Original Article pissn J Korean Soc Radiol 2012;67(3): Pulmonary Tuberculosis Mimicking Lung Cancer on Radiological Findings: Evaluat

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1 Original Article pissn J Korean Soc Radiol 2012;67(3): Pulmonary Tuberculosis Mimicking Lung Cancer on Radiological Findings: Evaluation of Chest CT Findings in Pathologically Proven 76 Patients 1 영상소견에서폐암의태성의폐결핵 : 조직병리학적으로진단된 76 명의환자에서흉부전산화단층촬영 (CT) 소견에대한연구 1 Hyoung Ook Kim, MD 2, Hyun Ju Seon, MD 2, Daun Lee, MD 1, Sang Soo Shin, MD 1, Yun Hyeon Kim, MD 1, Heoung Keun Kang, MD 2 1 Department of Radiology, Chonnam National University Hospital, Gwangju, Korea 2 Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea Purpose: To evaluate chest CT features of pulmonary tuberculosis mimicking lung malignancy. Materials and Methods: We retrospectively reviewed chest CT findings for 76 consecutive patients (21-84 years, average: 63 years; M : F = 30 : 46) who underwent an invasive diagnostic procedure under the suspicion of lung cancer and were pathologically diagnosed as pulmonary tuberculosis by bronchoscopic biopsy (n = 49), transthoracic needle biopsy (n = 17), and surgical resection (n = 10). We categorized the chest CT patterns of those lesions as follows: bronchial narrowing or obstruction without a central mass-like lesion (pattern 1), central mass-like lesion with distal atelectasis or obstructive pneumonia (pattern 2), peripheral nodule or mass including mass-like consolidation (pattern 3), and cavitary lesion (pattern 4). CT findings were reviewed with respect to the patterns and the locations of the lesions, parenchymal abnormalities adjacent to the lesions, the size, the border and pattern of enhancement for the peripheral nodule or mass and the thickness of the cavitary wall in the cavitary lesion. We also evaluated the abnormalities regarding the lymph node and pleura. Results: Pattern 1 was the most common finding (n = 34), followed by pattern 3 (n = 23), pattern 2 (n = 11) and finally, pattern 4 (n = 8). The most frequently involving site in pattern 1 and 2 was the right middle lobe (n = 14/45). However, in pattern 3 and 4, the superior segment of right lower lobe (n = 5/31) was most frequently involved. Ill-defined small nodules and/or larger confluent nodules were found in the adjacent lung and at the other segment of the lung in 31 patients (40.8%). Enlarged lymph nodes were most commonly detected in the right paratracheal area (n = 9/18). Pleural effusion was demonstrated in 10 patients. Conclusion: On the CT, pulmonary tuberculosis mimicking lung cancer most commonly presented with bronchial narrowing or obstruction without a central masslike lesion, which resulted in distal atelectasis and obstructive pneumonitis. Index terms Pulmonary Tuberculosis Chest CT Mimicking Lung Cancer Received June 6, 2012; Accepted July 4, 2012 Corresponding author: Hyun Ju Seon, MD Department of Radiology, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun , Korea. Tel Fax sunaura@hanmail.net Copyrights 2012 The Korean Society of Radiology 서론 폐결핵의다양한전형적또는비전형적 CT 소견들에대한 여러연구가있어왔으며 (1-7) 최근에는조기진단을위한 CT 의역할이강조되고있다 (8, 9). 폐결핵지방병성의지역 (endemic area) 인우리나라의경우에는영상의학과의사들이전형적인폐결핵영상소견에비교적익숙하고또한많은경우에는단순촬영소견이나고해상도 CT를포함한흉부 CT 소견만 submit.radiology.or.kr 대한영상의학회지 2012;67(3):

