直径小于10mm的GGO诊断与治疗进展

•综述•直径小于10mm的GGO诊断与治疗进展于冬怡陈晓峰GGO发病情况与诊疗意义肺癌是最常见的恶性肿瘤，自2004年我国已经成为世界第一肺癌大国ADDINEN.CITEADDINEN.CITE.DATA[\o"周脉耕,2010#16"1]，自1988年至2005年，我国肺癌发病率呈现逐年上升趋势,年平均增长1.63%,但年龄调整后每年降低0.55%ADDINEN.CITE<EndNote><Cite><Author>陈万青</Author><Year>2010</Year><RecNum>13</RecNum><DisplayText><styleface="superscript">[2]</style></DisplayText><record><rec-number>13</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1381734806">13</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>陈万青</author><author>张思维</author><author>邹小农</author></authors></contributors><auth-address>全国肿瘤防治研究办公室,北京,100021</auth-address><titles><title>中国肺癌发病死亡的估计和流行趋势研究</title><secondary-title>中国肺癌杂志</secondary-title></titles><periodical><full-title>中国肺癌杂志</full-title></periodical><pages>488-493</pages><volume>13</volume><number>5</number><keywords><keyword>肺肿瘤发病率死亡率流行病肿瘤登记中国</keyword></keywords><dates><year>2010</year></dates><isbn>1009-3419</isbn><urls><related-urls><url>/Periodical_zgfazz201005020.aspx</url></related-urls></urls><electronic-resource-num>10.3779/j.issn.1009-3419.2010.05.20</electronic-resource-num><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>chi</language></record></Cite></EndNote>[\o"陈万青,2010#13"2]，研究表明今后20年内我国肺癌发病数和死亡数还将持续上升，发病数超过死亡数ADDINEN.CITE<EndNote><Cite><Author>昌盛</Author><Year>2012</Year><RecNum>14</RecNum><DisplayText><styleface="superscript">[3]</style></DisplayText><record><rec-number>14</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1381735270">14</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>昌盛</author><author>代敏</author><author>任建松</author><author>陈玉恒</author><author>郭兰伟</author></authors><translated-authors><author>ChangSheag</author><author>D.A.I.Min</author><author>R.E.N.Jian-song</author><author>ChenYu-heng</author><author>G.U.O.Lan-wei</author></translated-authors></contributors><auth-address>中国医学科学院肿瘤医院,北京,100021 世界卫生组织国际癌症研究署 中国癌症基金会</auth-address><titles><title>中国2008年肺癌发病、死亡和患病情况的估计及预测</title><secondary-title>中华流行病学杂志</secondary-title></titles><periodical><full-title>中华流行病学杂志</full-title></periodical><pages>391-394</pages><volume>33</volume><number>4</number><keywords><keyword>肺肿瘤发病率死亡率LungneoplasmsIncidenceMortality</keyword></keywords><dates><year>2012</year></dates><isbn>0254-6450</isbn><urls><related-urls><url>/Periodical_zhlxbx201204010.aspx</url></related-urls></urls><electronic-resource-num>10.3760/cma.j.issn.0254-6450.2012.04.010</electronic-resource-num><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>chi</language></record></Cite></EndNote>[\o"昌盛,2012#14"3]。对于大多数肺癌患者由于缺乏早期症状以及健康意识，就诊时已属于中晚期，失去了手术机会，术后总体五年生存率只有15%ADDINEN.CITEADDINEN.CITE.DATA[\o"Hocking,2010#17"4]。但随着人们生活水平的提高，人们的健康意识也逐渐提高，同时胸部CT特别是胸部薄层高分辨率CT的广泛应用，使得越来越多早期肺癌被筛查出来，其中不乏很多10mm以下的微小病灶或磨玻璃样病灶（ground-glassopacity，GGO）。所谓磨玻璃病灶指计算机断层扫描（computeredtomography,CT）图像上表现为密度轻度增加，呈局灶性云雾状密度阴影，其内的支气管及血管纹理仍可显示。临床上我们将肺磨玻璃样病灶分为两类，一类为单纯磨玻璃样病灶（pureground-glassopacity，pGGO），一类为混合性磨玻璃样病灶（mixedground-glassopacity，mGGO）。有报道称，对于以GGO为表现的肺部结节，恶性率（34%）高于实性结节（7%），混合型GGO（部分实性结节）和单纯GGO的（非实性结节）恶性率分别为64%和18%ADDINEN.CITEADDINEN.CITE.DATA[\o"Goo,2011#15"5]。