122428705 curs-3-respirator ul
TRANSCRIPT
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APARATUL RESPIRATORSIMEDIASTINUL
Radio-imagistica Curs III
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PNEUMOPATII ACUTE
Inflamatorii nesupurative
Inflamatorii supurative : Primare : abcesul, gangrena pulmonară, supuraţia pulmonară
difuză Secundare : complicaţia unei
pneumonii, bronşiectazii, chiste pulmonare
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CLASIFICARE ETIOLOGICACLASIFICARE ETIOLOGICA A PNEUMONIILOR - BACTERIENE - Streptococcus pneumoniae ( pneumococ )
- Staphilococcus aureus - Streptococcus pyogenes - Klebsiella pneumoniae ( B. Friedlander) - Alti germeni gram-negativi : - Pseudomonas aereginosa ( B.placionic )
- Escherichia coli - Proteus
- Serratia - Haemophilus influenzae - Legionella pneumophila - Mycobacterium - Bordetella pertussis - Salmonella typhi si paratyphi - Brucela - B. anthracis , etc. -
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-VIROTICE : - Virusuri gripale si paragripale: - Varicela - Rujeola - Virusul sincitial respirator - Adenovirusuri - Enterovirusuri - Virusuri herpetice - Virusul citomegalic , etc. - CHLAMIDII : - Chlamidia psittaci - Chlamidia trachomatis - RICKETTSII : - Coxiella burnetti ( febra Q ) - MYCOPLASME : - Mycoplasma pneumoniae ( agentul EATON ) - FUNGICE : - Actinomices israeli - Aspergilus fumigatus - Candida albicans - Coccidioidomycasis - Histoplasma capsulatum - PROTOZOARE: - Pneumocystis carinii - NEINFECTIOASE : - Pneumonii prin aspiratie ( sindromul Mendelson ) - Pneumonii prin inhalatii cu gaze toxice - Pneumonii prin iradiere - Pneumonie lipoida Dupa GHERASIM 2002
CLASIFICARE ETIOLOGICA
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PNEUMOPATIILE INFLAMATORII (NESUPURATIVE)
Alveolare = pneumonii
Bronşiolo-alveolare = bronhopneumonii
Interstiţiale = pneumonii interstiţiale
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PNEUMONIA ALVEOLARĂ - perioada de stare
1. Localizare lobară sau segmentară2. Opacitate omogenă3. Intensitate variabilă in functie de
extindere4. Delimitare netă şi liniară (scizural)5. Delimitare difuză (zona nescizurală) 6. Nu modifică structurile din jur7. Nu modifică volumul pulmonar8. Bronhogramă si alveolograma
aerică prezentă
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Segmentita dorsală, lob sup. dr
PA TD
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Subsegmentită lob sup. dr.
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Pneumonie lob mediu, segment lateralcolectie mica in sinusul CD drept
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Proces congestiv, lob inf. dr.
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Pneumonie în tuse convulsivă (b. pertussis)
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Sdr . de umplere alveolara bilaterala
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EVOLUŢIA PNEUMONIEI
Complicaţii : - abces - pleurezie
Resorbţie: - omogenă - inomogenă : - tablă de
şah -
pseudocavitară
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Abces Fowler
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Pneumonie: evoluţie ?
