肺部CT树芽征的诊断价值课件.ppt

1、肺部肺部CT CT 树芽征的诊断价值树芽征的诊断价值1编辑版ppt树芽征树芽征(Tree-in-Bud Pattern)树芽征是指病变累及细支气管以下的小气树芽征是指病变累及细支气管以下的小气道，由于小气道的扩张和管腔内炎性物质道，由于小气道的扩张和管腔内炎性物质的填充，在肺部薄层的填充，在肺部薄层CTCT（thin-section thin-section computed tomographycomputed tomography）或）或HRCTHRCT上表现为直上表现为直径径2mm2mm4mm4mm的小叶中心软组织密度结节影的小叶中心软组织密度结节影和与之相连的分支线状影，状如树芽而得和

2、与之相连的分支线状影，状如树芽而得名。名。2编辑版pptThe tree-in-bud pattern is commonly seen at thin-section computed tomography(CT)of the lungs.It consists of small centrilobular nodules of soft-tissue attenuation connected to multiple branching linear structures of similar caliber that originate from a single stalk 3编辑版p

3、pt树芽征树芽征最早由Im等描述为结核杆菌沿支气管内播散的CT表现，Paslawski等则认为树芽征是细支气管炎的典型HRCT征象，其形成基础是小叶中心支气管内脓液、粘液、肉芽肿或炎性细胞充填所致。Pipavath等也认为树芽征和小叶中心结节为细支气管炎的直接征象。4编辑版ppt病因本征可见于累及小气道的多种肺疾病，包括周围性气道感染（细菌、病毒、霉菌或寄生虫感染）、先天性疾病、特发性疾病（闭塞性细支气管炎、弥漫性泛细支气管炎）、吸入性肺炎、毒气吸入、免疫性疾病、结缔组织病、周围性肺血管病（如肿瘤性栓塞）和肿瘤支气管内转移等。树芽征是由多种影响小气道的病变所引起的一种非特异性征象。5编辑版pp

4、t病因感染（Infection）先天性病变(Congenital Disorders)特发性疾病(Idiopathic Disorders)异物吸入 毒气吸入 结缔组织病 免疫性疾病 肿瘤(Neoplasms)6编辑版ppt7编辑版ppt(一)感染（Infection）8编辑版ppt1、细菌性感染(Bacterial Infection)树芽征常见于结核杆菌沿支气管内播散的患者，该征的出现高度提示结核具有活动性。9编辑版pptHRCT表现通常表现为2mm4mm大小的小叶中心结节和分支样线状影，合并表现有支气管壁增厚，伴有或不伴有支气管扩张、气腔实变影、空洞、血行播散所致的边缘清楚小结节影、胸腔

5、积液、淋巴结肿大（伴有中心坏死）等。Kashyap 等认为树芽征和小叶中心结节是支气管内结核的特征性HRCT表现。（Kashyap S,Mohapatra PR,Saini V.Endobronchial tuberculosisJ.Indian J Chest Dis Allied Sci.2003;45(4):247-256.）10编辑版ppt Postprimary active tuberculosis in a 66-year-old woman with a chronic cough.High-resolution CT scans of the right lung show

6、peripheral,poorly defined,small(24-mm-diameter)centrilobular nodules and branching linear opacities of similar caliber originating from a single stalk(the tree-in-bud pattern)in the lower lobe(arrow).These findings represent endobronchial spread of tuberculosis.11编辑版ppt Postprimary active tuberculos

7、is in a 34-year-old man with weight loss and a chronic cough.(a)High-resolution CT scan of the left lung shows a thick-walled cavity and multiple peripheral small nodules and branching linear structures(arrows).Note the thickening of the bronchial walls(arrowhead).12编辑版pptPhotomicrograph(original ma

8、gnification,x400;hematoxylin-eosin stain)shows impacted caseous material(*)in small peripheral airways(arrow).13编辑版ppt男性，33岁。咳嗽、咳痰2月。14编辑版ppt女性，35岁，咳嗽咳痰午后低热 1月15编辑版ppt16编辑版ppt男性，34岁，咳嗽发热2周。17编辑版ppt肺部非结核性分支杆菌（nontuberculous mycobacteria）或称非典型分枝杆菌（atypical mycobacteria）感染主要由鸟胞内分支杆菌(M avium-intracellul

