摘要
研究目的:
研究纵隔实性病变的影像与病理学特征;以病理学为基础,对比分析纵隔实性病变的影像学变化,探讨不同类型肿瘤的影像学特征,以期为纵隔病变的病理诊断提供重要的参考指标;并进一步提高对该类疾病的影像学与病理学的诊断和鉴别诊断水平。
材料与方法:
收集经临床及病理证实的纵隔实性病变86例,男性49例,女性37例。年龄11-82(平均50.6)岁。依据不同的细胞类型及组织形态分为7组,分别为胸腺瘤10例,胸腺鳞癌10例,其他上皮源性肿瘤(癌)15例,小细胞性恶性肿瘤32例,间叶来源肿瘤4例,生殖细胞肿瘤5例,良性病变10例。全部病例均进行至少一次胸部MSCT(4排或16排)检查,行常规及双期增强扫描。由2位有胸部诊断经验的放射科医师双盲阅片,重点观察纵隔实性病变的位置、大小、形态、病灶密度及有无纵隔血管侵袭等。病理切片由2位有病理诊断经验的病理科医师双盲阅片,并对于结果不一致或诊断依据不充分的病例,补充部分免疫组化染色后由2位病理医师会诊后确定诊断。
结果:
1、86例纵隔实性病变中,恶性肿瘤76例(88.4%),良性病变10例(11.6%),恶性肿瘤主要位于前纵隔(77.6%),形态为分叶状或不规则形(86.8%),边缘模糊(72.4%),密度不均(72.4%),及不均匀中等度强化(86.8%),明显与良性病变不同(P值均为0.000)。
2、胸腺肿瘤20例,其中胸腺瘤10例,胸腺鳞癌10例,均位于前纵隔。在肿物直径>5cm、呈分叶状、边界模糊、密度不均及钙化等CT特征中,B3型胸腺瘤所占比例高于其他组织类型;而胸腺鳞癌所占的百分数则明显高于胸腺瘤,比较胸腺瘤与胸腺鳞癌的形态、边缘及密度改变,二者间存在明显的统计学差异(P值<0.05)。
3、其它上皮源性肿瘤15例,其中非胸腺来源鳞状细胞癌(以下简称非胸腺鳞癌)9例,腺癌3例,非典型类癌3例。肿瘤多位于中纵隔及纵隔旁分别占86.7%和80%。比较胸腺鳞癌和非胸腺鳞癌的CT特征,二者在纵隔分布上存在显著的统计学差异(P值分别为0.000和0.033),非胸腺鳞癌均位于中纵隔偏于一侧,而胸腺鳞癌均位于前纵隔,50%居中。
4、小细胞性恶性肿瘤32例,包括淋巴瘤16例,小细胞癌12例,髓细胞肉瘤、浆细胞瘤、PNET和小圆细胞瘤各1例。平均年龄44.8(11~82)岁,其中淋巴瘤平均37.6岁,男性平均59岁,女性平均27.8岁。小细胞癌平均56.5岁,男性平均54.1岁,女性平均61.3岁。32例中,淋巴瘤和小细胞癌分别占50%和37.5%。淋巴瘤在发病年龄、纵隔分布、病灶密度上与小细胞癌存在明显的统计学差异(P值<0.05)。小细胞性肿瘤与上皮源性肿瘤对比,二者在纵隔分布、病灶密度及是否存在血管侵袭性方面存在统计学差异(P值<0.05)。小细胞性肿瘤多位于前纵隔,肿瘤密度多小于40Hu,肿块更易压迫血管移位并侵袭包绕血管。
5、间叶源性肿瘤4例,其中间皮瘤3例,单向性滑膜肉瘤1例。平均年龄52.3(20~77)岁。间皮瘤位于前纵隔,形态不整,边缘模糊,并累及胸膜。滑膜肉瘤位于后纵隔,圆形,边缘光滑,局部椎体骨质破坏,椎间孔扩大。
6、生殖细胞肿瘤5例,均为男性,平均年龄42.4(24~82)岁。其中未成熟畸胎瘤4例,精原细胞瘤1例。均位于前纵隔,圆形或类圆形,与纵隔血管间分界不清。病灶均大于5cm。增强CT扫描轻中度强化。
7、良性病变10例,平均年龄56.4(21~58)岁,其中良性肿瘤4例(神经鞘瘤4例,神经纤维瘤、胸骨后甲状腺肿各1例),良性病变4例(结核病2例,结节病2例)。前纵隔1例,见于胸骨后甲状腺肿;中纵隔3例,其中神经纤维瘤1例,结节病2例;后纵隔6例,为神经鞘瘤和结核病。神经鞘瘤均位于脊柱旁沟,1例可见椎间孔扩大。神经纤维瘤呈柱状,经胸廓入口延伸至颈部。胸骨后甲状腺肿与颈部甲状腺相连。结节病双侧肺门淋巴结肿大。结核病1例病灶内钙化,邻近椎体破坏,1例见邻近胸椎间隙变窄。增强轻中度均匀强化。
结论:
本研究通过对86例纵隔实性病变不同组织类型的CT征像分析和研究,初步得出以下结论:
1、恶性肿瘤主要位于前纵隔,形态为分叶状或不规则形,边缘模糊,密度不均,增强扫描表现为不均匀中等度强化,与纵隔良性病变明显不同。
2、B3型胸腺瘤较其它类型更多见肿物直径≥5cm、呈分叶状、边界模糊、密度不均及钙化等CT特征。胸腺癌与B3型胸腺瘤CT表现类似。
3、位于前纵隔,居中的鳞状细胞癌提示胸腺来源,而位于中纵隔偏于一侧的鳞状细胞癌提示非胸腺来源。
4、纵隔小细胞性恶性肿瘤多见于淋巴瘤和小细胞癌。对于小细胞肿瘤,年龄小于40岁、位于前纵隔、病变密度大于40Hu的纵隔小细胞恶性肿瘤倾向于淋巴瘤,而年龄大于40岁、位于纵隔旁及密度小于40Hu的病变倾向小细胞癌。
5、在小细胞性恶性肿瘤与上皮源性肿瘤病理鉴别存在困难时,如果影像学表现为肿块位于前纵隔、铸型包绕纵隔大血管及密度不均匀时有助于诊断小细胞性肿瘤。
Objective:
