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按編號分類

Case 101-120

cxr_1
cxr_2
ct_14
ct_17
ct_20
28歲男性病人,健康檢查發現胸部X光有異常,無任何呼吸道症狀,CXR及CT如上。

  • 答案是sarcoidosis stage I,X光上的特色是bilateral symmetric potato-shaped LAPs 。
  • CXR可見兩側的hilar lymphadenopathy,CT上除了hilar LAPs之外還可以發現paratracheal LAPs。
  • 需與lymphoma做鑑別診斷。
  • 絕大多數stage I 的病患都不會有症狀。
cxr 920317
hrct1
hrct2
一年前的CXR及HRCT
cxr940225
ct-post_16
ct-post_23
ct-post_28
ct-post_31
lw-1_16
lw-1_31
本次住院時的CXR及CT

 

51歲女性病人,一年前被診斷為bronchiectasis,於胸腔科門診追蹤。

兩週前開始感覺呼吸困難加劇、發燒、但是痰量並沒有明顯增加,CXR及CT如上。

答案是diffuse panbronchiolitis (DPB) with adult T-cell leukemia-lymphoma。

一年前的HRCT可以發現有bronchiectasis以及bronchioloectasis,並且可以看到許多centrilobular nodules and tree-in-bud pattern。這是DPB的HRCT特徵。所以當初的診斷應該是DPB而不是bronchiectasis。

一年後的CT上可發現bilateral lung consolidation with multiple mediastinal LAPs。

病患的淋巴結切片及骨髓切片顯示是high grade T-cell lymphoma,且病患之HTLV-1為陽性,因此確定診斷應為adult T-cell leukemia/lymphoma。

Malignancy中會出現air-bronchogram的要考慮兩種病lymphoma and bronchioloalveolar cell carcinoma,請參考case 27。

病患做了一個course的CHOP治療後CXR有明顯的改善。
postchemo
  • 有關adult T-cell leukemia (ATL) 的部分,Cecil Textbook of Internal Medicine 20th Ed.裡是這麼寫著:
    • The most common malignancy caused by HTLV-I is ATL; this is more accurately classified as a form of peripheral T-cell lymphoma that may include peripheral blood involvement. The HTLV-associated lymphomas include several subtypes of ATL: acute, chronic, smoldering, and lymphoma-type. These tumors represent high-grade lymphomas, usually of large, medium, and/or pleiotropic morphology and advanced clinical stage, and are associated with a poor prognosis.
    • The worldwide occurrence of these HTLV-I-associated malignancies is difficult to quantify because the incidence in any population depends on the prevalence of viral infection. In HTLV-I endemic areas such as southern Japan and the Caribbean Islands, the annual incidence of virus-associated leukemia is approximately 3 in 100,000 per year and may account for one half of adult lymphoid malignancies. The chance of an infected individual developing a malignancy over a lifetime is approximately 5%; early life exposure is associated with the greatest risk for subsequent disease.
    • The acute form of ATL is characterized by an aggressive mature T-cell lymphoma whose clinical course is often associated with high white count, hypercalcemia, and cutaneous involvement. Other cases resemble T-cell chronic lymphocytic leukemia and are termed chronic ATL. Smoldering ATL may clinically resemble mycosis fungoides/Sezary syndrome with cutaneous involvement presenting as erythema or as infiltrative plaques or tumors. Sometimes a long prodrome of symptoms is noted before transformation to an acute, rapidly fatal form of disease occurs. Sometimes ATL presents as a T-cell non-Hodgkin's lymphoma with no other clinical features of ATL except for monoclonal integration of HTLV-I in proviral DNA in the tumor cells. Most patients with acute and lymphoma-type ATL die within 6 months of diagnosis. The cause of death is usually an explosive growth of tumor cells, hypercalcemia, and various opportunistic infections including Pneumocystis carinii pneumonia and other infections observed in AIDS patients.
    • The age group ranges from adolescence to a peak in middle-aged adults. The diagnosis should be considered in an adult with mature T-cell lymphoma and hypercalcemia and/or cutaneous involvement, particularly if the individual is from a known risk group or endemic region. The diagnosis is established by testing serum for HTLV-I antibodies and finding leukemic T cells with the provirus in the blood or in biopsy specimens.
    • ATL has proven refractory to most conventional and experimental chemotherapeutic regimens. In general, smoldering ATL is the least aggressive form. The chronic type has a relatively poor prognosis with death occurring within a few years of diagnosis. Patients with chronic and smoldering ATL receive no therapy or they are treated with prednisone with or without cyclophosphamide. The more indolent forms of ATL have a high rate of complicating infections resulting from the immunosuppressive effects of aggressive therapy. Acute and lymphoma-type ATL's are aggressive high-grade lymphomas with a generally poor prognosis, although some cases do respond to multidrug regimens with prolonged remission.
    • Initial response rates, even for the poorest risk categories, are >50%, and complete remissions are achieved in 20% of the cases. Relapses often occur within weeks to months after treatment, although up to 15% of the patients have extended survival beyond 2 years (Fig. 342-4). Poor prognosis is associated with poor performance status at diagnosis: age over 40, extensive disease, hypercalcemia, and high serum LDH level. Relapses in long-term survivors often occur in the central nervous system (CNS) and prove refractory to subsequent therapy. Experimental approaches under investigation include using monoclonal antibodies to the interleukin-2 (IL-2) receptor linked with cell toxins selectively targeted to the leukemic cells and a combination of zidovudine and interferon.
CXR
CT1_10
CT1_20
CT2_15
LW_12
MR1
MR2
56歲女性病患,主訴下背痛,CXR,CT及MRI有以上表現。

  • 答案是plasmocytoma (multiple myeloma, extramedullary type) and breast augmentation(小針美容)。
  • CXR上可發現右側上縱隔腔有一腫瘤,CT上確定它是一個前縱隔腔腫瘤,且有軟組織的侵犯,MRI可以看到多節胸椎有腫瘤侵犯。在pre-contrast CT上還可發現乳房內有許多量點,這是小針美容的結果。
  • 鑑別診斷物主要還是考慮3T+1L,但是此病患的切片結果為plasmocytom,spinal tumor亦是相同的腫瘤細胞,所以診斷應是multiple myeloma。
  • Skull X-ray也可看到osteolytic lesions,bone scan顯示其他地方也有侵犯。
  • 病患後來做了bone marrow study,但沒有發現異常,其他light chain protein檢查也是正常。

skull-p

 

skull-l

 

BONE_SCAN

CXR
CT-P_11
CT1-C_11
LW_11
45歲女性病患,健康檢查發現胸部X光有異常,無任何呼吸道症狀,CXR及CT如上。

  • 答案是bronchioloalveolar cell carcinoma (BAC),noduar type。
  • CT上可見有明顯的air-bronchogram,這是BAC的特徵之一。
  • 另在還可以見到pleural traction sign (pleural-tail sign),雖然這並不能當作判斷是否為惡性病灶的證據,但是看到這樣的sign還是要法排除惡性病灶的可能性。
  • BAC有 pneumonic type 及 nudular type 兩種表現,其中以後者的癒後較好。
cxr
lw_14
61歲男性病人,健康檢查發現胸部X光有異常,無任何呼吸道症狀,CXR及CT如上。

  • 答案是azygos fissure。
  • CT上可明顯看到fissure的下方緣連接著azygos vein。
ct-c_14
ct-c_15
ct-c_16
ct-c_17
ct-c_18

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