Mediastinal lenfadenopati BT bulguları

Özet

Mediastinal lenf nodu büyümesi enfeksiyon ve granülomatöz hastalıklardan lenfoma ve metastaza kadar farklı nedenlerle görülebilir. BT, nodun kısa eksenini, IASLC istasyonunu, iç yapısını ve hiler nodlarla dağılım ilişkisini aynı incelemede gösterir. Boyut tek başına etiyolojiyi belirlemez; özellikle kanser evrelemesinde görüntüleme bulguları gerektiğinde doku örneklemesinin yerini tutmaz. Nekroz, damar veya hava yolu basısı ve eşlik eden akciğer bulgularının atlanması tanı ve evrelemeyi değiştirebilir.

Faz ve pencere

Kontrastsız tanısal: Kısa eksen ve nodal dağılım ölçülür; kalsifikasyonlar görülebilir, ancak santral nekroz ve çevresel kontrastlanma gibi detaylar için kontrastlı inceleme gereklidir.
Kontrastlı tanısal: Kontrastlı toraks BT'de nodların homojenliği, çevresel kontrastlanma, santral nekroz, nodal birleşme ve komşu damar-hava yolu basısı değerlendirilir.

Önerilen pencereler: Mediasten (G 350 / M 50), Akciğer (G 1500 / M -600).

BT bulguları

Her nod için kısa eksen ölçümü ve IASLC istasyonunun (ör. 4R, 7) kaydı.
Yuvarlaklaşmış nod morfolojisi ve yağlı hilusun seçilememesi; tek başına malignite ölçütü değildir.
Santral düşük atenüasyon ve çevresel kontrastlanma; tüberküloz gibi nekrotizan süreçleri düşündürür.
Bilateral, simetrik hiler ve sağ paratrakeal nodlar; sarkoidoz dağılımıyla uyumludur.
Ön mediastende hacimli, birleşen yumuşak doku nodları lenfomada görülebilir.
Noktasal, kaba veya yumurta kabuğu biçimli kalsifikasyon; geçirilmiş granülomatöz hastalık ve silikoz bağlamında yorumlanır.
Tek taraflı ve ardışık istasyonlara yayılan nodal hastalıkta komşu akciğer, özofagus ve meme primerleri araştırılır.

Ölçütler ve sınıflamalar

Mediastinal nodda tarihsel kısa eksen anormallik eşiği (tek başına tanı veya izlem kararı koydurmaz): >10 mm
Tek merkezli otopsi çalışmasının 4R için önerdiği normal uzun eksen çapı; CT kısa eksen eşiği değildir: 15 mm (uzun eksen)
Tek merkezli otopsi çalışmasının istasyon 7 için önerdiği normal uzun eksen çapı; CT kısa eksen eşiği değildir: 20 mm (uzun eksen)
IASLC akciğer kanseri nodal istasyon haritası: Akciğer kanseri evrelemesinde TNM-9, ipsilateral mediastinal veya subkarinal tek istasyon tutulumunu N2a, çok istasyonlu tutulumu N2b olarak ayırır. Akciğer kanserinde TNM-9, ipsilateral mediastinal/subkarinal tek istasyon tutulumunu N2a, çok istasyon tutulumunu N2b olarak ayırır.

Normalde

Normal lenf nodu çapı istasyona özgüdür; 4R istasyonu için normal uzun eksen 1,5 cm, 7 istasyonu için 2,0 cm olarak tanımlanmıştır. Aynı düzeyde sağ ve sol paratrakeal, subkarinal ve hiler zincirleri karşılaştır; iki taraflı benzer dağılım ile tek taraflı kümelenmeyi birbirinden ayır.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s1278; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Sarkoidoz: iki taraflı hiler ve sağ paratrakeal dağılım, bazen simetrik nod kalsifikasyonu.
Tüberküloz: tek taraflı/asimetrik nodlar, santral nekroz ve çevresel kontrastlanma görülebilir.
Lenfoma: çok istasyonlu birleşen yumuşak doku kitlesi, özellikle ön mediastinal hacim.
Akciğer kanseri metastazı: primer kitleyle anatomik olarak tutarlı hiler ve mediastinal zincir.
Silikoz: üst lob ağırlıklı küçük nodüller ve yumurta kabuğu nod kalsifikasyonu.

Tuzaklar

Kısa ekseni 10 mm'yi aşan her nodu metastaz sayma; normal boyut istasyona göre değişir ve reaktif nodlar da büyüyebilir.
Kontrastsız çekimde santral hipodensiteyi nekroz olarak kesinleştirme; içi kontrastlanan hiler damar ve kısmi hacim etkisiyle karışabilir.
Kalsifik nodları aktif hastalık kabul etme; bilateral ve simetrik kalsifikasyon geçirilmiş sarkoidozla da görülebilir.
Birbirine yakın nodları tek kitle gibi kaydetme; multiplanar görüntülerde damar ve bronşları izleyerek istasyon sınırlarını belirle.

Kendini dene

BT'de iki taraflı hiler ve sağ paratrakeal nodlar simetrik büyümüş; akciğerde perilenfatik mikronodüller var. En uyumlu tanı hangisidir?
Cevabı göster
Sarkoidoz. Simetrik bilateral hiler ve sağ paratrakeal tutulum, perilenfatik nodüllerle birlikte sarkoidozu destekler. Tüberkülozda asimetri ve nekroz; lenfomada birleşen kitle; metastazda primer tümörle uyumlu dağılım daha olasıdır.
Silika tozuna mesleki maruziyeti olan hastada üst loblarda çok sayıda küçük nodül ve hiler-mediastinal lenf nodlarında yumurta kabuğu tarzı kalsifikasyon görülüyor. En olası tanı hangisidir?
Cevabı göster
Silikoz. Silika tozuna mesleki maruziyet ve üst zonlarda dağılmış çoklu nodüller, lenf nodlarındaki periferik kalsifikasyon biçimiyle birlikte bu meslek hastalığını destekler. Kalsifikasyon tek başına özgül değildir; klinik maruziyet ve parankimal dağılımla beraber yorumlanmalıdır.

Kaynaklar

Bu sayfadaki 44 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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