Tümör ilişkili pulmoner kanama

Özet

Tümör ilişkili pulmoner kanama, tümörün alveollere kanaması, hava yoluna açılması veya komşu pulmoner damar duvarını invaze etmesiyle ortaya çıkabilen acil bir durumdur. BT kanamanın parankim içindeki dağılımını, tümörle ilişkisini ve uygun anjiyografik protokolde olası damar kaynağını göstererek acil lokalizasyon sağlar. Tümör çevresindeki buzlu cam veya konsolidasyon kanamayı düşündürür; aktif ekstravazasyonun görülmemesi aralıklı ya da yavaş kanamayı dışlamaz. Kanamanın atlanması hava yolu dolumu ve solunum yetmezliğine ilerleyebilir; kanama alanını tümör progresyonu veya enfeksiyon sanmak da müdahaleyi geciktirir.

Okuma sırası

1. Tümör ve segmental bronkovasküler demet. Önce tümörün hangi segment bronşu ve damarına komşu olduğunu bu aksiyel kesitte yerleştirin; kanamanın aynı loba sınırlı olup olmadığını belirleyin.
2. Peritümöral alveoler opasite. Akciğer penceresinde tümör çevresindeki opasitenin buzlu cam mı yoksa yoğun konsolidasyon mu olduğunu, bronş ve damarların hâlâ içinden seçilip seçilmediğini inceleyin.
3. Kavite duvarı ve pulmoner arter. Arteriyel anjiyo görüntülerinde kavite duvarına komşu pulmoner arter dalını kesitler boyunca izleyip düzensiz kontur, fokal genişleme veya damar dışına kontrast geçişi arayın.
4. Hava yolları, plevra ve pulmoner arterler. Son olarak bronş içi pıhtı, karşı akciğere aspirasyon yayılımı, plevral kan ve eşlik eden arteriyel emboli işaretlerini kontrol edin.

Faz ve pencere

BTA tanısal

Hemoptizi için uygun sistemik ve pulmoner arter opasifikasyonlu BT anjiyografide tümör çevresindeki buzlu cam/konsolidasyon, nekrotik kavite duvarındaki düzensiz damar, psödoanevrizma veya aktif kontrast ekstravazasyonu aranır. Arteriyel görüntüler kanama kaynağı olabilecek bronşiyal, bronş dışı sistemik ve pulmoner damarları haritalar.

Kontrastsız

Akciğer penceresinde tümörün çevresindeki sınırlı buzlu cam veya konsolidasyon alveoler kanama alanını gösterebilir; hava yollarında yüksek atenüasyonlu kan pıhtısı dolum defekti oluşturabilir. Kontrastsız seri kanın parankimal dağılımını saptar fakat aktif damar kaçağını göstermez.

Önerilen pencereler: Akciğer (G 1500 / M -600), Mediasten (G 350 / M 50), Anjiyo (G 600 / M 150).

BT bulguları

• Peritümöral buzlu cam — kitle çevresinde damar ve bronş işaretleri silinmeden artmış atenüasyon, alveoler kanamayla uyumlu olabilir.
• Alveoler kanama konsolidasyonu — segment veya lob içinde hava boşluğu opasitesi; tümörle doğrudan komşuluk kanama kaynağına işaret eder.
• Hava yolu pıhtısı — bronş lümeninde yüksek atenüsyonlu (>40 HU) yumuşak doku yoğunluğunda dolum defekti olarak görülür ve bu değer genellikle mukus tıkacından ayrım sağlar.
• Düzensiz pulmoner arter — kavite duvarı boyunca arterin keskin kontur kaybı veya fokal genişlemesi invazyon ya da psödoanevrizmayı düşündürür.
• Aktif ekstravazasyon — damardan dışarı taşan, damar havuzuyla aynı şekilde kontrastlanan odak; her incelemede görülmeyebilir.
• Hemotoraks — plevral aralıkta kanla uyumlu yoğun sıvı; eşlik eden plevral tümör veya vasküler yaralanma araştırılır.
• Eşzamanlı pulmoner arter dolum defekti — tromboemboli veya septik trombus olabilir; obstrüksiyonun boyutu ve kontrastlanma deseni incelenir.