同时，以GGO为表现的早期肺癌术后五年生存率达100%ADDINEN.CITE<EndNote><Cite><Author>Duann</Author><Year>2013</Year><RecNum>2</RecNum><DisplayText><styleface="superscript">[6]</style></DisplayText><record><rec-number>2</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1381723865">2</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Duann,C.W.</author><author>Hung,J.J.</author><author>Hsu,P.K.</author><author>Huang,C.S.</author><author>Hsieh,C.C.</author><author>Hsu,H.S.</author><author>Wu,Y.C.</author><author>Hsu,W.H.</author></authors></contributors><auth-address>DivisionofThoracicSurgery,DepartmentofSurgery,TaipeiVeteransGeneralHospitalandNationalYang-MingUniversitySchoolofMedicine,Taipei,Taiwan,ROC.</auth-address><titles><title>Surgicaloutcomesinlungcancerpresentingasground-glassopacitiesof3cmorless:Areviewof5years'experience</title><secondary-title>JChinMedAssoc</secondary-title><alt-title>JournaloftheChineseMedicalAssociation:JCMA</alt-title></titles><periodical><full-title>JChinMedAssoc</full-title><abbr-1>JournaloftheChineseMedicalAssociation:JCMA</abbr-1></periodical><alt-periodical><full-title>JChinMedAssoc</full-title><abbr-1>JournaloftheChineseMedicalAssociation:JCMA</abbr-1></alt-periodical><edition>2013/10/09</edition><dates><year>2013</year><pub-dates><date>Oct4</date></pub-dates></dates><isbn>1726-4901</isbn><accession-num>24099986</accession-num><urls></urls><electronic-resource-num>10.1016/j.jcma.2013.08.005</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>Eng</language></record></Cite></EndNote>[\o"Duann,2013#2"6]。高恶变率和早期治疗后的高生存率使得GGO的诊治日益受到广泛关注。GGO的诊断方法与发展方向GGO作为一种非特异表现，可以是弥漫性的如非典型肺炎、肺挫伤、肺间质纤维化等，也可以是局限性的，如局灶性肺出血、肺曲菌病、非典型腺瘤样增生(atypicaladenomotoushyperplasia，AAH)和支气管肺泡癌(bronchioto-alveolarcarcinoma，BAC)。pGGO大多数无外侵性生长，其病理类型多为非典型腺瘤样增生(atypicaladenomotoushyperplasia，AAH)和支气管肺泡癌(bronchioto-alveolarcarcinoma，BAC)，。AAH在2004年世界卫生组织肺癌组织学分类中被认为是肺腺癌的癌前病变，病理学表现为单层立方肺泡上皮的灶性轻至中度非典型增生，病灶通常不超过5mm，且无间质性炎症反应和纤维化变，BAC的病理特点是Clara细胞和Ⅱ型肺泡细胞沿着肺泡壁生长，不侵犯肺泡间隔，故BAC是一种原位癌，而AAH是BAC的癌前病变ADDINEN.CITE<EndNote><Cite><Author>Kitamura</Author><Year>2010</Year><RecNum>38</RecNum><DisplayText><styleface="superscript">[7]</style></DisplayText><record><rec-number>38</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384698298">38</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Kitamura,H.</author><author>Okudela,K.</author></authors></contributors><auth-address>DepartmentofPathology,GraduateSchoolofMedicine,YokohamaCityUniversity3-9Fukuura,Kanazawa-ku,Yokohama236-0004,Japan.pathola@med.yokohama-cu.ac.jp</auth-address><titles><title>Bronchioloalveolarneoplasia</title><secondary-title>IntJClinExpPathol</secondary-title><alt-title>Internationaljournalofclinicalandexperimentalpathology</alt-title></titles><periodical><full-title>IntJClinExpPathol</full-title><abbr-1>Internationaljournalofclinicalandexperimentalpathology</abbr-1></periodical><alt-periodical><full-title>IntJClinExpPathol</full-title><abbr-1>Internationaljournalofclinicalandexperimentalpathology</abbr-1></alt-periodical><pages>97-9</pages><volume>4</volume><number>1</number><edition>2011/01/14</edition><keywords><keyword>Adenocarcinoma,Bronchiolo-Alveolar/genetics/*pathology</keyword><keyword>Adenoma/genetics/pathology</keyword><keyword>Animals</keyword><keyword>DiseaseModels,Animal