This study aimed to investigate CT features in different pathological types of mediastinal lesions, analyze CT manifestations of benign and malignant lesions, find differentiation methods, and try to elucidate the mechanism of the CT signs to improve diagnosis level of mediastinal solid lesions in radiology and pathology.
Materials and Methods:
86 cases of pathologically confirmed mediastinal lesions, 49 cases of male and female 37 cases. Aged 11-82 (mean 50.6) years. According to the cell type and tissue morphology they were divided into 7 groups: 10 cases of thymoma, 10 cases of thymic squamous carcinoma, 15 cases of other epithelium-derived tumors (cancer), 32 cases of small cell cancer, 4 cases of mesenchymal tumor, 4 cases of germ cell tumors, and 10 cases of benign lesions. All patients took chest MSCT (4 rows or 16 rows) examination at least once, by either routine or double-phase enhanced scan. The films were diagnosed by two experienced radiologists independently, focusing on the location, size, shape, density and mediastinal vessels invasion of the lesions. Pathological sections were examed by 2 experienced pathologists independently. If diagnosis was different, additional immunohistochemical staining was performed to get a final diagnosis by two pathologists.
Results:
1. In 86 cases of mediastinal lesions, 76 cases of malignant tumors (88.4%), 10 cases of benign lesions (11.6%), malignant tumors mainly located in the anterior mediastinum (77.6%), lobulated or irregular in shape (86.8 %), blurred edge (72.4%), uneven density (72.4%), enhanced scan showed inhomogeneous moderate degree of enhancement (86.8%) and benign lesions was significantly different (P = 0.000).
2. In 20 cases of thymic tumors, 10 cases of thymoma, 10 cases of thymic squamous cell carcinoma, all located in the anterior mediastinum. Among the CT features such as tumor diameter> 5cm, lobulated, blurred edge, uneven density and calcification, the proportion of B3 type thymoma was higher than other type; and the percentage of thymic squamous cell carcinoma was significantly higher than that of thymoma, thymoma and thymic carcinoma were significantly statistically different in shape, edge and density (P value <0.05).
