性肺结节PETCT良恶性鉴别诊疗PET-CTPET-CT在实性结节评价方面起着越来越重要的作PET-CT: benign versus malignant n nPET-CT plays an increasingly important role in the PET-CT plays an increasingly important role in the evaluation of solitary nodules.evaluation of solitary
44、nodules.n nWhen you perform PET-CT, you have to realize When you perform PET-CT, you have to realize the following: the following: PET has a very high sensitivity 95%, but a lesser specificity of PET has a very high sensitivity 95%, but a lesser specificity of only 81% only 81% PET is false positive
45、 in granulomatous disease PET is false positive in granulomatous disease PET is usually false negative in size 10 mm and low-grade PET is usually false negative in size 10 mm and low-grade malignancy including bronchoalveolar carcinoma and carcinoid malignancy including bronchoalveolar carcinoma and
46、 carcinoid n nWith these specificity numbers, there will be false With these specificity numbers, there will be false positives in about 20%, depending on the positives in about 20%, depending on the background prevalence of granulomatous disease. background prevalence of granulomatous disease. On t
47、he left a patient with an adenocarcinoma, On the left a patient with an adenocarcinoma, that was not hypermetabolic on the PET, so it is a that was not hypermetabolic on the PET, so it is a false negative PET.false negative PET.9/11/202424孤立性肺结节PETCT良恶性鉴别诊疗PET-CT: benign versus malignan结论n n在良恶性肺结节的
48、鉴别诊断中，我们要尤其注意以下影像学特征：磨玻璃征、充气支气管征及结节的三维比值。n n在进行PET-CT检查时，要注意PET-CT的准确性问题，要注意感染性或非感染性肉芽肿性疾病诊断的可能性。9/11/202425孤立性肺结节PETCT良恶性鉴别诊疗结论在良恶性肺结节的鉴别诊断中，我们要尤其注意以下影像学特征Conclusionn nIn the differentiation of benign versus malignant In the differentiation of benign versus malignant solitary pulmonary nodules nowa
49、days new solitary pulmonary nodules nowadays new imaging features have to be added. imaging features have to be added. We especially have to look for the presence of We especially have to look for the presence of areas of ground-glass opacity, air bronchograms areas of ground-glass opacity, air bron
50、chograms or cavities and the three-dimensional ratios of a or cavities and the three-dimensional ratios of a lesion.lesion.n nWith the increasingly important role of PET-CT, With the increasingly important role of PET-CT, we have to be aware of the accuracy of PET-CT we have to be aware of the accur
51、acy of PET-CT and we should have an idea about the prevalence and we should have an idea about the prevalence of infectious and non-infectious granulomatous of infectious and non-infectious granulomatous disease in the area that we practice.disease in the area that we practice.9/11/202426孤立性肺结节PETCT良恶性鉴别诊疗ConclusionIn the differentiati
