第139课 X线平片对胸腺瘤（Thymoma）和畸胎瘤（Teratoma）的鉴别浅说

上期试题：痛风易受累的关节d

A.膝关节、髋关节、踝关节

B.膝关节

C.腕关节、掌指关节、近指关节

D.第1跖趾关节

E.近端指间关节、腕关节、足部关节

---

          胸腺瘤（Thymoma）和畸胎瘤（Teratoma）的都是常见的纵隔肿瘤，但在X线的鉴别诊断中还是比较有难度，这期说说这两种疾病的一般X线表现及如果鉴别。

         Thymoma (Thymoma) and Teratoma (Teratoma) are common mediastinal tumor, but in the differential diagnosis of X-ray was more difficult, this issue about these two diseases if general X-ray manifestations and identification.

病例一：

       男性，26岁，入院前1个月再体检胸透时发现纵隔肿块，除稍有胸闷外，无其他不适症状。

↑胸部正位片可见右纵膈有一外缘为圆弧形的肿块突入肺野，边缘光滑。

侧位片其后上缘呈边缘清楚的弧形，位于前中纵隔区。

胸部CT右前纵隔肿块大部分囊性变，CT值17-23HU，无钙化，靠近纵隔固有结构处部分为实质性，MCI为灌注型。经手术切除，病理诊断为胸腺瘤（淋巴细胞型）伴囊肿形成。

ps：根据陈金城对纵隔肿瘤的MCI（MassCardiovascular interface,肿块心脏大血管接触面）分型：凸出型、平坦型、凹陷型及灌注型4种类型。

Ps: according to Chen Jincheng MCI of mediastinal tumors (MassCardiovascular interface, mass heart vascular contact) classification: projection type, flat type, depressed tubulovillous adenoma and perfusion type four types.

病例二：

     男性，14岁，体检发现胸内巨大肿块1周入院，无症状，一般情况较好。

↑胸部正位片可见右纵隔有一外缘为圆弧形的肿块突入肺野。边缘清楚，呈均匀软组织密度。

胸部侧位片可见前中纵隔区有一边缘清楚的圆形软组织影。

胸部CT示前纵隔右份有一圆形囊状影，边缘清楚，内壁尚有小结节，增强后CT值约64HU。手术摘除纵隔肿物，病理诊断为囊性畸胎瘤。

          以上一二病例均位于前中区的纵隔肿瘤，该处最常见的为胸腺瘤和畸胎类肿瘤，国外曾有人提出以40岁为分界线，40岁以上者首先考虑胸腺瘤，40岁以下者首先考虑畸胎类肿瘤。当然并非绝对的。此两例均无明显症状，分别为26岁和14岁，正位上见自纵隔向肺野凸出的软组织影，边缘清楚呈圆弧形，侧位靠前，位于前中纵隔区。据所见胸片此两例均诊断为畸胎类肿瘤似乎有一定道理。

          Before the above two cases are located in the central district of mediastinal tumor, it is the most common for thymoma and teras cancers, abroad have been put forward in the dividing line is 40 years old, more than 40 first consider thymoma, those under the age of 40, first consider teras cancers. Of course not absolutely. The two cases had no obvious symptoms, respectively, 26, and 14 years old, is a see the mediastinal soft tissue shadow of protruding to the lung field assumes the circular edge clear, side, mediastinal area is located in the former. The diagnosis of teratoid tumors appears to be reasonable in both cases.

           但全面回顾次两例胸片资料，在胸部正位上，病例一二的纵隔肿块表现十分相似，几乎无法区分。而仔细目测估计突出于肺野的纵隔肿块的左右径与上下径之比，仍可发现此比值病例一小于病例二。更主要的是在侧位片上，病例二为一边缘清楚的圆形而病例一则上下径偏长，且只有后上部边缘清楚，其余大部分边缘不清楚。从平片所见，病例二诊断为畸胎类肿瘤是有依据的；而病例一虽然只有26岁，但根据影像学表现也应该首先考虑有胸腺瘤的可能，至少不能排除。经过大数据统计的平片表现进行观察，肿块呈圆形者多为畸胎类肿瘤，而肿瘤呈长形者多为胸腺瘤。在CT图像上，两者的差别是显而易见的。病例二纵隔肿块的赤道面为典型的囊性病变，MCI呈突出型，内壁有增强的小结节，虽未见典型的牙齿影及脂肪密度结构，仍应做出囊性畸胎瘤的诊断；而病例一纵隔肿块虽然有部分囊变但仍有实质部分，MCI为灌注型，这并非典型的畸胎瘤表现，应首先考虑胸腺瘤。