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BRONHOPNEUMONIA
1. Inflamaţie bronhiolo-alveolară2. Opacităţi multiple rotunde3. Micro sau macronodulare4. Intensitate medie5. Contur difuz6. Diseminate inomogen (cale bronhogena)
7. Aspectul se schimbă rapid (de la o examinare la alta)
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Bronhopneumonie
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Pneumonie stafilococică (bronhopneumonie)
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PNEUMONII INTERSTIŢIALE
Etiologie: - virală,
- bacteriană ( p. mixte) - mycoplasma, - chlamidii, - rickettsii, - protozoare
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PNEUMONIILE INTERSTIŢIALE
1. Interstiţiul peribronhovascular vizibil ( accentuat)
2. Aspect reticular infrahilar
3. Benzi opace uni sau bilaterale în câmpurile inferioare
4. Opacităţi micro sau macronodulare
5. Hil pulmonar mărit moderat
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Pneumonie virală
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Pneumonie cu v. varicelei
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Pneumonie cu Pneumocystis carinii
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Abces pulmonar (primar)
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Pneumonie cu gram negativi
Proteus Pseudomonas
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EXAMINARI RADIO-IMAGISTICE IN PLEUREZII
Radiografia toracica in :– ortostatism– decubit lateral cu raza orizontala
Ecografia toracica
C T
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ETIOLOGIA PLEUREZIILOR
Canceroase------------------------------ 45% Infectioase ------------------------------ 21%
– Tuberculoase 10%– Bacteriene 9%– Virotice 1%– Fungice 1%
Cardiace---------------------------------- 12% Infarct pulmonar ------------------------ 3% Ciroza ------------------------------------ 2% Colagenoze ------------------------------- 1% Diverse ------------------------------------ 5% Cauza necunoscuta --------------------10% !!!
Dupa HAUSHEER 1985
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CLASIFICAREA RADIOLOGICA A
PLEUREZIILORPLEUREZII:
– LIBERE in marea cavitate - in cantitate:• mica
• medie
• mare
– INCHISTATE • in marea cavitate pleurala
• in scizuri
• in spatiul pleural mediastinal
• supradiafragmatice
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Colecţii pleurale libere
ecografie
lateral stg.
lateral dr.
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Colecţii pleurale libere
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Colectie pleurala
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Colectie pleurala
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Colecţii închistate
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Colectii pleurale inchistate
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Mezotelioame benign
malign
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TUMORI BRONHO-PULMONARE
Aspecte radiologice
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TUMORI BENIGNE
Tumori benigne: - adenoame, - fibroame, - hamartoame, - lipoame, - condroame;Radiologic :- opacitate rotundă pulmonară
solitară
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CARACTERE RADIOLOGICE TU BE
- contur regulat, net delimitată
- intensitate variabilă cu dimensiunea - structură omogenă - calcificări (hamartoame) - ( nu intotdeauna
calcificare intratumorala = benign, vezi “scar cancer”
- nu modifică ţesutul din jur - creştere lentă > 12 luni
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Adenom bronşic
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Principalele semne clinice care sugereaza un CBP1. Semne locale:
– tuse 45 - 75%– slabire 20 – 70%– dispnee 40 – 60%– dureri toracice 30 – 45%– hemoptizii 25 – 35%– nici unul 2 – 5% !!!
2. Semne locoregionale: – disfonie - recurent– paralizie frenica - frenic– disfagie - prin adenopatii– sindrom V.C.S.– colectie pleurala sau pericardica
3. Sindroame paraneoplazice: endocrine, neurologice, musculoscheletice, hematologice, etc.
Dupa Kraut , 2000
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CELE 4 MARI TIPURI HISTOLOGICE DE C.B.P. IN PRACTICA
Carcinoame epidermoide ( 40% ) – sediu preferential pe marile bronsii
Adenocarcinoame ( 20-30% ) - sediu periferic dar si central
Carcinoame cu celule mari ( 20% )Carcinoame cu celule mici ( 10% )Cancere “non – small”
– carcinoame epidermoide – adenocarcinoame – carcinoame cu celule mari
Cancere “small” - a priori non-chirurgicale, chimio si radiosensibile
rezectie chirurgicala daca e posibil
Dupa Travis 1999
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TIPURI ANATOMO – RADIOLOGICE ALE C.B.P.