2 영상소견에서폐암의태성의폐결핵 으로도합리적인신뢰성을가지고폐결핵을진단할수있지만어떤경우에는특수한진단적확진을요하는경우가있다. 폐결핵이비전형적인영상소견을보이는경우에는임상의사나영상의학과의사모두비정상적영상소견이폐결핵으로인한것임을생각하기힘들게되며놀랍게도결핵으로진단되는경우가종종있다. 단순흉부촬영또는 CT에서폐결핵이폐암을모방하는영상소견을갖는경우에는진단이나치료가늦어질수있으며결국은폐암으로판단하게되어좀더침습적인진단방법이시행되고나아가서는불필요한수술까지하게된다. 이제까지폐암의태성의결핵에대한여러증례보고들이있어왔으나대부분은소수의환자들만을대상으로한증례보고형식이었고기관내결핵에대한소견에국한되어있다 (10-15). 본연구에서는병리조직학적으로폐결핵으로확진된 76 명의환자에서폐암의태성의기관내폐결핵을포함한다양한폐결핵의흉부 CT 소견을알아보고자하였다. 대상과방법 최근 2년동안본원에내원한환자가운데영상의학적검사에서폐암이의심되어침습적인조직병리학적진단을시행했으나결국에는폐결핵으로확진된 76 명의환자를대상으로흉부 CT 소견을후향적으로분석했다. 대상환자는남자 30명, 여자 46명이었으며, 환자의연령은 21세에서 84세까지로, 평균연령은 63세였다. 조직병리학적검사는 49명의환자에서는기관지내시경검사로, 17 명의환자에서는 CT 유도하경피적절단생검을통해, 그리고 10명의환자에서는수술적절제를함으로써이루어졌다. 수술적절제를시행했던대부분의경우 (n = 8) 에는설상절제 (wedge resection) 를시행했고한명의환자에서는우하엽절제를, 다른한명의환자에서는좌전폐절제술 (left pneumonectomy) 을시행했다. 폐결핵에대한조직병리학적진단은전형적인건락괴사 (caseous necrosis) 를동반한만성육아종성감염증이있을때, 또는 Mycobacterium tuberculosis 에대한배양검사나 polymerase chain reaction 이양성인경우를진단의기준으로삼아이루어졌다. 모든환자에서흉부 CT를시행하였는데 49명에서는 Light- Speed QX/I (GE Medical Systems, Milwaukee, WI, USA), 27 명에서는 Sensation Cardiac 64 (Siemens Medical Systems, Erlangen, Germany) 를이용하여폐첨부에서부터양측부신수준의상복부까지고식적 CT를시행하였다. 120 kvp 의관전압, 230~250 ma의관전류를주었으며, 절편두께는 2~10 mm, 절편간격은 5 mm, pitch 는 1로설정하여영상을얻었다. 120~130 ml 조영제 (Iohexol, Omnipaque, Amersham health, Cork, Ireland; Iopromid, Ultravist 300, Bayer Schering Pharma, Berlin, Germany) 를 2 ml/sec 의속도로상완정맥에주입한후조영증강스캔을시행하였으며좁은창 (width: 400, level: 40) 그리고넓은창 (width: 1500, level: -700) 장치 (settings) 로각각영상을얻었다. 또한, 7 mm 간격 (intervals) 과 7 mm 폭조절 (collimation) 로병변의주변부에서는절편의두께를얇게 (1 mm) 하고영상재구성시물체의경계면을선명하게하는연산법 (sharp, high spatial frequency, bone algorithm) 을이용해추가적으로고해상스캔을얻었다. 폐병변의흉부 CT 양상 (pattern) 은중심성종괴양병변을동반하지않은기관지의협착이나폐쇄 (pattern 1), 원위부무기폐나폐쇄성폐렴을동반한중심부종괴양병변 (pattern 2), 종괴양폐경화를포함한주변부결절또는종괴 (pattern 3), 그리고공동성병변 (pattern 4) 으로분류했다. CT 소견은폐병변의양상 (pattern), 폐병변의위치, 병변주위폐의이상, 주변부결절또는종괴인경우에는병변의크기, 경계그리고조영증강양상, 또한공동성병변인경우에는공동벽의두께에관심을가지고이루어졌다. 또한림프절과흉막의이상유무도평가하였다. 결과 CT 스캔상 76명의환자들에서병변의양상 (pattern) 은 pattern 1이가장흔한소견이었으며 (n = 34, 44.7%)(Fig. 1), 그다음으로 pattern 3(n = 23, 30.3%)(Figs. 3, 4), pattern 2(n = 11, 14.5%)(Fig. 2), 그리고 pattern 4(n = 8, 10.5%) (Fig. 5) 의순서였다 (Table 1). Pattern 1과 2의경우에는병변의발생이우중간엽에가장많았으나 (n = 14/45, 31.1%) pattern 3과 4 의경우에는우하엽의상분절에가장많았다 (n = 5/31, 16.1%) (Table 2). 병변은우측폐에더많이분포했다 (n = 49/76, 64.5%). 원위부무기폐나폐쇄성폐렴을동반한기관지협착이나폐쇄성병변 (pattern 1, 2) 인경우에는좀더흔하게한엽에발생했지만공동성또는비공동성의주변부결절이나종괴의경우 (pattern 3, 4) 에는좀더흔하게한분절에발생했다. Pattern 1의병변을보인 34 명의환자중 6명 (17.6%) 에서는다른분절에도같은양상의병변이있었으며 1명의환자에서는다른분절에 pattern 2의병변이함께보였으나병리조직학적으로확진되지는않았다. 병변주변이나다른분절에경계가좋지않은위성소결절이나융합성병변은 76 명의환자중 31명 (40.8%) 의환자들에서관찰되었으며 9명의환자 (11.8%) 에서는다른분절에비활동성결핵성병변들이추가로관찰되었다. 주변부결절이나종괴 162 대한영상의학회지 2012;67(3): submit.radiology.or.kr

rupt cutoff of bronchus without central mass-like lesion. A.

bronchus of the right upper lobe with distal peribronchial consolidation. C.

