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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2702_Библиотеки_им_академика_М_И_Перельмана
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1.3 Method oftheReading Branch Using CT Images
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Fig. 1.17 Horizontal–vertical pattern
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Fig. 1.18 Horizontal–oblique pattern
Horizontal–oblique pattern: the bronchus advances nearly
parallel to the axial CT images and further branches
obliquely. When the distal bronchus advances further in
an oblique direction from the proximal branch to parallel
to the axial CT images, on the bronchial branch diagram,
the proximal bronchus branches into the distal bronchi as
observed oblique from the axis of the proximal bronchus.
We consider the oblique bronchus advances to which the
other surrounding bronchus is close, parallel, or on the
opposite side. Because it branches obliquely as observed
from the direction of the axis of the proximal bronchus
running horizontally, we call the direction of the oblique
bronchus as the dial of the clock. For example, it is
“branching in 2 o’clock direction.”
[Representative case 1 (Fig.1.18): spur of right B3biβx
and B3biβy]. In this case, there are two branches of the
horizontal medial branch (B3biβy) and the cranial lateral
branch (B3biβx), branched from the right B3biβ running in
the horizontal direction. The cranial lateral branch
(B3biβx: →) is located close to B1 running vertically to the
cranial direction and has its proximal orice close to B3a,
as shown in Fig.1.18. B3biβx is advancing in the direction
of 1 o’clock. In addition, the horizontal medial branch
(B3biβy: →) advances far from B1 and has its proximal
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Fig. 1.19 Horizontal–oblique pattern at the spur of right B2a and B2b
1 To Trace theBronchial Branch Accurately
orice far from B3a. As shown in the gure, it is presumed
that B3biβy branches in the 7 o’clock direction of B3biβ.
[Representative case 2 (Fig.
1.19): spur of right B2a and
B2b].
The branch advancing in the direction nearly parallel to the
CT section is visualized as long on the axial CT images.
The length of the branch branching diagonally is usually
short in the axial CT images. By comparing their lengths,
we may infer the angle of the branch (e.g., right B2a).
Compared with the length of the right B2b, the length of B2a
was about half on the same axial CT slice. It can be
deduced that B2a advances obliquely upward, and B2a in
actual bronchoscopic nding branches obliquely upward,
implying that B2a branched in the 1 o’clock direction and
B2b branched in the 7 o’clock direction.
We need to think about where the tip of the bronchoscope is
located.
[Representative case 3 (Fig.1.20): spur of right B4bi and
B4bii and B4biiα and B4biiβ].
In this case, the tip of the bronchoscope is directed forward
in the right middle lobe bronchus, with the upper side
being cranial side, the lower side being the caudal side,
the right side being the lateral side, and the left side being
the medial side. Consider whether the traced bronchus is
close with which branch of the surrounding branches, is
parallel with which branch of the surrounding branches,
or is opposite with which branch of the surrounding
branches. In this case, B4bi is advancing in the cranial and
ventral directions, and close to B5 (11 o’clock direction),
4
bii is advancing in the caudal and dorsal directions,
and B
and opposite to B5 (5 o’clock direction; the spur between
4
bi and B4bii runs from lower left-hand to upper right-
B
hand). Furthermore, B4bii branches into B4biiα in the cranial direction, opposite to B5, and B4biiβ in the caudal
direction, close to B
5
(medial; the spur between B4biiα
and B4biiβ runs from upper left-hand to lower
right-hand).
Considering the bronchus branching from the bronchi that
runs horizontally.
Bronchi that run in the horizontal direction (horizontal
branch) can be visualized as long on the axial CT images.
Points to consider when drawing a bronchus branching
from the horizontal bronchus are as follows:
1. First, in the proximal site of the horizontal bronchus,
we are standing perpendicular to axial CT slices. It
resembles the state in which the tip of the bronchoscope bending with the up-/down-angle lever enters
into the horizontal bronchus (B6).
2. Imagine that you are looking at the branch of the next
bronchial generation (horizontal branch) from the
lumen of the horizontal bronchus. It is the same as
looking at the next horizontal branch from the bronchoscope (the spur between B6bi and B6bii).
