最新 非实性结节的诊断和处理指南

1、肺内非实性结节诊断处理指南Subsolid Pulmonary Nodules and the Spectrum of Peripheral Adenocarcinomas of the Lung: Recommended Interim Guidelines for Assessment and Management2021/4/261screen2.9-19%由Nordri（ ） 设计提供2021/4/262LOGOGGN的病理基础1GGN的CT-病理对照研究及预后的相关性2良恶性GGN的鉴别诊断3GGN的处理指南 Guidelines for Assessment and Managem

2、ent4由Nordri（ ） 设计提供2021/4/263Current Concepts in the Diagnosis andManagement of Subsolid Nodules周围型小腺癌不同分型与CT表现有密切关系 (close correlation between CT findings and the spectrum of peripheral adenocarcinoma)不是所有的GGN都是恶性的，尤其是GGO；有时需要随访、PET-CT的帮助，甚至穿刺活检(the diagnosis and management of these lesions remain

3、problematic)12021/4/264Travis WD, et al. J Thorac Oncol 2011;6:244 IASLC/ATS/ERS classification2004 WHO classificationPreinvasive AAH AIS AAH BACMIAInvasive AD Lepidic predominant Acinar, papillary, micropapillary Solid predominant with mucin productionAD, mixed subtype Acinar, papillary Solid predo

4、minant with mucin productionVariants Invasive mucinous AD Colloid, Fetal, EntericVariants Colloid, fetal, mucinous cystadenocarcinoma, signet ring,Clear cell 2021/4/265Pathology, CT, Prognosis of AdenocarcinomaPrecursorSpectrum of ADNoguchiABCD, E, FWHO 2004AAHBACAD with mixed subtypeADIASLCAAHAISMI

5、AADADLepidic vs invasiveNoneLepidic InvasiveInvasiveProportion of GGOPure GGNPure GGN Part-solid SolidSolidPrognosisGood Bad2021/4/2662021/4/267Growth Rate of Small Peripheral Adenocarcinomas in Low-Dose CT Screening for Lung Cancer由于AAH可向AIS、MIA逐步发展，生长较慢，非实性结节的倍增时间明显较实性结节长(subsolid nodules tend to

6、present considerably slower growth rates compared with solid lesions)；Hasegawaet等: HRCT下的pGGN、mGGN及实性结节的平均倍增时间分别为813、457、149天；以前随访两年无明显增大诊断良性不适用于非实性结节(previous concept that lack of growth over a 2-year follow-up indicates a benign etiology does not apply for subsolid nodules)，故随访两年以上是必要的。22021/4/268

7、Methods for Measuring Interval Changein the Appearance of Focal NodulesGGN缺乏与肺实质的良好密度对比，准确测量其大小非常困难(hard to access the accurate volume of GGN because of lack contrast to normal lung )用合适的剂量，1-3毫米的薄层CT靶成像观察或随访 (most importantly the use of thin (13-mm) sections , as well as appropriate exposure factor

8、s)；Methods: 1)测量病灶长径，测量后对直径进行修正，计算结节的体积；2)用肺结节分析软件；3) Vanishing ratio:窗位变化，看病灶的消失率来判断有无增大。32021/4/269薄层1-3mm靶重建是选择方法的共识2021/4/26109、 人的价值，在招收诱惑的一瞬间被决定。2022/7/122022/7/12Tuesday, July 12, 202210、低头要有勇气，抬头要有低气。2022/7/122022/7/122022/7/127/12/2022 9:07:16 PM11、人总是珍惜为得到。2022/7/122022/7/122022/7/12Jul-22

9、12-Jul-2212、人乱于心，不宽余请。2022/7/122022/7/122022/7/12Tuesday, July 12, 202213、生气是拿别人做错的事来惩罚自己。2022/7/122022/7/122022/7/122022/7/127/12/202214、抱最大的希望，作最大的努力。12 七月 20222022/7/122022/7/122022/7/1215、一个人炫耀什么，说明他内心缺少什么。七月 222022/7/122022/7/122022/7/127/12/202216、业余生活要有意义，不要越轨。2022/7/122022/7/1212 July 202217

10、、一个人即使已登上顶峰，也仍要自强不息。2022/7/122022/7/122022/7/122022/7/12VDT计算公式注：a、b分别为长、短径； V0:首次检查的容积； Vt：复查时的容积； t:随访间期；2021/4/26129、 人的价值，在招收诱惑的一瞬间被决定。2022/7/122022/7/12Tuesday, July 12, 202210、低头要有勇气，抬头要有低气。2022/7/122022/7/122022/7/127/12/2022 9:07:16 PM11、人总是珍惜为得到。2022/7/122022/7/122022/7/12Jul-2212-Jul-2212、