9、are complex,MAIC)和Kansasii分支杆菌致病。典型放射学表现类似于继发性肺结核（包括树芽征在内）。18编辑版pptCT表现Jeong等报告1组，其薄层CT扫描最常见表现有双肺小结节（100%）、静脉曲张型支气管扩张（91%）、树芽征（77%），相关的病理组织学表现为细支气管扩张、细支气管壁增厚、伴有或不伴有肉芽肿的细支气管及其周围炎症。-Jeong YJ,Lee KS,Koh WJ,et al.Nontuberculous mycobacterial pulmonary infection in immunocompetent patients:comparison of

10、thin-section CT and histopathologic findings.RadiologyJ,2004,231(3):880-886.19编辑版pptInfection with M avium-intracellulare complex in a 44-year-old woman with malaise and a chronic cough.High-resolution CT scans of the right lung show multiple peripheral small nodules connected to branching linear op

11、acities and a thick-walled cavity in the superior segment of the lower lobe.Note the thickening of the bronchial walls,bronchial dilatation,and mucus impaction.The diagnosis was confirmed with bronchoalveolar lavage.20编辑版ppt细支气管其他细菌感染如金黄色葡萄球菌、流行性嗜血杆菌感染的细支气管炎也可表现为周围分布的树芽征，其病理学基础为细支气管壁的炎性细胞浸润和管腔内炎性渗出物

12、充填所致。AIDS患者马红球菌（Rhodococcus equi）肺部感染CT扫描也可见树芽征表现。医源性绿脓假单胞菌肺炎(nosocomial Pseudomonas aeruginosa Pneumonia，PAP)有50%患者CT表现有结节影，其中1/3可见树芽征，21编辑版pptS aureus bronchiolitis in a 32-year-old man with acquired immunodeficiency syndrome(AIDS).(a)High-resolution CT scan shows small peripheral centrilobular no

13、dules and branching linear opacities,resulting in the tree-in-bud pattern.22编辑版ppt23编辑版ppt2、霉菌感染(Fungal Infection)气道侵袭性曲菌病是由曲菌孢子引起的真菌病，临床常见于免疫妥协中性粒细胞减少患者和AIDS患者。主要临床表现包括急性气管-支气管炎、细支气管炎和支气管肺炎，气管受累者占14%-34%。24编辑版pptCT表现HRCT表现为支气管周围的实变和小叶中心结节,细支气管炎薄层CT扫描的特征性表现为小叶中心结节和分支状线样影（即树芽征），其他HRCT表现有肺实变影合并周围毛玻璃密度

14、影（halo，晕征），因此在免疫妥协患者或AIDS患者肺部HRCT显示晕征结节和树芽征可提出肺曲菌病的诊断。25编辑版ppt Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation.(a)High-resolution CT scan(lung window)shows peripheral branching structures(arrow)associated with focal areas of consolidation in the right lower

15、lobe.26编辑版ppt病毒感染（Viral Infection）巨细胞病毒感染主要见于免疫缺陷患者，临床症状有发热、干咳、气短和低氧血症。CT表现常无特征性，为散在分布或广泛分布的磨玻璃密度影、肺实变影及边缘模糊的结节影伴有晕征，少见表现有支气管血管束增粗和树芽征。组织病理学上小叶中心结节为细支气管及其周围有巨噬细胞、红细胞和纤维蛋白聚集所致。27编辑版ppt呼吸道合胞病毒（RSV）也可引起下呼吸道感染，所致的细支气管炎和支气管肺炎最常见于婴幼儿和儿童，在成人也可引起肺炎。HRCT表现有磨玻璃密度影、气腔实变影、支气管壁增厚和扩张以及树芽征，有时还可见空气潴留.Ko JP,Shepard

16、JA,Sproule MW,et al.CT manifestations of respiratory syncytial virus infection in lung transplant recipientsJ.J Comput Assist Tomogr,2000,24(2):235241.28编辑版ppt Cytomegalovirus pneumonia in a 51-year-old man with chronic myelogenous leukemia who underwent bone marrow transplantation.(a)Thin-section C

17、T scan of the right lung shows centrilobular ground-glass opacities in addition to nodules and tree-in-bud opacities(arrow).29编辑版ppt59-year-old man with adenovirus infection after hematopoietic stem cell transplantation for Hodgkins disease.Transverse thin-section(1-mm collimation,lung window)CT sca