</keyword><keyword>Hyperplasia/genetics/pathology</keyword><keyword>LungNeoplasms/genetics/*pathology</keyword><keyword>Mice</keyword><keyword>Mutation</keyword><keyword>PrecancerousConditions/genetics/pathology</keyword><keyword>Proto-OncogeneProteins/genetics</keyword><keyword>Receptor,EpidermalGrowthFactor/genetics</keyword><keyword>rasProteins/genetics</keyword></keywords><dates><year>2010</year></dates><isbn>1936-2625</isbn><accession-num>21228931</accession-num><urls></urls><custom2>Pmc3016107</custom2><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"Kitamura,2010#38"7]。mGGO病理类型多为腺癌或者BAC，mGGO直径多大于pGGO，和pGGO相比，mGGO恶性程度高，生长速度快，淋巴结转移率高。局灶行肺部磨玻璃影(focalground-glassopacity，fGGO)是早期肺癌，尤其是肺泡细胞癌的表现已基本达成共识，是胸外科医生研究的重点。对于fGGO的诊断，特别是直径<10mm的GGO如何判断其良恶性一直是胸外科的难题，尽管螺旋CT对于筛查fGGO的检出率很高，但是目前尚无任何明确的术前诊断良恶性的方法。通常是结合患者的既往史和影像学特征进行综合分析。目前广泛认可的肺癌高危因素主要是年龄>60岁，吸烟>20支/天、>30年、戒烟<10年，既往恶性疾病史等ADDINEN.CITE<EndNote><Cite><Author>王涛</Author><Year>2012</Year><RecNum>48</RecNum><DisplayText><styleface="superscript">[8]</style></DisplayText><record><rec-number>48</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1385570772">48</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>王涛</author><author>陈保俊</author></authors></contributors><auth-address>210008,南京大学医学院附属南京鼓楼医院心胸外科</auth-address><titles><title>肺部≤1.0cm亚厘米结节的临床诊疗策略</title><secondary-title>中华胸心血管外科杂志</secondary-title></titles><periodical><full-title>中华胸心血管外科杂志</full-title></periodical><pages>387-389</pages><volume>28</volume><number>7</number><dates><year>2012</year></dates><isbn>1001-4497</isbn><urls><related-urls><url>/Periodical_zhxxxgwk201207002.aspx</url></related-urls></urls><electronic-resource-num>10.3760/cma.j.issn.1001-4497.2012.07.002</electronic-resource-num><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>chi</language></record></Cite></EndNote>[\o"王涛,2012#48"8]。对于非吸烟人群来说，二手烟、煤烟、非肿瘤肺部疾病（主要指结核、肺炎、COPD）及肿瘤家族史是主要的危险因素ADDINEN.CITEADDINEN.CITE.DATA[\o"Sisti,2012#40"9]。根据一项长期的随访研究显示，以GGO为表现的危险因素主要为：初始大小>10mm、男性、年龄大于65岁、GGO含有实性成分ADDINEN.CITE<EndNote><Cite><Author>Lee</Author><Year>2013</Year><RecNum>43</RecNum><DisplayText><styleface="superscript">[10]</style></DisplayText><record><rec-number>43</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384943657">43</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Lee,S.W.</author><author>Leem,C.S.</author><author>Kim,T.J.</author><author>Lee,K.W.</author><author>Chung,J.H.</author><author>Jheon,S.</author><author>Lee,J.H.</author><author>Lee,C.T.</author></authors></contributors><auth-address>DepartmentofInternalMedicine,SeoulNationalUniversityBundangHospital,Seongnam,Gyeonggi-do,RepublicofKorea.</auth-address><titles><title>Thelong-termcourseofground-glassopacitiesdetectedonthin-sectioncomputedtomography</title><secondary-title>RespirMed</secondary-title><alt-title>Respiratorymedicine</alt-title></titles><periodical><full-title>RespirMed</full-title><abbr-1>Respiratorymedicine</abbr-1></periodical><alt-periodical><full-title>RespirMed</full-title><abbr-1>Respiratorymedicine</abbr-1></alt-periodical><pages>904-10</pages><volume>107</volume><number>6</number><edition>2013/03/22</edition><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0954-6111</isbn><accession-num>23514949</accession-num><urls></urls><electronic-resource-num>10.1016/j.rmed.2013.02.014</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"Lee,2013#43"10]。