3. 15 cases of other epithelium-derived tumors, including 9 cases of non-thymus derived squamous cell carcinoma, 3 cases of adenocarcinoma, 3 cases of atypical carcinoid. Tumors mainly located in the middle- and para-mediastinum: 86.7% and 80%. CT features of thymic squamous cell carcinoma and non-thymus derived squamous cell carcinoma showed significant statistical difference in location (P = 0.000 and 0.033, respectively), the former located in the anterior mediastinum, 50% in the center, and the later located unilaterally in the middle-mediastinum.
4. 32 cases of small cell malignancies, including lymphoma in 16 cases, small cell carcinoma in 12 cases, myeloid sarcoma, plasma cell tumor, PNET, and small round cell tumor in 1 case. The average age of 44.8 (11 ~ 82) years old, average 37.6 years old of lymphoma, average 59 years male, female average 27.8 years old. average 56.5 years of small cell carcinoma, average 54.1 years male, female average 61.3 years old. In 32 casess, lymphoma and small cell carcinoma accounting for 50% and 37.5%. This two types showed significant statistical difference in the age of onset, distribution of mediastinum and the density there (P value <0.05). Compared with epithelium-derived tumors, small cell tumors showed significant difference in the distribution of mediastinum , lesion density and the vascular invasion (P value <0.05). Small cell tumors located mainly in the anterior mediastinum, accompanied with vascular displacement or invasion.
5. 4 cases of mesenchymal tumors, including 3 cases of mesothelioma, unidirectional synovial sarcoma in 1 case. The average age of 52.3 (20 ~ 77) years of age. Mesothelioma located in the anterior mediastinum, with irregular shape, blur edge, pleura invation. Synovial sarcoma located in the posterior mediastinum, with round shape, smooth edges, local vertebral destruction, and enlargement of intervertebral foramen.
6. Germ cell tumor in 5 cases, all male, mean age 42.4 (24 ~ 82) years. immature teratoma in 4 cases, 1 case of seminoma. Are located in the anterior mediastinum, round or oval, with unclear boundaries to the mediastinal vessels. All lesions were larger than 5cm. CT scan showed mild to moderate enhancement.
7. 10 cases of benign lesions, the average age of 56.4 (21 ~ 58) years, of which 4 benign tumors (4 cases of schwannoma, 1 case of neurofibroma and substernal goiter), benign lesions in 4 cases (2 cases of tuberculosis , sarcoidosis in 2 cases). Anterior mediastinum in 1 case, which is substernal goiter; middle mediastinum in 3 cases, including 1 case of neurofibroma, sarcoidosis in 2 cases; posterior mediastinum in 6 cases, which are nerve sheath tumors and tuberculosis. Schwannomas located in the ditch beside the spine, and 1 foramen enlargement. Neurofibromas were columnar, extending from thoracic inlet to neck. Substernal thyroid goiter connected to thyroid in the neck. Sarcoidosis with the enlargement of bilateral hilar lymph node. Calcified lesions seen in 1 case of tuberculosis, with the destruction of adjacent vertebral body, 1 narrowing of adjacent thoracic vertebra space. CT scan showed mild to moderate homogeneous enhancement.
Conclusion:
In this study, we get the following conclusions by analyzing CT manifestations of different pathological types of 86 mediastinal lesions:
1. Malignant tumors mainly located in the anterior mediastinum, the morphology lobulated or irregular, edge blur, density uneven, and enhanced scan showed moderate heterogeneous enhancement, while mediastinal benign lesions was significantly different.
2. Compared with other types, CT features of B3 thymoma tended to be lobulated, diameter> 5cm, blur edge, uneven density and calcification. B3 thymoma and thymic carcinoma were similar in CT features.
3. The pathological diagnosis showed squamous cell carcinoma, located in the anterior mediastinum and center suggesting the thymus-derived, while located unilaterally in the middle-mediastinum suggesting nonthymus-derived.
4. Small cell cancer was more common in lymphomas and small cell carcinoma, accounting for 87.5%, see also PNET, plasma cells, and myeloid sarcoma cases. For small cell cancer, if age less than 40 years old, located in the anterior mediastinum, and the lesions density greater than 40Hu the lesion tended to be lymphoma. If age older than 40 years old, located in the paramediastinum and density less than 40Hu, the lesions tended to be small cell carcinoma.
5. Concerning the differentiation between small cell carcinoma and epithelium-derived tumors, if the images showed lesion located in the anterior mediastinum, surrounded large blood vessels and had uneven density, the diagnosis of small cell carcinoma should be considered.
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