Central (hilar) al bronsiilor mari
– exobronsic
– endobronsic (stenoza atelectazie)
Periferic
Bronhioloalveolar
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CANCER BRONŞIC CENTRAL (HILAR)
endobronşic
exobronşic
mediastino-pulmonar
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CARCINOM CU CELULE SCUAMOASE
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CANCER BRONŞIC HILAR MIC
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CANCER BRONŞIC - MEDIASTINAL
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Coexistenţa cu alte leziuni
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CANCER ENDOBRONŞIC-CONSECINŢE
Obstrucţie bronşică: - completă =ATELECTAZIE
- incompletă :1. Ventil expirator =
hipertransparenţă2. Inspir insuficient = hipoventilaţie
+pneumonie
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Tu. pulmonara – forma atelectatică
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Tu. pulmonara – forma atelectatică
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Tu. pulmonara –forma pneumonică
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Tu. pulmonara - forma hilară
OAD
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TUMORI PULMONARE PERIFERICE PRIMARE
Bronho-pulmonare: - carcinoame nediferenţiate
- adenocarcinoame - bronşiolo-alveolar
Alte origini: - sarcom - neuroblastom - pneumoblastom - melanom
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Contur regulat / neregulat
net delimitat
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Cancer periferic – contur malign
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CARACTERE NODUL PULMONAR MALIGN
Dimensiune > 4 cmContur malignCreştere (rata dublarii volumului tu.) : 3-6 luni
Asocierea cu: - adenopatii hilare - liză costală - colecţii pleurale - metastaze pulmonare (mai mici
ca tu. primară)
o Complicaţii: necroza centrală/invazie vasculara
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Tu. pulmonara – forma periferică
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CBP periferic cu adenopatii
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CBP periferic cu adenopatii
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Tu. pulmonara – formă necrozată
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Tu. pulmonara – formă necrozată
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CT
CBP – ADP/liza costala/invazie vasculara/necroza
CT
IRM
CT
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CBP – invazie mediastinala
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PANCOAST TOBIAS
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Adenocarcinom
Barbat 41 ani cu durere in umarul drept
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Tu. pulmonara –forma bronşiolo-alveolară
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METASTAZAREA C.B.P.extensie metastatica pulmonara
– prin metastaza propriu-zisa si/sau parenchimatoasa
– prin limfangita carcinomatoasaextensie tumorala in mediastinextensie parietala prin contiguitateextensie locoregionala
– gg. mediastinali homo – si/sau controlateral– gg. supraclaviculari
extensie la distanta
– creier – suprarenale– ficat– os
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CELE MAI FRECVENTE METASTAZE PULMONARE ALE ALTOR CANCERE
1. C. mamar2. Tu. osoase3. C. tiroidian4. Seminom, C. prostată5. C. uterin6. C. digestiv7. C. renal
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Metastaze –forme nodulare
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Metastaze - forme nodulare
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Metastaze -cc. tiroidian
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Carcinoză miliară
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Limfangită carcinomatoasă
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Metastază unică
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MEDIASTINUL
Modificări radio-imagistice
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Sindromul mediastinal
Compresiv1. S. mediastinal superior (al venei
cave sup)
2. S. medistinal mijlociu (bronho-recurential)
3. S. mediastinal inferior (al venei cave inferioare)
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MEDIASTINUL- METODE1. Radioscopie + - esofag baritat2. Radiografie PA şi LL (raze dure)3. CT 4. IRM5. Ecografie 6.Aortografie7. Cavografie8. Scintigrafie
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CT MEDIASTINAL nativ In functie de examenul
cu substanta de contrast permite diferentierea intre:
• tumori solide ( vascularizate)• tumori lichide (nevascularizate)• formatiuni adipoase• formatiuni mixte (continut lichidian, solid,
grasos)• calcificari
Stabileste raporturile si gradul de invazie al unei tumori
Detectarea unor eventuale metastaze, inclusiv adenopatii patologice (>de 10 mm)
• locoregionale • la distanta
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TOPOGRAFIA MEDIASTINULUI ÎN PA
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TOPOGRAFIA MEDIASTINULUI ÎN LL
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COMPARTIMENTAREA MEDIASTINALA
m. anterior:
1, 2, 3
m. mijlociu: 4,5,6
m. posterior:
7
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PRINCIPALELE AFECTIUNI MEDIASTINALEEtaj superior - compartiment anterior:
• timus • tiroida•paratiroide
Etaj mijlociu - compartiment anterior:• tiroida• timus• tumori disembrioplazice: - teratoame - chist dermoid
- chist bronhogenic
Etaj inferior - compartiment anterior: – cord si pericard– chist pleuropericardic (celomic)
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PRINCIPALELE AFECTIUNI MEDIASTINALEEtaj mijlociu – compartiment mijlociu:
– adenopatii: - bacteriene - bacilare - virale - tumorale: - primare
- secundare - alte etiologii
Compartiment posterior: – neurinom– simpatoblastom– afectiuni ale asofagului– afectiuni ale Ao. toracice– afectiuni ale coloanei toracale
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1. MEDIASTIN ANTERIOR ŞI SUPERIOR
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Etaj superior - compartiment anterior: Patologie tiroidiana
Struma
retrosternala Cancer tiroidian
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Etaj superior - compartiment anterior: Patologie tiroidiana
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Etaj superior - compartiment anterior: Patologie tiroidiana
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2. ETAJ MIJLOCIU – COMPART. ANTERIOR: MEDIASTIN ANTERIOR ŞI MIJLOCIU
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Timom
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23 ani , F, asymptomatica
2. ETAJ MIJLOCIU – COMPART. ANTERIOR: MEDIASTIN ANTERIOR ŞI MIJLOCIU
Timom
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Chist dermoid
Semnul Phemister
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Chist bronhogen
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Chist bronhogenic
IRM-T1 IRM-T2
Chist cu hipersemnal = continut proteic
Perete cu epiteliu ciliat pseudostratificat si continut mucos
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Teratom mediastinal malign
Exam.IRM
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F, 50 ani, dispnee
Teratom mediastinal malign
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Liposarcom mediastinal
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PET SCAN- tu mediastin anterior etaj mijlociu
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3. Mediastin anterior şi inferior
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Chist pleuropericardic
CT
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Chist pleuropericardic
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Chist pleuropericardic
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Chist pericardic
PA OAS
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Schwannom de n. frenic
CT mediastinal
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3. MEDIASTIN ANTERIOR ŞI INFERIOR
Chist pleuropericardicMase adipoase
Hernii diafragmatice anterioare (digestiv)
CORD si pericard la capitolul respectiv
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4. MEDIASTIN MIJLOCIU COMPARTIMENT MIJLOCIU
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Etaj mijlociu – compartiment mijlociu: – adenopatii:
•bacteriene•bacilare•virale•tumorale: - primare
- secundare•alte etiologii
4. MEDIASTIN MIJLOCIU COMPARTIMENT MIJLOCIU
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inflamatorii -infectioasesarcoidozasilicozametastaticelimfoame Hodgkinlimfoame non-Hodgkin
4. MEDIASTIN MIJLOCIU COMPARTIMENT MIJLOCIU - ADENOPATII
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Pneumonie virala
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Sarcoidoza
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Sarcoidoza - forma mediastino- pulmonară
Aug. 05 Sept 2005 Oct 2005
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Adenopatii ’’ în coajă de ou’’
silicoza stadiul III
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4. MEDIASTIN MIJLOCIU Adenopatii - IRM
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LIMFOGRANULOMATOZA MALIGNA
Hodgkin -Paltauf - Sternberg
80% si in mediastin
10-20 % debut mediastinal
biopsie ggl.
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STADIALIZAREA LIMFOMULUI HStadiul I: 1grup ggl sau o regiune
extralimfatica
Stadiul II: 2 grupe ggl. sau 1 grup ggl + o reg. extralimfatica de acceasi parte a diafragmului
Stadiul III: 2 grupe ggl de ambele parti ale diafragmului +/- reg extralimfatica
(splina)
Stadiul IV: afectare multipla organica +/- ggl.
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Limfom Hodgkin
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Limfom Hodgkin
iniţial post chimioterapie
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LIMFOM NON-HODGKIN
limfosarcom nodular si difuz
plasmocitomul
reticulosarcomul
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Limfom non-Hodgkin (recidivă)
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7. MEDIASTIN POSTERIOR (PARAVERTEBRAL)
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Compartiment posterior: – neurinom– simpatoblastom– afectiuni ale esofagului (la
digestiv)– afectiuni ale Ao. Toracice (la
cord vase)– afectiuni ale coloanei toracale
(la os)
7. MEDIASTIN POSTERIOR (PARAVERTEBRAL)
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Neurofibrom
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Neurinom
IRM
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Neurofibrom
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