(arrow) without evidence of bronchial compression. D.

marked contraction of the lesion. A B C D Fig. 2.

Lateral chest radiograph in a 68-year-old man shows atelectasis and consolidation in

CT scans show concentric wall thickening of the right bronchus intermedius (arrow in

lobar bronchial lumen, which has continuity to surrounding calcified lymph nodes

Pattern 3 (I): Heterogeneously enhancing peripheral mass. A.

mass-like opacity obscuring the diaphragmatic border in the right lower lung field

CT scan at the level of the inferior vena cava shows a heterogeneously enhancing

3 김형욱외 A B C D Fig. 1. Pattern 1: Abrupt cutoff of bronchus without central mass-like lesion. A. Chest radiograph in a 65-year-old woman shows ill-defined mass-like opacity in the right perihilar area. B. CT scan at the carinal level shows abrupt cutoff (arrow) of anterior segmental bronchus of the right upper lobe with distal peribronchial consolidation. C. Coronal reformatting CT scan shows enlarged lymph node in the right hilar area (arrow) without evidence of bronchial compression. D. Follow-up chest radiograph after ten months of antituberculous chemotherapy shows marked contraction of the lesion. A B C D Fig. 2. Pattern 2: Bronchial obstruction with central mass-like lesion. A. Lateral chest radiograph in a 68-year-old man shows atelectasis and consolidation in lower lung zones. B-D. CT scans show concentric wall thickening of the right bronchus intermedius (arrow in B) and central mass-like lesion (arrow in C), which is obliterating the right lower lobar bronchial lumen, which has continuity to surrounding calcified lymph nodes (arrow in D) at a slightly upper level of C. A B C D Fig. 3. Pattern 3 (I): Heterogeneously enhancing peripheral mass. A. Chest radiograph in a 35-year-old man shows approximately a 6 cm well defined mass-like opacity obscuring the diaphragmatic border in the right lower lung field and patchy and nodular increased opacity in the right mid lung field. B. CT scan at the level of the inferior vena cava shows a heterogeneously enhancing mass containing multiple areas of necrotic low attenuation areas with peripheral rim enhancement and extension to the adjacent pleural space in the posterior aspect of the right basal lung. A small amount of pleural effusion is also noted (arrowheads). C, D. CT scans at the level of the left atrium show another subpleural nodule (about 2 cm) with adjacent pleural thickening (arrowheads in C) and multiple small satellite nodules in the surrounding lung parenchyma (D, lung window setting). submit.radiology.or.kr 대한영상의학회지 2012;67(3):

영상소견에서폐암의태성의폐결핵 A B C D Fig. 4. Pattern 3 (II): Poorly enhancing peripheral nodule with necrotic lymphadenopathy. A. Chest radiograph in a 37-year-old woman shows about a 1.

CT scan at the level of the aortic arch shows a poorly enhancing (mean HU: about 8) nodule in the apicoposterior segment of the left upper lobe. C.

CT scan at a slightly lower level shows an enlarged lymph node (arrow) containing low attenuation necrotic portion with peripheral rim-like enhancement in the aortopulmonary window area. Note.

of Lesions (%) Pattern 1 Bronchial narrowing or obstruction without a central mass-like lesion 34 (44.7) Pattern 2 Central mass-like lesion with distal atelectasis or obstructive pneumonia 11 (14.