18、n obtained at level of lower pulmonary veins shows branching distal structures(tree-in-bud pattern)(arrow).30编辑版ppt31编辑版ppt(二)先天性病变(Congenital Disorders)32编辑版ppt1、囊性纤维化（Cystic fibrosis）囊性纤维化是一种以外分泌腺功能异常、粘液栓形成为特征的常染色体隐性遗传性多系统疾病，为相对常见的影响上下呼吸道、胰腺、肝脏、胆囊、肠道和生殖道的先天性病变。以外分泌腺功能异常和粘性物的分泌为特征，与水和盐的细胞运转缺陷有关，发生率

19、为1/2000，主要发生于白种人。33编辑版pptCT表现本病的最常见的CT表现为支气管壁增厚、支气管周围间质增厚、支气管扩张、细支气管扩张、指套状高密度粘液栓影并肺不张或肺实变，尽管典型病例可累及所有肺叶，但病变早期主要累及肺上叶尖后段。树芽征可能是病变的一个早期征象，这主要是由于细支气管内有大量的粘性分泌物停留所致。Oikonomou A,Manavis J,Karagianni P,et al.Loss of FEV1 in cystic fibrosis:correlation with HRCT featuresJ.Eur Radiol,2002,12(9):2229-2235.34

20、编辑版ppt Cystic fibrosis in a 17-year-old boy with a chronic cough.High-resolution CT scan shows dilated thick-walled bronchi and diffuse tree-in-bud patterns(arrow).35编辑版ppt2、Kartagener 综合症原发性纤毛运动功能障碍综合症是包括纤毛功能和结构异常的一组遗传性疾病，Kartagener 综合症是其一个亚型，包括内脏转位、鼻窦炎和支气管扩张三联症，支气管纤毛运动异常可导致反复的呼吸道感染和支气管扩张。HRCT表现包括支

21、气管壁增厚、支气管扩张，气道损伤延伸到小气道引起细支气管扩张、小叶中心结节影（树芽征）和空气潴留 Rossi SE,Franquet T,Volpacchio M,et al.Tree-in-bud pattern at thin-section CT of the lungs:radiologic-pathologic overviewJ.Radiographics,2005,25(3):789-801.。36编辑版pptKartagener syndrome in a 39-year-old woman with situs inversus,sinusitis,and bronchiec

22、tasis.(a)High-resolution CT scan shows bilateral bronchiectasis(white arrow)and small centrilobular nodules and branching linear opacities in the right lower lobe(black arrow).37编辑版ppt其他先天性异常其他多种先天性异常尤其是有支气管粘膜纤毛清除功能异常、免疫功能缺陷或有支气管壁结构异常者也可发生细支气管病。例如：Williams-Campbell综合症（先天性支气管软骨缺陷）Mounier-Kuhn综合症（先天性巨

23、气管支气管）Bruton氏低丙球蛋白血症、IgA 和IgA-IgG缺乏 Yellow nail综合症（黄甲综合症）20。38编辑版ppt（三）特发性疾病 (Idiopathic Disorders)39编辑版ppt1、闭塞性细支气管炎（Obliterative Bronchiolitis）闭塞性细支气管炎是指细支气管粘膜下及其周围不可复性纤维化导致的管腔向心性狭窄。尽管本病可见于病毒感染、胶原血管病（如类风湿性关节炎尤其是用青霉胺或金盐治疗后）、毒气吸入和脏器移植（肺或骨髓移植）等，但大部分为特发性的。40编辑版ppt临床表现患者常有进行性呼吸困难和气道阻塞的功能检查异常。本病的诊断标准为无肺

24、气肿、慢性支气管炎、哮喘及其他原因气道阻塞的患者有不可复性气流受限，FEV1小于60%等。41编辑版ppt影像学表现胸部X 线片表现肺血减少、肺叶过度膨胀。HRCT表现有中央性和周围性支气管扩张、支气管壁增厚，呼吸末HRCT扫描有空气潴留是发现闭塞性细支气管炎的最敏感征象，此外粘液嵌塞引起的小叶中心结节和树芽征也可见。42编辑版ppt Obliterative bronchiolitis after bone marrow transplantation in a 47-year-old man with myeloma.(a)Expiratory high-resolution CT sca