           But in the overall review of the two cases, in the chest, the lumps of the case were very similar and almost indistinguishable. However, the ratio of the diameter of the tumor to the upper and lower diameter of the lumps in the lung is estimated to be less than 2. More major is on the side slice, case 2. A round at the edge of the clear cases and a top and bottom diameter slightly long, and only after the upper edge is clear, most of the rest of the edge is not clear. As seen in pingping, case 2 diagnosis is based on the diagnosis of teratoid tumor. While case 1 is only 26 years old, according to the imaging performance, it should be considered the possibility of a sternoid tumor, at least not ruled out. In the case of large data, it was observed that the mass of the mass was a teratoid tumor, and the tumor was a long-form tumor. On CT images, the difference is obvious. Case 2 a mediastinal mass the equatorial plane of the typical cystic lesion, MCI is outstanding, the lining has enhanced nodules, did not see a typical teeth shadow and fat density structure, still should make the diagnosis of cystic teratoma; And the case of a mediastinal mass, although there is a partial cystic change but there is a substantial part, MCI is a perfusion, and this is not a typical teratoma, and it should be considered first.

那么如何对发生部位相仿的胸腺瘤与畸胎瘤进行鉴别呢？

So how do you identify the chest adenomas and teratoma that occur in the same area?

            首先在胸片上纵隔内如有牙齿、骨影，不管位于何处即可诊断为畸胎瘤，但要警惕与胸腺瘤内的蛋壳样钙化相鉴别；纵隔肿瘤内含脂肪甚至出现脂液面也是诊断畸胎瘤的重要依据；前纵隔肿块若有典型的帆状征（或称钩鼻征：以后我们会在影像征象单元里讲到），则首先考虑为胸腺瘤。

           First on the chest radiograph in the mediastinum, such as with teeth, bone, no matter in where can be diagnosed with teratoma, but be wary with thymoma in eggshell 'calcification identification; Even the presence of fat and even lipid in the mediastinal tumor is an important basis for diagnosing teratoma. If there is a typical sail pattern (or the hook and nose sign: we'll talk about it later in the imaging unit), consider first the thoracic gland tumor.

下面还有几点有助于胸腺瘤和畸胎瘤肿瘤的鉴别诊断：

Here are a few other differential diagnoses for breast adenomas and teratoma tumors:

1、外形：在胸部正侧位片上畸胎类肿瘤倾向为圆球形，其前后径与上下径相仿，边缘较清楚；胸腺瘤往往在正位胸片上突出肺野部分较少，侧位片上则表现为长形，只有部分边缘清楚，有时可见典型的舌状征。

1、Appearance: the shape of teratoid tumor in the right side of the chest is spherical, and the diameter is similar to the upper and lower diameter. Thymoma often less in part is a prominent lung field appear on chest radiograph, lateral slice is characterized by long, only part of the edge is clear, sometimes shows a typical tongue.

2、根据陈金城对纵隔肿瘤的MCI（MassCardiovascular interface,肿块心脏大血管接触面）分型：凸出型、平坦型、凹陷型及灌注型4种类型 ，畸胎类肿瘤的MCI多为凸出型，有感染时个别也为灌注型，但边缘模糊；胸腺瘤的MCI多为平坦型，也可为灌注型，但边缘多较清楚。我们还未遇到过胸腺瘤的MCI呈凸出型，也未遇到过畸胎类肿瘤的平坦型。

2、according to the Chen Jincheng mediastinal tumor MCI (MassCardiovascular interface, mass heart vascular contact) classification: projection type, flat type, depressed tubulovillous adenoma and perfusion type four types, teras cancers of MCI is convex type more, there are individual also is perfusion model, infection but edge blur; The MCI of thymus is flat and perfusion, but the edges are more clear. We have not yet encountered the MCI of the thymus, or the flat type of a teratoid tumor.

3、胸内其他并发情况：肿瘤侵犯肺、伴同侧胸腔积液多见于畸胎瘤。

3、Other complications in the chest: the tumor encroachments on the lungs, the associated side pleural effusion is seen in teratoma.

4、同样大小的肿块，畸胎类的占位效应（如表现出来的对大血管的推压移位）往往较胸腺瘤明显，但靠近中线在大血管前紧贴前胸壁的肿块（上述两例即如此）则此区别不大。

4、the same size lump, teras placeholder effect of a class (e.g., shows the great vessels push shift) is often a thymoma is apparent, but close to the center line in front of the great vessels to bump the anterior chest wall (the above two cases), the difference is not big.

随着经验的积累，用胸部正侧位加胸部CT扫描，绝大多数部位相仿的胸腺瘤与畸胎类肿瘤是可以做出正确的鉴别诊断的。但要注意胸腺瘤囊变可以会给鉴别诊断带来一定的困难。

With the accumulation of experience, with the positive side of the chest and chest CT scans, the vast majority of similar parts of thymoma with teras cancers can make the correct differential diagnosis. However, it is important to note that the thoracic adenoma can be difficult to identify the differential diagnosis.

再次感谢陈金城老师的经验之谈！！！

---

本期试题：前纵隔内最常见的纵隔肿瘤是？

A．胸腺瘤

B．胸骨后甲状腺肿

C．淋巴源性肿瘤

D．畸胎瘤与皮样囊肿

E．心包囊肿