4 영상소견에서폐암의태성의폐결핵 A B C D Fig. 4. Pattern 3 (II): Poorly enhancing peripheral nodule with necrotic lymphadenopathy. A. Chest radiograph in a 37-year-old woman shows about a 1.5 cm nodule in the left upper lung field with multiple small nodules along the bronchovascular bundle in the surrounding lung field. B. CT scan at the level of the aortic arch shows a poorly enhancing (mean HU: about 8) nodule in the apicoposterior segment of the left upper lobe. C. CT scan with lung window setting shows small centrilobular nodules and linear branching opacities in the surrounding lung parenchyma. D. CT scan at a slightly lower level shows an enlarged lymph node (arrow) containing low attenuation necrotic portion with peripheral rim-like enhancement in the aortopulmonary window area. Note.-HU = Hounsfield unit Table 1. Chest CT Features of 76 Patients of Pulmonary Tuberculosis Mimicking Lung Cancer CT Pattern CT Findings No. of Lesions (%) Pattern 1 Bronchial narrowing or obstruction without a central mass-like lesion 34 (44.7) Pattern 2 Central mass-like lesion with distal atelectasis or obstructive pneumonia 11 (14.5) Pattern 3 Peripheral nodule or mass including mass-like consolidation 23 (30.3) Pattern 4 Cavitary mass 8 (10.5) Table 2. Locations of Lesions according to CT Patterns of Cancer- Mimicking Pulmonary Tuberculosis CT Patterns No. of Lesions Locations Pattern 1, 2 14 RML 6 Lingular segment of LUL 5 RLL 3 RUL 3 Anterior segment of RUL 2 RBIM 2 Lateral segment of RML 2 Anterior segment of LUL 8 The others Pattern 3, 4 5 Superior segment of RLL 4 Posterior segment of RUL 4 Apicoposterior segment of LUL 3 Apical segment of RUL 2 Anterior segment of RUL 2 Lateral basal segment of RLL 2 Lateral basal segment of LLL 2 Superior segment of LLL 7 The others Note.-LLL = left lower lobe, LUL = left upper lobe, RBIM = right bronchus intermedius, RLL = right lower lobe, RML = right middle lobe, RUL = right upper lobe 로나타났던 23개의병변들중 13개의병변은균질한조영증강을, 10개의병변은비균질한조영증강을보였으며 5개의병변에서는공기기관지조영상이관찰되었다. 최장경을기준으로했을때결절이나종괴의평균크기는 3.5 cm였고범위는 1.5~7.3 cm였다. 경계는분엽상경계 (n = 7), 침상의경계 (n = 6) 와평활한경계 (n = 5), 그리고분엽상과침상의경계가섞인경계 (n = 5) 의순으로관찰되었다. 8개의공동성병변의평균크기는 3.9 cm였고범위는 3.3~4.9 cm였다. 공동벽의평균최대두께는 1.6 cm였고범위는 0.7~2.8 cm였다. 이가운데 4개 (50%) 의공동성병변은액체음영 [ 평균 Hounsfield unit ( 이하 HU): 4~6] 정도의거의조영증강되지않는공동벽을보였다 (Fig. 5). 경계는분엽상 (n = 5/8, 62.5%) 이가장흔했고두개의병변은평활한경계, 그리고한개의병변은분엽상과침상의경계가섞인모양으로관찰되었다. 흉막삼출은 10명의환자에서있었으며 9명은동측에, 1명은양측에있었다. 또한 6명의환자에서는병변이인접한흉막에흉막비후가있었는데특히 pattern 3, 4 병변에서우세하게보였다 (n = 5/31). 림프절병증은 76 명의환자가운데 18명의환자에서보였고단경의평균크기는 1.3 cm였다. 림프절병증의흔한장소는우기관주위 (n = 9), 분기부하 (n = 9), 그리고우 164 대한영상의학회지 2012;67(3): submit.radiology.or.kr

김형욱외 A B C Fig. 5. Pattern 4: Cavitary lesion with homogeneous low-attenuated wall. A. Chest radiograph in a 60-year-old man shows about a 3.

CT scans at the level of the left atrium show a cavitary mass (maximal thickness: about 12 mm) with a necrotic low attenuation wall (B, mean HU: about 4), speculated margin, and multiple small

4). 고찰 광범위한범위의폐결핵의전형적, 또는비전형적영상소견이많이보고되었지만 (1-7, 16) 아직도일상적인진료영역에서방사선학적, 그리고임상적으로폐암의태성의폐결핵과폐암의분명한감별진단은힘든상태이다. 어떤경우에는병변의위치가악성과양성을구별하는데도움을주기도하지만편견으로인한잘못된진단을내리게도한다.