25、n shows diffuse centrilobular nodules connected to branching linear opacities bilaterally.Note the air trapping in the right lower lobe.43编辑版ppt2、弥漫性泛细支气管炎(Diffuse Panbronchiolitis,DPB)弥漫性泛细支气管炎是一种几乎仅发生于亚洲人的进行性肺部炎症性病变，其原因不明，特征性病理改变是副鼻窦和呼吸性细支气管的慢性炎症，呼吸性细支气管壁增厚，管壁全层有淋巴细胞、浆细胞和组织细胞浸润，病变进展可形成细支气管扩张。大部分患者

26、为非吸烟者且几乎都有慢性鼻窦炎。44编辑版pptCT表现HRCT表现有小的小叶中心结节（5mm）、小叶中心结节与分支样线状影相连即树芽征，此外可见支气管壁增厚、支气管扩张，病变主要累及肺的基底部，病变晚期可见囊性病变和空气潴留.45编辑版pptDiffuse panbronchiolitis in a 44-year-old Japanese man.High-resolution CT scan shows diffuse small centrilobular nodules and branching linear opacities(arrow),which resemble the

27、objects used in the game of jacks.Note the bronchiolar dilatation and mucoid impaction(arrowheads).46编辑版ppt（四）异物吸入47编辑版ppt病因弥漫性吸入性细支气管炎是由于异物颗粒反复多次吸入细支气管所引起的慢性炎症。造成因素有咽部结构异常、食道病变（贲门失弛缓症、食道裂孔疝、食道癌）、神经系统病变以及慢性疾病等。48编辑版ppt影像学表现无特征，可见肺叶、肺段或弥漫性分布的1mm3mm的小阴影，HRCT表现有小叶中心结节、单侧或双侧分支状高密度病灶及树芽征，病灶的分布取决于吸入物在细支气管

28、的位置。Franquet T,Gimenez A,Roson N,et al.Aspiration diseases:findings,pitfalls,and differential diagnosisJ.RadioGraphics,2000,20(3):673685.。49编辑版pptDiffuse aspiration bronchiolitis in a 61-year-old woman with achalasia（贲门失迟症）who experienced recurrent aspiration of foreign particles.Thin-section CT sca

29、n shows multiple centrilobular areas of increased attenuation with a characteristic tree-in-bud appearance.Esophageal dilatation with an air-fluid level is also seen.50编辑版ppt（五）毒气吸入51编辑版ppt毒气或有毒的烟尘吸入可导致急慢性肺部损害。病理主要表现为肺泡毛细血管的损伤、肺水肿、支气管炎和细支气管炎，有时并发肺不张和肺炎，病变后期可见闭塞性细支气管炎。HRCT可见支气管壁增厚、双肺实变影、支气管扩张和树芽征。52编

30、辑版pptInhalation bronchiolitis in a 56-year-old man after accidental exposure to sulfur dioxide.High-resolution CT scan shows bronchiectasis in combination with the tree-in-bud pattern in the right lower lobe.53编辑版ppt（六）结缔组织病54编辑版ppt类风湿性关节炎和干燥综合症可影响小气道，最常见的胸部表现是囊状支气管炎、支气管扩张、细支气管炎、闭塞性细支气管炎和机化性肺炎。Perez

31、 T,Remy Jardin M,Cortet B.Airways involvement in rheumatoid arthritis:clinical,functional,and HRCT findingsJ.Am J Respir Crit Care Med,1998,157(5):16581665.，55编辑版ppt干燥综合症可合并淋巴细胞性间质性肺炎，薄层CT表现可见支气管扩张、边缘模糊的小叶中心结节和分支线状影（树芽征）。此外可有磨玻璃密度影、空气潴留和蜂窝。Lohrmann C,Uhl M,Warnatz K,et al.High-resolution CT imaging

32、of the lung for patients with primary Sjogrens syndromeJ.Eur J Radiol,2004,52(2):137-143.。56编辑版ppt Sjgren syndrome in a 54-year-old woman.Thin-section CT scan shows peripheral tree-in-bud patterns in the right lower lobe.Note the bronchial dilatation,bronchial wall thickening,and consolidation.57编辑版