3. When branching further horizontally from the bronchi
in the horizontal direction, it diverges to the left and
right branch as observed from the horizontal bronchi
(Figs.1.21 and 1.22).
4. When branching further from the horizontal branch
toward the cranial and caudal directions, it branches
into the up and down branch as observed from
the direction of the proximal horizontal branch
(Fig.1.23).
1.3 Method oftheReading Branch Using CT Images
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cranial
medial
lateral
caudal
Fig. 1.20 Representative case 3
Fig. 1.21 Horizontal–horizontal branch [representative case 1]
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Fig. 1.22 Horizontal–horizontal branch [representative case 2]
Fig. 1.23 Horizontal–vertical
branch [representative case]
1.3 Method oftheReading Branch Using CT Images
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Points to remember while drawing bronchi in four patterns.
Vertical pattern: draws the angle of the spur at the bifurca-
tion of the bronchi on the axial CT images.
In the case of a horizontal pattern, consider which direction
(e.g., cranial side/caudal side, lateral side/medial side) the
upper, lower, left, and right in the direction of the bronchoscopic view are.
Horizontal–horizontal pattern: draw distal branches so
that they are divided into the left and right as observed
from the long axis of the proximal bronchus running
horizontally.
Horizontal–vertical pattern: draw distal branches so
that they are divided into up and down as observed
from the long axis of a proximal bronchus running
horizontally (Fig.1.23).
Horizontal–oblique pattern: draw how oblique the
bronchus runs and which bronchus in the vicinity is
approaching to or departing from the bronchus.
Points of tracing the bronchi (middle lobe, lingular seg-
ment, or bilateral lower lobes) that advance to the caudal direction and, then, turn to the cranial direction.
Axial CT images.
• Reverse the CT images horizontally for middle lobe/
lingular segment/lower lobe. After reversing, these CT
images can be observed from the cranial side.
• When the bronchoscope moves toward the caudal side
rst and changes the direction to the cranial side, focus
on tracing the bronchus.
• As a representative case (e.g., B6a and B8a), the bronchus
moves in the caudal direction and, then, turns to the cranial direction. In this condition, focus on the following:
B6 advances in the caudal direction and branches into B6a
in the cranial direction.
• Right B6a will be explained as the following represen-
tative example (Fig.1.24):
• On the fourth photo from the top of Fig.1.24, the CT
image, which is ipped horizontally. B6a branches into
B6ai (red) in the cranial direction and B66ii (yellow) in
the dorsal direction.
B6aii advances in the dorsal direction (this bronchus
branches to the lung eld of the caudal side of S6a) close to
B6b and B6c; B6aii is located at a position close to B6b and
B6c in B6a on the bronchial branch diagram.
As B6a is diverging to the cranial branch of B6ai in a
direction far from the basal bronchus, B6ai is located distant
from the basal bronchus in B6a on the bronchial branch
diagram.
The correlation of positions of B6ai and B6aii is opposite
between the bronchial branch diagram on the axial CT
images and the bronchoscopic image at the orice of B6 as
observed from the intermediate trunk.
MPR Image (Another Case)
1. Rotating the coronal image of multiplanner reconstruc-
tion (MPR) created from the CT images by 180° and
observing at the left lung (right gure), it is a view look-
ing down on the patient from the cranial side when the
head of the patient is lying in the supine position during
bronchoscopy (Fig.1.25).
2. Tracking B6a on the coronal image MPR rotated 180°.
B6aii, distributing over the caudal part of S6a, advances in the
dorsal–horizontal direction close to B6b and B6c and
slightly medial direction. B6aii in the B6a (lower left g-
ure, lower right drawing) is located in the vicinity of the
basal bronchus (1 o’clock direction) on the bronchial
branch diagram (Fig.1.26).
In the bronchial branch diagram, B6ai (distributing over
the cranial part of S6a) in the B6a is far from B6b, B6c, and
basal bronchus and slightly lateral (7 o’clock direction on
the bronchial branch diagram). When using the MPR coronal
images, you can draw the branch as it is.
Summary of the reading CT anatomy using the axial CT
images
1. Follow the bronchi as to which subsegment the lesion is
located in.