5 김형욱외 A B C Fig. 5. Pattern 4: Cavitary lesion with homogeneous low-attenuated wall. A. Chest radiograph in a 60-year-old man shows about a 3.5 cm well-defined mass-like opacity in the right infrahilar area. B, C. CT scans at the level of the left atrium show a cavitary mass (maximal thickness: about 12 mm) with a necrotic low attenuation wall (B, mean HU: about 4), speculated margin, and multiple small satellite nodules (C, lung window setting) in the superior segment of the right lower lobe. Note.-HU = Hounsfield unit 폐문 (n = 8) 부위등이었다. 림프절병증의석회화는 5명의환자에서있었고주변에윤상의조영증강을동반한중심부저음영은 7명의환자에서있었다 (Fig. 4). 고찰 광범위한범위의폐결핵의전형적, 또는비전형적영상소견이많이보고되었지만 (1-7, 16) 아직도일상적인진료영역에서방사선학적, 그리고임상적으로폐암의태성의폐결핵과폐암의분명한감별진단은힘든상태이다. 어떤경우에는병변의위치가악성과양성을구별하는데도움을주기도하지만편견으로인한잘못된진단을내리게도한다. 일반적으로폐결핵은양상엽의첨단분절이나후분절, 그리고양하엽의상분절에많은것으로알려져있는데 (17) 이는이부위의상대적으로높은산소분압과부족한림프액의배출때문인것으로알려졌다 (18). 따라서병변이상엽의전분절에있거나기저분절들에있는경우는폐결핵이외의다른폐렴이나폐암을먼저생각하게되는데비전형적폐결핵은이러한흔치않은위치인전분절이나기저엽, 그리고중엽이나설상엽등에생기는것으로알려졌으며 (17, 19), Woodring 등 (17) 의연구에서는상엽의전분절에발생한경우가 46%, 그리고하엽의기저분절들에서발생한경우가 32% 에까지이르렀다. 본연구에서도 pattern 1, 2에서는주로 (95%, n = 43/45) 무기폐나폐쇄성폐렴이비전형적위치에만있거나분절에만국한되기보다는엽전체에발생해진단에혼선을주었다. 하지만고립성결핵종 ( 공동성또는비공동성, pattern 3, 4) 으로발현해서폐결핵의진단이힘들었던경우에는 52%(16/31) 에서전형적인위치에있어서폐결핵을의심하는데도움을주었다. 하지만이경우에도 3개의증례에서는어떤분절의주변부결절로발현하기보다는어떤엽 의중심부에종괴양의기강경화로보여폐암과의감별이힘들었다. 이제까지몇몇연구자들이분절성또는세분절성무기폐나기관지내의종괴로발현해서폐암과의감별이힘들었던기관지내폐결핵의흉부단순촬영소견뿐만아니라흉부 CT 소견을보고했는데 (10-15) Matthews 등 (10) 은 4명의환자중 3명에서상엽의전분절에부분적인분절성무기폐가있었다고보고했다. Lee 등 (12) 도결핵성임파선염이인접한기관지내로파급될수있으며이러한경우에가장흔한발생장소가우상엽의전분절 (n = 3/5) 이었다고보고했는데이러한비전형적위치에발생하는경우중심성폐암과폐결핵과의감별은더욱힘들어진다. 본연구에서는임파선염또는기관지내결핵종으로인해중심부에종괴양병변을동반하면서그원위부에무기폐나폐쇄성폐렴을동반했던경우 (pattern 2) 는우하엽의중심부에가장많았고중심부종괴양병변을동반하지않고근위부기관지의협착이나폐색이있었던경우 (pattern 1) 는우중엽 (n = 14/34) 이나좌상엽의설상분절 (n = 6/34) 에많았다. 근위부의폐쇄성종괴없이초래된우중엽의만성적무기폐를 중엽증후군 (middle lobe syndrome) 이라고하는데어떠한엽도허탈될수있지만특히우중엽과설상분절 (lingular division) 에잘생긴다. 이는비교적길이가긴기관지주위를둘러싸는많은림프절과완전한엽간열때문에측부공기통로를통한통기가거의생기지않는것에기인하는것으로설명된다. 결핵성혹은진균성림프절확대에의한압박성기관지협착이중엽증후군을일으키는주된원인으로알려져왔지만, 현재는이전의폐렴으로부터비롯된만성염증성과정이불충분한측부공기통로때문에쉽게제거되지못하는현상으로이해되고있다 (20). 위에서언급한본연구의결과는염증성기관지협착이나폐색이다른폐렴에서와마찬가지로결핵의경우에도양측 submit.radiology.or.kr 대한영상의학회지 2012;67(3):