33、ppt58编辑版ppt（七）免疫性疾病59编辑版ppt病因与病理过敏性支气管肺曲菌病是由于支气管内增殖的曲菌菌丝引起的I型和III型（IgE 和IgG）免疫反应，免疫复合物和炎性细胞沉积于支气管粘膜导致支气管粘膜坏死和嗜酸细胞浸润，支气管壁受损继发支气管扩张，过敏反应引起支气管分泌物增加，与繁殖的菌丝混合使得分泌物粘性增加不易咳出引起粘液嵌塞。过敏性支气管肺曲菌病最常见于囊性纤维化和支气管哮喘患者。60编辑版ppt影像学表现本病的典型放射学表现是以肺上叶分布为主的支气管扩张和粘液嵌塞，粘液嵌塞表现为密度均匀的管状或“手套状”致密影，粘液嵌塞可向细支气管延伸产生树芽征。Gotway MB,Daw

34、n SK,Caoili EM,et al.The radiologic spectrum of pulmonary Aspergillus infectionsJ.J Comput Assist Tomogr,2002,26(2):159173.,61编辑版ppt Allergic bronchopulmonary aspergillosis in a 36-year-old man with a history of asthma.High-resolution CT scans show peripheral mild bronchiolar dilatation and mucoid i

35、mpaction in the anterior segment of the left upper lobe(long arrow)and the posterior segment of the right upper lobe,resulting in the tree-in-bud pattern.Note the bronchial wall thickening(short arrow).62编辑版ppt（八）肿瘤 (Neoplasms)63编辑版ppt据尸体解剖发现肺血管内肿瘤栓子的发生率为2.4%-26%，常见的引起肺血管肿瘤栓子的肺外原发性恶性肿瘤有乳腺癌、肝癌、肾癌、胃癌、

36、前列腺癌和卵巢癌。Rossi SE,Goodman PC,Franquet T.Nonthrombotic pulmonary emboli:reviewJ.AJR Am J Roentgenol 2000;174(6):14991508.64编辑版ppt影像学表现薄层CT可显示多处血管扩张或串珠状影、周围性楔形影、小叶内间隔增厚、小叶中心结节和树芽征。肿瘤的支气管内转移累及小气管也可表现为呈树芽征的小叶中心结节影，近期Kao29 等报告了1例胸腺癌支气管内转移在HRCT上就主要表现为树芽征。Tack D,Nollevaux MC,Gevenois PA,et al.Tree-in-bud p

37、attern in neoplastic pulmonary emboliJ.AJR Am J Roentgenol,2001,176(6):1421-1422.65编辑版ppt Tumor emboli from Ewing sarcoma in a 16-year-old boy.High-resolution CT scan shows enlarged and beaded peripheral arteries in the posterior right lower lobe(arrow),which resemble the tree-in-bud pattern.66编辑版pp

38、t Pulmonary neoplastic thrombotic microangiopathy caused by gastric adenocarcinoma in a 48-year-old man.(a)High-resolution CT scan shows multiple centrilobular nodules and branching lines with the tree-in-bud appearance(arrows),which is caused by tumor emboli.67编辑版pptWe report a case of pulmonary in

39、travascular metastases from pancreatic adenocarcinoma manifesting as tree-in-bud pattern on thoracic computed tomography.Although infectious bronchiolitis is the most common cause of tree-in-bud pattern,this case emphasizes that the differential diagnoses include pulmonary intravascular metastases,p

40、articularly in patients with extrapulmonary adenocarcinomas.Tree-in-bud pattern on thoracic CT due to pulmonary intravascular metastases from pancreatic adenocarcinoma.Li Ng Y,Hwang D,Patsios D,Weisbrod G.J Thorac Imaging.2009 May;24(2):150-1.68编辑版ppt小小 结结69编辑版ppt树芽征是常见的放射学表现，其特点是呈软组织密度的、小的小叶中心结节影与多分支的线样结构影相连。过去认为树芽征对结核性分支杆菌感染、非结核性分支杆菌感染、病毒感染和囊性纤维化有缩小鉴别诊断范围的价值，但现在认为该征可见于多种种类不同的病种，重新认识该征的多种病因对预防诊断错误非常有用，另外尽管放射学不能区别导致树芽征的原因，但若结合病史、临床表现和合并存在的其他放射学表现则常有可能提出合适的诊断。70编辑版ppt71编辑版ppt美丽的丹霞72编辑版ppt