有趣的是，我们发现支气管肺泡癌常见于不吸烟女性，且常表现为多发pGGO，日本一项研究发现雌激素水平过高或过低都将增加BAC甚至腺癌发生的危险，初潮的年龄、绝经过早和过晚都具有相关性ADDINEN.CITEADDINEN.CITE.DATA[\o"Kohno,2010#36"11]。而pGGO无毛刺和分叶等边缘征象、支气管充气征、含气腔隙等其他影像学特征诊断价值有限，具备一定经验的医师在进行经皮肺穿刺活检中，效果还是令人满意的，诊断的准确率可达到87.1%(病灶直径<=10毫米)、90.0%(病灶直径>10毫米，<=20毫米)和100.0%(病变>20毫米)ADDINEN.CITEADDINEN.CITE.DATA[\o"Yamagami,2013#34"12]。目前研究提出CYFRA21-1对于表现为GGO的肺癌具有诊断意义ADDINEN.CITEADDINEN.CITE.DATA[\o"Kim,2013#37"13]。有人提出以GGO为表现的早期肺癌其CEA可能升高，其诊断价值有待进一步验证ADDINEN.CITE<EndNote><Cite><Author>Zou</Author><Year>2013</Year><RecNum>42</RecNum><DisplayText><styleface="superscript">[14]</style></DisplayText><record><rec-number>42</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384942707">42</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Zou,Y.</author><author>Wang,L.</author><author>Zhao,C.</author><author>Hu,Y.</author><author>Xu,S.</author><author>Ying,K.</author><author>Wang,P.</author><author>Chen,X.</author></authors></contributors><auth-address>BiosensorNationalSpecialLab,KeyLabforBiomedicalEngineeringofMinistryofEducation,DepartmentofBiomedicalEngineering,ZhejiangUniversity,310027Hangzhou,People'sRepublicofChina.</auth-address><titles><title>CEA,SCCandNSElevelsinexhaledbreathcondensate-possiblemarkersforearlydetectionoflungcancer</title><secondary-title>JBreathRes</secondary-title><alt-title>Journalofbreathresearch</alt-title></titles><periodical><full-title>JBreathRes</full-title><abbr-1>Journalofbreathresearch</abbr-1></periodical><alt-periodical><full-title>JBreathRes</full-title><abbr-1>Journalofbreathresearch</abbr-1></alt-periodical><pages>047101</pages><volume>7</volume><number>4</number><edition>2013/11/05</edition><dates><year>2013</year><pub-dates><date>Nov1</date></pub-dates></dates><isbn>1752-7155</isbn><accession-num>24185583</accession-num><urls></urls><electronic-resource-num>10.1088/1752-7155/7/4/047101</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>Eng</language></record></Cite></EndNote>[\o"Zou,2013#42"14]。另外，尽管PET已应用于肺癌的诊断，但GGO是PET检查的盲区，存在着明显的假阳性，对于其良恶性的鉴别价值有限，定期动态CT观察有助于鉴别癌性GGO，对于急性炎症反应导致的GGO，经过2-4周的随访后病灶可消散或明显缩小；若随访观察过程中GGO内出现高密度实性成分，我们认为此过程可能或为肿瘤侵犯致肿瘤内中心细胞支架结构破坏、肺泡腔实变，或为癌结节堆聚致软组织成分增多，需首先疑诊早期肺癌，并进行肺癌相关的化验检测。目前较为统一的意见是，mGGO患者应积极接受肺组织活检，若病灶周围出现血管聚拢集中，支气管充气征消失，含气腔隙减少，则高度提示恶性可能，应争取利用各种手段获得病理诊断，进行有创诊断包括支气管镜组织活检，经胸壁细针穿刺活检、胸腔镜或开胸手术肺活检。对pGGO，可定期随诊，随诊时间3个月以上，不能排除肺泡癌或AAH，考虑手术探查。GGO的治疗及随访研究发现在MDCT(Multi-detectorspiralcomputedtomography）上表现为GGO的结节的平均倍增时间为486.4±368.6天(89.0-1583.0天)，AAH、BAC和AC分别是859.2±428.9，421.2±228.4和202.1±84.3天，pGGO和mGGO的倍增时间分别为628.5±404.2和276.9±155.9天ADDINEN.CITEADDINEN.CITE.DATA[\o"Oda,2011#46"15]。根据最新的美国胸外科医师协会（ACCP）制定的肺部孤立性小结节的诊疗指南，对临床上无明显症状、无高危因素的患者，如无明确的良性指证，根据其结节大小，我们建议：对于小于5mm的pGGO，不进行进一步评估；对于大于5mm的pGGO，随访至少三年，每年进行1次胸部薄层CT检查。对于实性成分大于50%的GGN，如果直径小于8mm，于前大约3、12、24个月时进行CT检查，之后CT随访1到3年；如果直径大于8mm，建议于3月后复查CT，之后进一步行PET，非手术方法活检或手术切除ADDINEN.CITEADDINEN.CITE.DATA[\o"Gould,2013#47"16]。监测中GGO中生长出实行成分的经常是恶性的，需进一步评估或考虑手术切除。虽然pGGO恶性程度低、无淋巴结转移，但因pGGO或为BAC与AAH难以鉴别、存在高危因素、随访过程中实性成分增加增大或随着人们健康意识的提高强烈要求等原因，基于防止其进展为癌的可能的考虑，亦有手术。