11、人乱于心，不宽余请。2022/7/122022/7/122022/7/12Tuesday, July 12, 202213、生气是拿别人做错的事来惩罚自己。2022/7/122022/7/122022/7/122022/7/127/12/202214、抱最大的希望，作最大的努力。12 七月 20222022/7/122022/7/122022/7/1215、一个人炫耀什么，说明他内心缺少什么。七月 222022/7/122022/7/122022/7/127/12/202216、业余生活要有意义，不要越轨。2022/7/122022/7/1212 July 202217、一个人即使已登上顶峰，

12、也仍要自强不息。2022/7/122022/7/122022/7/122022/7/12Getting used to volumes5mm = 65mm3 (approx 50)10mm = 524mm3 (approx 500)2021/4/2614Automated three-dimensional segmentation. (a) Magnified 1-mm CT section through the right upper lobe shows a nodule with GGO with indistinct margin. (b) Corresponding three-

13、dimensional segmentationprovides automated estimation of its volume and cross-sectional dimensions in the x, y, and z planes, as well as minimum and maximum diameters measured in off-axial planes.机器的测量软件对实性结节较好，但对非实性结节仍然存在很大挑战。2021/4/2615增长速率19%，VDT 322天。164mm3195mm3右上叶腺癌2021/4/2616Thin-section CT i

14、mages of nodule with mixed solid component and GGO. The vanishing ratio represents the percentage of the area of the lesion that is not seen at thin-section CT when comparing images reconstructed with (a) lung versus (b) mediastinal window settings. The mediastinal window setting is used to enhance

15、visualization of the delimitation of the solid component.2021/4/2617每次随访 都需在相同的扫描条件及测量软件下对GGN的体积及其内实质性成分的含量进行详细记录、动态监测：病灶体积增大，则其恶性可能性也增大。单纯病灶密度的变化很有诊断意义（病灶大小不变甚至短期内缩小)；GGN的恶性进展可表现为边缘由光滑逐渐进展为分叶、毛刺或不规则样2021/4/2618AIS. Sequential magnified 1-mm CT sections through the right upper lobe show minimal incr

16、easein size of a nodule with GGO over a 3-year period. The central area of higher attenuation represents avessel bifurcation and not a solid component, which was better characterized on sequential images.2021/4/2619Mixed subtype adenocarcinoma, progression of GGO to a nodule with mixed solid compone

17、nt and GGO. (a) Magnified 1-mm CT section shows a discrete GGO (arrows). (b) Follow-up CT scan obtained 1 year later shows clear progression of the disease, with the development of a central solid component, although there is no appreciable enlargement of the lesion (arrows).2021/4/2620MIA. (a) Magn

18、ified 1-mm CT section through the left lower lobe shows a nodule with mixed solid component and GGO. (b) Follow-up CT scan obtained 6 months later shows increase in the extent of the solid component within the nodule.2021/4/2621F/52体检发现200220062021/4/2622GGN与PET-CT? Marom EM 等（ 2000)：对于直径8-10mm的病灶，1

19、8F-FDG PET对其进行良恶性鉴别诊断的敏感度、特异度和准确率分别为96%、88%和94%Tsunezuka等(2007)：18F-FDG PET对直径2cm的腺癌，A型的假阴性率为100%，B型为80%，C型为47%，D-F的阳性率分别为67%、100%、86%。PET表现也和预后具有相关性（PET has been shown to correlate with prognosis）: 低FDG摄取的恶性结节往往预后较好，而高FDG摄取的恶性结节则预后差。42021/4/2623A、Coronal CT shows multicentric BAC(AIS) characterized

20、 by GGOs in the left upper and lower lobes corresponding to Noguchi types A； B, Correlated coronal PET image shows no FDG uptake by the lesions C、another patient shows MIA(Noguchi C）MGGO. D、Correlated coronal PET image showsFDG uptake (arrow) by the lesion (maximum uptake value 3.4).2021/4/2624Role

21、of Transbronchial and Transthoracic Needle Biopsy for Diagnosis of AIS单纯细胞病理甚至组织病理常常难以区分AAH、AIS以及腺癌的各种亚型（accurate differentiation between AAH, BAC, and mixed type adenocarcinomas may not be feasible on the basis of limited cytologic or even histologic sampling）有报道59例外科切除病例，冰冻初诊为AIS，进一步病理诊断为侵袭性腺癌；另有1

22、0例5mm以下病灶，开始诊断AAH，后证明9例为AIS ，1例为侵袭性腺癌。Kim et al报道一组病例，28%的病例手术切除后证实为侵袭性腺癌合并AIS成分52021/4/2625经皮穿刺活检: 只有51.2%GGO为主型非实性结节（GGO比例大于50%）及75.6%的实性为主型非实性结节（GGO比例小于50%）能做出诊断，总体准确率只有64.6%，其中10mm以下GGO为主型结节的准确率只有35.2%。穿刺适应证：不准备外科切除的，虽准备外科切除但仍然需要证明是恶性的，病灶多发的。2021/4/2626Surgical Resection of Small PeripheralAdeno