Normalde

Karşı akciğerle kıyaslanarak, tümör çevresindeki parankimal opasite, hava yolu tutulumu ve toraks damarlarının yapısı değerlendirilmeli; aktif ekstravazasyon veya damar hipertrofisi gibi anormal bulgular tespit edilmelidir. Tümör çevresindeki opasiteyi karşı akciğerin aynı bronkovasküler düzeyiyle karşılaştırın ve arter dalının kesintisiz seyrini, duvar dışına kontrast çıkışı ya da lümene pıhtı olup olmadığını değerlendirin.

Ayırıcı tanı

Postobstrüktif pnömoni

büyük hava yollarındaki kan ürünleri nedeniyle oluşan atelektazi ve hava yolu tıkanıklığı, hemoraji kaynaklarına ek olarak değerlendirilmelidir.

Hemoraji akut dönemde alveoler buzlu cam veya konsolidasyon ile kendini gösterirken, fokal tümör progresyonu solid kütleler veya lenfanjitik yayılıma bağlı septal kalınlaşma olarak görülebilir; ancak subakut hemorajide de septal çizgiler oluşabildiğinden diferansiyel tanıda her iki durum göz önünde bulundurulmalıdır.

Pulmoner infarkt

subpleural lezyon veya segmental konsolidasyon, eşlik eden pulmoner arter obstrüksiyonu ile uyumludur.

Diffüz alveoler kanama

iki akciğerde yaygın yamalı buzlu cam/konsolidasyon; bilinen tümör odağı veya tümörle ilişkili damar bulgusu olmayabilir.

Tuzaklar

• Tümör çevresindeki buzlu cam tek başına kanamayı kanıtlamaz; enfeksiyon, ödem ve tümörün hava boşluğu yayılımı da benzer opasite yapabilir.
• Aktif kontrast ekstravazasyonu yokluğu kanamayı dışlamaz; kanama aralıklı olabilir ve anjiyografi çekim anında durmuş olabilir.
• Hemoptizi BT anjiyografisinde yalnız pulmoner arterlere odaklanmak bronşiyal veya bronş dışı sistemik kaynakları kaçırabilir.
• Kavite duvarına komşu damar psödoanevrizması küçük kesitlerde kavite içi nodül sanılabilir; damar devamlılığını çok düzlemli ve anjiyo penceresinde takip edin.

Kendini dene

1. Akciğer tümörü çevresinde yamalı buzlu cam var; anjiyoda kavite duvarındaki pulmoner arterden dışarı kontrast uzanıyor. En olası durum nedir?

   • Tümör kaynaklı aktif kanama
   • Pulmoner infarkt
   • Postobstrüktif pnömoni
   • Kardiyojenik ödem
   Cevabı göster

   Tümör kaynaklı aktif kanama. Damar dışına uzanan kontrast ekstravazasyonu aktif kanamayı destekler; komşu alveoler buzlu cam kanın parankime yayılımıyla uyumludur.

2. Hemoptizili kanser hastasında bronş lümeninde pıhtı ve peritümöral buzlu cam mevcut; anjiyoda kaçak görülmüyor. En doğru yorum hangidir?

   • Kanama yine de olasıdır
   • Kanama dışlanmıştır
   • Kesin pulmoner embolidir
   • Bulgular yalnız fibrozistir
   Cevabı göster

   Kanama yine de olasıdır. Bronş içi pıhtı ve alveoler opasite kanamayı destekler; ancak aktif ekstravazasyon her vakada gözlenmeyebilir. Hava yolu dolum defektleri kan pıhtısını gösterirken, fibrozis bronş içi pıhtı oluşumuna neden olmaz.

Kaynaklar

Bu sayfadaki 37 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 8 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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