2. Reverse horizontally or rotate the CT image (Fig.1.27).
For lesions in the left and right lower lobe, right middle
lobe, and left lingular segment, reverse the left and
right CT images.
In the right upper lobe, rotate the CT images counter-
clockwise 90° (so that the lateral chest wall is
downward).
In the left superior segment, rotate the CT images clock-
wise 90° (so that the lateral chest wall is downward).
3. Follow the slices gradually from the lobar bronchus to the
peripheral pulmonary lesion.
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1 To Trace theBronchial Branch Accurately
Fig. 1.24 Points of tracing the bronchi that advance to the caudal direction and, then, turn to the cranial direction
4. We will follow the bronchi that branches on the CT
images and, then, recognize the position where the lobar
bronchus exists and further recognize the position of the
next bifurcation. I will repeat pursuing bifurcation of this
bronchial route (Fig.1.28).
5. On the reversed/rotated CT images, while the bronchial
branch is running in the craniocaudal (vertical) direction,
the spur direction at the bifurcation is drawn at precisely
the same angle (vertical pattern).
6. On the reversed/rotated CT images, while the bronchial
branch is running in the horizontal direction, the direction (cranial side/caudal side, dorsal side/ventral side,
lateral side/medial side) in the eld of view observed
from the bronchoscope is conrmed. Furthermore, we
will consider the direction in which the bronchus is
advancing, which another bronchus is approaching to/
departing from the traced bronchus (horizontal–horizon-
1.3 Method oftheReading Branch Using CT Images
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Fig. 1.25 Coronal MPR image rotated 180°
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tal pattern, horizontal–vertical pattern, or horizontal–
oblique pattern).
Analysis of internal structures of pulmonary peripheral
lesions [13].
Type the classication of EBUS images (Fig.1.29).
When the ultrasonic probe (20 MHz, radial type;
Olympus) reaches the peripheral pulmonary lesion, it can be
visualized. High-frequency ultrasonic waves are traveling
into the peripheral pulmonary lesion, repeating reections,
and scattering; then, the EBUS image is created from the
ultrasonic wave returned from the tissue to the ultrasonic
probe. At present, we classify an EBUS image, which has
higher resolution than CT and MRI, by assessing the internal
echo, patency of the blood vessels, and hyperechoic points
and lines because of the reection of air with high-frequency
ultrasonic waves. This type of classication estimates benign
or malignant and so on.
Fig. 1.26 B6a on the coronal image (MPR) rotated 180°
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B4 and B5 (→).
B5a and B5b.
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Fig. 1.27 To reverse horizontally or rotate the CT image
Fig. 1.28 To follow the
bifurcations
1 To Trace theBronchial Branch Accurately
Fig. 1.29 The classication of EBUS images
The first branch of the right middle lobe
bronchus has the division of
The next branches of right B5
have the division (→) of
1.3 Method oftheReading Branch Using CT Images
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Type I: Internal echo is homogeneous.
Type Ia: Internal echo is homogeneous, and the blood
vessels are patent without compression. We suspect
acute inammation such as pneumonia (relatively soft
lesion that is deduced from the blood vessels without
compression).
Type Ib: Internal echo is homogeneous, and no blood ves-
sels are found. We suspect chronic inammation (relatively hard lesion) such as organized pneumonia.
Type II: Hyperechoic points exist inside the lesion.
Type IIa: Hyperechoic points exist inside the lesion, and
no blood vessels are found. Ultrasound reected by the
air inside the alveoli displays hyperechoic points. I
suspect well-differentiated adenocarcinoma primarily
based on the ground-glass opacity.
Type IIb: Hyperechoic points exist inside the lesion, and
the blood vessels are present. As the amount of air in
the alveoli decreases, the ultrasonic wave enhances the
propagation, and the blood vessels in the lesion are visible. I suspect well-differentiated adenocarcinoma primarily based on part-solid lesions.
Type III: Internal echo is heterogeneous.
Type IIIa: Linear echoes are scattered with heterogeneous
internal echoes. I think that the linear echo corresponds
to the air in the compressed bronchus and so on.