6 영상소견에서폐암의태성의폐결핵 중간엽에가장많은것을시사한다할수있겠다. Chung 등 (14) 은기관지내결핵이폐암과구별되는특징중에하나가한환자에서두곳이상의기관지폐쇄를보이는 double obstructive lesion 이라고보고했는데본연구결과에서도 pattern 1의 34명의환자중에서 7명의환자는두개분절이상에서기관지협착이나폐쇄로인한무기폐나폐쇄성폐렴이있었다. 하지만 Chung 등 (14) 도언급했듯이기관지폐암인경우에도다발성종양, 기관지배열의변이, 원발성기관지폐암이엽간열 (fissure) 을통해주변기관지로침범했을때등에서는예외적으로 double obstructive lesion 이보일수있어서 double obstructive lesion 만으로기관지폐암의가능성을완전히배제할수는없다. 전통적으로병변의주변에여러개의위성결절들이있으면좀더양성의염증성질환을시사하는것으로알려져있으며기관지주변에분포하는다양한크기의결절들이존재할때는어느정도는경기관지파급하는결핵을시사하는것으로알려져있다 (21). 하지만중심성폐종양의경우에도원위부의폐쇄성폐렴으로인해기관지주변에분포하는여러결절들을볼수있다. 그러므로어떤폐쇄성병변의원위부에존재하는위성결절들은양성병변과악성병변의감별에의미있는도움을주지못하는경우가종종있다. 하지만폐쇄성병변의원위부를제외한다른부위의폐영역에서관찰되는기관지주변에분포하는결절들은양성의염증성질환을진단하는데의미있는진단적단서를제공한다고할수있다. 따라서폐쇄성병변의원위부를제외한다른부위에이러한결절들이관찰될때는 CT상결핵의가능성을가장높게생각하고반복적객담검사를통해결핵을확진했거나경험적인결핵치료를시행해대개는침습적인진단방법을선택하지않았으므로본연구의대상군에서는많은경우가제외되었다. 그러므로이러한경우의발생빈도를정확히알수없었으며이는이연구의하나의제한점이라할수있겠다. 흉부 CT상폐결절의조영증강정도를기준으로해서악성여부를감별하려는노력이꾸준히있어왔는데악성폐절이좀더강한조영증강을보인다는것은잘알려진사실이다 (22, 23). Swensen 등 (22) 은악성종양 ( 평균, 46.5 HU; 범위, 11~110 HU) 은양성종양이나육아종 ( 평균, 8 HU; 범위, -10~94 HU) 보다통계적으로의미있는조영증강을보였으며 20 HU 를한계치로했을때민감도가 98%, 특이도가 73%, 정확도가 85% 인것으로보고했다. 본연구의조영증강후흉부 CT상 pattern 3이나 pattern 4의병변들은상대적으로균질한조영증강을보였으며평균조영증강정도는 28 HU 정도로염증성병변에서기대되는수치보다는약간높은값이었다. 하지만공 동성병변의경우에는 50%(4/8) 에서액체음영의감쇄값 ( 평균, 4~6 HU) 을보이는비교적조영증강이되지않은공동벽을가지고있어서이러한액체음영의감쇄값을보이는공동벽이결핵의진단에도움을주리라생각된다. 비균질한조영증강을보인병변들은특징적으로내부에윤상의조영증강을동반하는저음영성의괴사성병변을동반했다. 본연구결과에서는공동성병변의경우에공동벽의두께나불규칙성등으로악성과양성을구분했던전통적인기준들이별로유용한정보를주지못했으며공동벽의두께나불규칙성보다는주변위성결절들, 액체음영의비교적조영증강되지않는공동벽, 비교적편측에위치하는공기와동의종괴내위치등이악성공동성종괴로부터양성의병변을감별하는데좀더도움을주는것으로사료된다. 주변위성결절들이양성의공동성병변을좀더시사하는소견임은 Honda 등 (24) 의보고와일치한다. 폐이외의다른흉곽내의영상소견또한감별진단에도움을줄수있는데이에는림프절병증이나흉막병변등이해당된다. 결핵성림프절병증의전형적인영상소견은주변부에윤상의조영증강 (enhancing rim) 을동반한중심부저음영 (central low attenuation) 을보이는것이다 (25). 본연구에서도 9%(7/76) 의환자들에서이러한특징적인림프절병증을보였는데이런경우폐실질의병변이결핵일가능성을먼저생각할수있다. 하지만림프절병증으로만나타나는비전형적인결핵이있을수있으며폐암과폐결핵이동반될수있으므로역시감별에주의를요한다. 결핵성흉막삼출이나악성흉막삼출둘다주로편측성흉막삼출을동반하는것으로알려져있는데 (26, 27) 본연구에서도역시흉막삼출이동반된경우의 90%(9/10) 가편측성흉막삼출이었다. 하지만비교적악성흉막삼출의전형적인소견으로알려진 (26) 비균질한결절성흉막비후는관찰되지않았다. Kim 등 (27) 의보고에의하면결핵성흉막염환자에서단일성또는다발성의결핵성폐종괴가나타날수있는데이는특징적으로주변부폐혹은늑막하폐에분포하면서 CT상불균등한혹은중심부저음영을동반한주변부조영증강, 늑막하지방침범, 위성결절및간유리상음영동반을보인다고보고했다. 본연구에서도 1명의환자에서이러한병변이보였다. 전형적인결핵성병변의경우에는더많은경우에서이러한소견이보일것으로사료되며이러한전형적인결핵성흉막염의소견과동반된폐종괴에서는폐암보다는결핵종의가능성을먼저생각해볼수있겠다. 본연구의제한점으로는앞에서언급했듯이 CT상폐결핵을어느정도높은진단적신뢰를가지고진단할수있었던증례들은연구대상군에서거의제외가되고비교적비전형적소견들 166 대한영상의학회지 2012;67(3): submit.radiology.or.kr