对于mGGO患者因其多为腺癌或者腺癌合并有肺泡癌成分宜早期手术，对于实性成分少于50%的mGGO，少见有淋巴结转移和血管侵犯，预后较好，对于实性成分超过50%，则可能已有淋巴结转移和血管侵犯ADDINEN.CITE<EndNote><Cite><Author>H</Author><Year>2004</Year><RecNum>29</RecNum><DisplayText><styleface="superscript">[17]</style></DisplayText><record><rec-number>29</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1382016483">29</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>MatsugumaH</author><author>NakaharaR</author><author>AnrakuM</author><author>KondoT</author><author>TsuuraY</author><author>KamiyamaY</author><author>MoriK</author><author>YokoiK</author></authors></contributors><auth-address>DivisionofThoracicSurgery,TochigiCancerCenter,4-9-13Yohnan,Utsunomiya,Tochigi320-083,Japan.</auth-address><titles><title>Objectivedefinitionandmeasurementmethodofground-glassopacityforplanninglimitedresectioninpatientswithclinicalstageIAadenocarcinomaofthelung</title><secondary-title>Europeanjournalofcardio-thoracicsurgery</secondary-title></titles><periodical><full-title>Europeanjournalofcardio-thoracicsurgery</full-title></periodical><pages>1102-1106</pages><volume>25</volume><number>6</number><keywords><keyword>ExcisionDiagnosticNeoplasmStagingIntra-ArterialInfusionsClinical</keyword></keywords><dates><year>2004</year></dates><isbn>1010-7940</isbn><urls><related-urls><url>/NSTLQK_NSTL_QKJJ028094478.aspx</url></related-urls></urls><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"H,2004#29"17]。因此，对于表现为fGGO直径<10mm高度怀疑恶性的患者，我们主张在尽量获取病理及影像学证据的前提下特别是高龄患者，宜早期手术切除，对于长期随访无法获得病理的mGGO，手术更是一种确证手段。通过积极有效的治疗，减少进入II期可能。随着VATS的发展日益成熟，早期行胸腔镜手术探查已成为处理fGGO的共识，辅助小切口或胸腔镜辅助切口应用手术触摸病灶位置，文献中报道的术中定位还包括CT引导穿刺留置HookWire定位针、亚甲蓝注射、放射性示踪剂注射、影像辅助导航定位、术中B超定位和胸内超声定位等。但目前还是以手指探查为主，依靠术者丰富的经验定位。对于经验不足者，术前CT引导下的钢丝定位技术具有较高的准确率，日本一项研究表明，对于VATS或开胸手术中因结节太小术中很难发现的GGO患者，术前CT引导下定位+术中CT引导下注射美兰或钢丝引导辅助定位，术中找不到或遗漏病灶的可能性为0～5％ADDINEN.CITEADDINEN.CITE.DATA[\o"Kodama,2008#25"18]。这尤其对于直径小于10mm距脏层胸膜超过10mm的肺部小结节大有裨益。国内有单位报道应用钢丝定位成功率达100%ADDINEN.CITE<EndNote><Cite><Author>陈海泉</Author><Year>2011</Year><RecNum>31</RecNum><DisplayText><styleface="superscript">[19]</style></DisplayText><record><rec-number>31</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1382017485">31</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>陈海泉</author></authors></contributors><auth-address>复旦大学附属肿瘤医院胸外科,上海,200032</auth-address><titles><title>肺部孤立性结节诊治进展</title><secondary-title>癌症进展</secondary-title></titles><periodical><full-title>癌症进展</full-title></periodical><pages>472-478</pages><number>5</number><keywords><keyword>肺癌肺部小结节FDG-PET</keyword></keywords><dates><year>2011</year></dates><isbn>1672-1535</isbn><urls><related-urls><url>/Periodical_azjz201105003.aspx</url></related-urls></urls><electronic-resource-num>10.3969/j.issn.1672-1535.2011.05.003</electronic-resource-num><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>chi</language></record></Cite></EndNote>[\o"陈海泉,2011#31"19]。若能扪及病灶即行胸腔镜下切除，若术前评估腔镜切除困难，则选择直接开胸手术。对于10mm以下、侵袭程度较低的pGGO，行楔形切除或肺段切除无需淋巴结清扫是可行的ADDINEN.CITE<EndNote><Cite><Author>Fukui</Author><Year>2010</Year><RecNum>44</RecNum><DisplayText><styleface="superscript">[20]</style></DisplayText><record><rec-number>44</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384944840">44</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Fukui,T.