Several lung cancer types are classied as type IIIa.
Type IIIb: Internal echoes are heterogeneous, and no linear
echoes are found. We estimate the state where cancer cells
are densely present and the air in the lesion is decreasing.
Overall, I suspect poorly differentiated adenocarcinoma.
Morphology of the bronchial branch.
Lateral branch (daughter branch).
The form of the bronchial branching is divided into two sys-
tems. The main system of the bronchial branching is to
branch bronchi symmetrically in approximately the same
diameter repeatedly from the hilum to the periphery.
Another system of the bronchial branching (lateral branch)
is to branch bronchi in different diameters, angulated
approximately 90°. The lateral branch (daughter branch)
branches into the half diameter against the counterpart and
at a wide angle close to 90°, primarily distributed in the
lungs close to the hilum; Hayward etal. [14] reported a
lateral pathway; Yamashita [2] reported a daughter branch;
Ito [15] and Onuma [16] called it a lateral branch; and this
book describes it as the lateral branch.
In Japan, the lateral branch (daughter branch) has been inves-
tigated since the 1980s. Kato [11] performed detailed
measurements in stretch xed lungs, and the anatomical
features of the lateral branch were the following: (1) the
average value of the branching angle was 56.3°
± 19.6°
between the daughter branch and the parent branch (the
proximal bronchus by one generation), 21.0° ± 14.9°
between the main axis branch (the counterpart of the
daughter bronchus) and the parent branch (the proximal
bronchus by one generation), and 34.8° ± 16.1° between
the proximal bronchus and the next distal bronchus of the
symmetrical branching system (Fig.1.30); (2) the inner
diameter ratio was 0.54 ± 0.11 between the daughter
branch and the parent branch, 0.91 ± 0.10 between the
Fig. 1.30 Symmetrical
branching system and
asymmetrical branching
system
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1 To Trace theBronchial Branch Accurately
main axis branch (the proximal bronchus by one generation) and the parent branch, and 0.77 ± 0.15 between the
main axis branch (the proximal bronchus by one generation) and the next distal bronchus with symmetrical
branching; and (3) the ratio of the diameter between the
daughter branch and the branched counterpart is <0.75
and between the symmetrical branching bronchi is
0.75–1.30.
Kato etal. [10] reported that the lung parenchyma from the
visceral pleura about 1.5-cm distance was classied as the
outer layer, the lung parenchyma from the hilum to the subsegmental bronchus as the inner layer, and the layer
between the outer layer and inner layer as the middle layer.
Lateral bronchi were common in the inner and middle layers, and symmetrical bronchi are common in the outer
layer. Ito [9] reported that the frequency of the parent
branch with the daughter branch closest to the hilum was in
the order of the IV bronchus (sub-subsegmental bronchus)
> III> V> VI> II and the diameter ratio between the daughter bronchus with the parent branch was 0.55 ± 0.09. Hence,
criteria for suspecting lateral branches are considered as
follows: (1) it should be in the inner and middle layers; (2)
the diameter ratio of the branched counterpart to the lateral
bronchus is <0.75; and (3) the branching angle is steep.
Although there seems to be no stipulation of the description
of the lateral branch at present, the summarized
Chairman’s comment [12] in the Symposium “Over the
daughter branch” in the 11th Japanese Society for
Bronchology recommended attaching ∗ (star, asterisk) on
the right shoulder of the parent branch. Based on this proposal, we decided that lateral branches should be marked
with ∗ (star, asterisk) on the right shoulder of the name of
the branch and should not count the generation of the lateral branch. For example, the lateral branch branched
from left B3a is described as left B3a∗.
In the case that the parent branch (the proximal bronchus by
one generation) is a common trunk, for example, when a
lateral branch comes out from B10b + B10c, it is described
in this book as B10b + B10c∗.
The ultrasonic probe (transducer) used for EBUS-GS.
At present, the ultrasonic probe used for EBUS-GS is
mechanical radial scanning [17]. A transducer at the tip of
the probe is rotated to perform circular scanning
(Fig.1.31).
Fig. 1.31 The ultrasonic
probe (transducer)
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