7 김형욱외 을보였던증례들만이포함되어서폐결핵을진단하는데좀더유용한정보들이간과되었을수있다는점, 전형적소견들과의비교가이루어지지않았다는점, 그리고비전형적소견의발생빈도등을알수없었다는점등이다. 그리고비슷한영상소견을보일수있는폐암의증례들과의비교가되지않아좀더체계적인진단적기준을마련하지는못했다는점이다. 결론적으로, 흉부 CT상폐암의태성의폐결핵은중심부에종괴양병변을동반하지않은기관지의협착이나폐쇄로인한분절성또는엽성의원위부무기폐나폐쇄성폐렴으로보인경우가가장흔하였으며우중엽에가장많았다. 또한폐암의태성의폐결핵은종괴주변에여러개의위성결절들이나폐쇄성병변의원위부를제외한다른부위에서관찰되는기관지주변의결절들, 액체음영에가까운공동벽의음영, 그리고윤상의조영증강을동반하는저음영병변으로이루어진종괴나림프절종대를보였다. 참고문헌 1. Kuhlman JE, Deutsch JH, Fishman EK, Siegelman SS. CT features of thoracic mycobacterial disease. Radiographics 1990;10: Im JG, Itoh H, Han MC. CT of pulmonary tuberculosis. Semin Ultrasound CT MR 1995;16: Hatipoǧlu ON, Osma E, Manisali M, Uçan ES, Balci P, Akkoçlu A, et al. High resolution computed tomographic findings in pulmonary tuberculosis. Thorax 1996;51: Goo JM, Im JG. CT of tuberculosis and nontuberculous mycobacterial infections. Radiol Clin North Am 2002;40: 73-87, viii 5. Andreu J, Cáceres J, Pallisa E, Martinez-Rodriguez M. Radiological manifestations of pulmonary tuberculosis. Eur J Radiol 2004;51: Jeong YJ, Lee KS. Pulmonary tuberculosis: up-to-date imaging and management. AJR Am J Roentgenol 2008;191: Lee JJ, Chong PY, Lin CB, Hsu AH, Lee CC. High resolution chest CT in patients with pulmonary tuberculosis: characteristic findings before and after antituberculous therapy. Eur J Radiol 2008;67: Lee SW, Jang YS, Park CM, Kang HY, Koh WJ, Yim JJ, et al. The role of chest CT scanning in TB outbreak investigation. Chest 2010;137: Schluger NW. CT scanning for evaluating contacts of TB patients: ready for prime time? Chest 2010;137: Matthews JI, Matarese SL, Carpenter JL. Endobronchial tuberculosis simulating lung cancer. Chest 1984;86: Maguire GP, Delorenzo LJ, Brown RB, Davidian MM. Endobronchial tuberculosis simulating bronchogenic carcinoma in a patient with the acquired immunodeficiency syndrome. Am J Med Sci 1987;294: Lee KS, Kim YH, Kim WS, Hwang SH, Kim PN, Lee BH. Endobronchial tuberculosis: CT features. J Comput Assist Tomogr 1991;15: Van den Brande P, Lambrechts M, Tack J, Demedts M. Endobronchial tuberculosis mimicking lung cancer in elderly patients. Respir Med 1991;85: Chung HH, Oh YW, Kim KA, Kim JH. Differntiation between endobronchial tuberculosis and bronchogenic carcinoma associated with atelectasis or obstructive pneumonitis: CT evaluation. J Korean Radiol Soc 1995;33: Lee JH, Chung HS. Bronchoscopic, radiologic and pulmonary function evaluation of endobronchial tuberculosis. Respirology 2000;5: McAdams HP, Erasmus J, Winter JA. Radiologic manifestations of pulmonary tuberculosis. Radiol Clin North Am 1995;33: Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG. Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol 1986;146: Goodwin RA, Des Prez RM. Apical localization of pulmonary tuberculosis, chronic pulmonary histoplasmosis, and progressive massive fibrosis of the lung. Chest 1983;83: Hadlock FP, Park SK, Awe RJ, Rivera M. Unusual radiographic findings in adult pulmonary tuberculosis. AJR Am J Roentgenol 1980;134: Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of diseases of the chest, 2nd ed. St. Louis: Mosby, 1995: Itoh H, Tokunaga S, Asamoto H, Furuta M, Funamoto Y, Kitaichi M, et al. Radiologic-pathologic correlations of small lung nodules with special reference to peribronchio- submit.radiology.or.kr 대한영상의학회지 2012;67(3):