23、carcinomas以往多采用肺叶切除，但近来用局部切除（肺段或楔形)已大大提高了非实性结节的5年存活率（despite previous consensus for the need to perform lobectomy for stage 1 lung cancer, the potential role of limited surgical resections, including partial wedge resections and segmentectomies, has come under renewed scrutiny）。目前对MIA及GGO成分大于50%的多主张

24、采用肺段+肺门纵隔淋巴结切除。没有发现复发，治愈率很高。Noguchi A C型采用局部切除的5年生存率为70.3%（Mun et al 等）。 多发性腺癌没有淋巴结转移的手术切除后与单发孤立结节没有淋巴结转移的预后相当。62021/4/2627Current Status and Ongoing Controversies in the Management of Subsolid Lung NodulesPatients for Whom Follow-up Studies Are Prioritized in Place of Biopsy or SurgeryPatients with

25、 Multiple Subsolid NodulesIs There Overdiagnosis of Lung Cancer in Patients with Subsolid Nodules?72021/4/26281、哪些病人首先选择随访而非活检或手术？Patients for Whom Follow-up Studies Are Prioritized in Place of Biopsy or Surgery目前仅仅依赖CT形态学判断pGGO密度变化和体积增长速率是困难的。哪些CT征象提示病灶会进展也难以分辨。非实性结节的最佳随访时机和随访间隔尚无定论。随访2年不足以证明是良性，尤其

26、pGGO。随访过程中测量病灶的方法同样是不确定的，尤其对边界不清或不规则的病灶。2021/4/2629There are no predictive CT features to aid in differentiating lesions likely to progress versus those that remain stable.stableHistologic analysis of the second lesion showed mixed subtype adenocarcinoma composed of acinar adenocarcinoma (40%) and B

27、AC(AIS) (60%). 2021/4/26302、多发性非实性肺结节 Patients with Multiple Subsolid Nodules由于多发非实性结节的组织亚型分布与多发实性结节不同，所以治疗的效果尚不清楚；同为多发性非实性结节，多发5mm以下的GGO结节与多发大小不等的非实性结节的治疗不同；多发结节中10mm以上或有实性成分的结节的局部切除价值有待确定。2021/4/2631Variable-sized subsolid nodules. (a) Magnified 1-mm CT section through the right upper lobe shows m

28、ultiple small lesions with GGO and one dominant larger nodule with GGO (arrow). (b) CT scan at 4-year follow-up shows no substanital interval change (arrow) and the lesions were presumed to represent AAH and BAC(AIS) (dominant lesion).2021/4/2632Multiple subsolid nodules with variable size and appea

29、rance. (a, b) Sequential axial 1-mm CT sections through the mid thorax in the same patient showmultiple subsolid pulmonary nodules differing in size and attenuation located in the superior segment of the right and left lower lobes (arrows), including nodules with mixed solid component and GGO, nodul

30、es with GGO, and a solid nodule. In such cases, selective limited resection of the dominant lesions may be acceptable.2021/4/26333、肺内非实性结节过度诊断了吗？Is There Overdiagnosis of Lung Cancer in Patients with Subsolid Nodules?CT发现的非实性结节基本都过度诊断和过度治疗了。Carter et al：37个年度筛查发现的174个肺癌中，84例为非实性结节，其中只有14（17%）例手术切除后证

31、实有侵袭性。非实性结节的侵袭性高低今后有望通过生物标记物等的检测而预判。2021/4/26342001.12.262002.12.112021/4/26352005.07.122006.10.262021/4/26362021/4/26372021/4/2638Suggested Guidelines in theManagement of Subsolid NodulesLesions Smaller than 10 mm with Pure GGOSolitary Lesions 10 mm or Larger in Size with GGOLesions with Mixed Soli

32、d Component and GGOMultiple Subsolid Nodules82021/4/26391、Lesions Smaller than 10 mm with Pure GGO单发的5mm的pGGO常常是局灶的AAH，无需随访单发5-10mmpGGO可在首次CT后间隔3-6个月复查看有无自然吸收（或抗生素治疗后复查），此类病灶长期随访比外科切除要更好。至少随访5年，当中有任何大小及密度变化都提示恶性，需要外科切除。随访中CT剂量应尽可能低（1cm的pGGO，至少间隔3-6个月后复查，随访过程中发现病变增大者或其内部实性成分增加者，建议外科局部切除。不建议经皮穿刺活检，因为取样不一定能确定诊