8 영상소견에서폐암의태성의폐결핵 lar nodules. AJR Am J Roentgenol 1978;130: Swensen SJ, Brown LR, Colby TV, Weaver AL, Midthun DE. Lung nodule enhancement at CT: prospective findings. Radiology 1996;201: Yi CA, Lee KS, Kim EA, Han J, Kim H, Kwon OJ, et al. Solitary pulmonary nodules: dynamic enhanced multi-detector row CT study and comparison with vascular endothelial growth factor and microvessel density. Radiology 2004; 233: Honda O, Tsubamoto M, Inoue A, Johkoh T, Tomiyama N, Hamada S, et al. Pulmonary cavitary nodules on computed tomography: differentiation of malignancy and benignancy. J Comput Assist Tomogr 2007;31: Pombo F, Rodríguez E, Mato J, Pérez-Fontán J, Rivera E, Valvuena L. Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by computed tomography. Clin Radiol 1992;46: Roh IG, Kook SH, Lee YR, Chin SB, Park YO, Park HW. CT findings of diffuse pleural diseases: differentiation of malignant diseases from tuberculosis. J Korean Radiol Soc 1997;36: Kim YK, Kim HJ, Lee SW, Park SW, Lee SM, Cho KS, et al. Newly appearing tuberculous pulmonary masses during antituberculous treatment of tuberculous pleurisy: radiographic and CT findings. J Korean Radiol Soc 2001;45: 영상소견에서폐암의태성의폐결핵 : 조직병리학적으로진단된 76 명의환자에서흉부전산화단층촬영 (CT) 소견에대한연구 1 김형욱 2 선현주 2 이다운 1 신상수 1 김윤현 1 강형근 2 목적 : 기관내폐결핵을포함한폐암의태성의폐결핵의다양한흉부 CT 소견을알아보고자했다. 대상과방법 : 조직병리학적으로폐결핵으로진단된 76 명의환자 (21~84 세, 평균 : 63세, 남 : 여 = 30 : 46) 에서흉부 CT 소견을후향적으로분석했다. 폐결핵의병리조직학적진단은기관지내시경을통한조직검사 (n = 49), 경피적절단생검술 (n = 17), 그리고수술적절제 (n = 10) 를통해이루어졌다. 폐병변의양상 (pattern) 은중심성종괴양병변을동반하지않은기관지의협착이나폐쇄 (pattern 1), 원위부무기폐나폐쇄성폐렴을동반한중심부종괴양병변 (pattern 2), 종괴양폐경화를포함한주변부결절또는종괴 (pattern 3), 그리고공동성병변 (pattern 4) 으로분류했다. CT 소견은폐병변의양상 (pattern), 폐병변의위치, 병변주변폐의이상, 주변부결절또는종괴인경우에는병변의크기, 경계그리고조영증강양상, 또한공동성병변인경우에는공동벽의두께를분석하였다. 또한림프절과흉막의이상유무도평가하였다. 결과 : Pattern 1(n = 34) 이가장흔한소견이었고 pattern 3(n = 23), pattern 2(n = 11), 그리고 pattern 4(n = 8) 의순서였다. Pattern 1과 2의경우에는병변이우중엽에가장많았으나 (n = 14/45) pattern 3과 4의경우에는우하엽의상분절에가장많았다 (n = 5/31). 병변주변이나다른분절에경계가좋지않은위성소결절이나융합성결절은 31명 (40.8%) 에서보였다. 커진림프절은우기관주위 (n = 9/18) 에가장많았고흉막삼출은 10명의환자에서보였다. 결론 : CT에서폐암의태성의폐결핵은중심부에종괴양병변을동반하지않은기관지의협착이나폐쇄로인한원위부무기폐나폐쇄성폐렴으로보이는경우가가장흔하였다. 1 전남대학교병원영상의학과, 2 화순전남대학교병원영상의학과 168 대한영상의학회지 2012;67(3): submit.radiology.or.kr

Kbcs002.hwp

Kbcs002.hwp Does Real-time Compound Imaging Improve Evaluation of reast Cancer Compared to Conventional Sonography? o Kyoung Seo, M.D., Yu Whan Oh, M.D., Kyu Ran Cho, M.D., Young Hen Lee, M.D., Hyung Joon Noh, M.D.,