</author><author>Mitsudomi,T.</author></authors></contributors><auth-address>DepartmentofThoracicSurgery,AichiCancerCenterHospital,1-1Kanokoden,Chikusa-ku,Nagoya,464-8681,Japan.</auth-address><titles><title>Smallperipherallungadenocarcinoma:clinicopathologicalfeaturesandsurgicaltreatment</title><secondary-title>SurgToday</secondary-title><alt-title>Surgerytoday</alt-title></titles><periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></periodical><alt-periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></alt-periodical><pages>191-8</pages><volume>40</volume><number>3</number><edition>2010/02/25</edition><keywords><keyword>Adenocarcinoma/*diagnosis/pathology/*surgery</keyword><keyword>Humans</keyword><keyword>LungNeoplasms/*diagnosis/pathology/*surgery</keyword></keywords><dates><year>2010</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0941-1291</isbn><accession-num>20180071</accession-num><urls></urls><electronic-resource-num>10.1007/s00595-008-4100-4</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"Fukui,2010#44"20]，且因其术后5年存活率高，临床上不采用化疗和放疗。术后随访以两年以上ADDINEN.CITEADDINEN.CITE.DATA[\o"Min,2010#35"21]。对于10mm以下mGGO，手术方式存在较大争议，尽管许多研究显示局部切除拥有其可行性，但因其样本含量因素以及病人复发时间可以超过10年以上等因素，目前尚无统一治疗方法。有研究发现曾患有BAC的复发患者，76%-95%复发于初始的肺叶，远远超过其他种类的非小细胞肺癌ADDINEN.CITE<EndNote><Cite><Author>Fukui</Author><Year>2010</Year><RecNum>44</RecNum><DisplayText><styleface="superscript">[20]</style></DisplayText><record><rec-number>44</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384944840">44</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Fukui,T.</author><author>Mitsudomi,T.</author></authors></contributors><auth-address>DepartmentofThoracicSurgery,AichiCancerCenterHospital,1-1Kanokoden,Chikusa-ku,Nagoya,464-8681,Japan.</auth-address><titles><title>Smallperipherallungadenocarcinoma:clinicopathologicalfeaturesandsurgicaltreatment</title><secondary-title>SurgToday</secondary-title><alt-title>Surgerytoday</alt-title></titles><periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></periodical><alt-periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></alt-periodical><pages>191-8</pages><volume>40</volume><number>3</number><edition>2010/02/25</edition><keywords><keyword>Adenocarcinoma/*diagnosis/pathology/*surgery</keyword><keyword>Humans</keyword><keyword>LungNeoplasms/*diagnosis/pathology/*surgery</keyword></keywords><dates><year>2010</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0941-1291</isbn><accession-num>20180071</accession-num><urls></urls><electronic-resource-num>10.1007/s00595-008-4100-4</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"Fukui,2010#44"20]。存在的问题及展望如何第一时间明确诊断其良恶性，并给与科学的治疗仍旧是未来最重要的课题。对于高风险人群如长期吸烟者应定期进行低剂量螺旋CT检查，有助于早期肺癌的发现，但吸烟者多发生鳞癌且常为中心型，筛查阳性率不高同时值得注意的是，对于以GGO为表现的周边型肺癌以女性、不吸烟者和BAC占多数，同样不可忽略ADDINEN.CITE<EndNote><Cite><Author>郭峰</Author><Year>2008</Year><RecNum>30</RecNum><DisplayText><styleface="superscript">[22]</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1382016953">30</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>郭峰</author><author>张志庸</author><author>崔玉尚</author><author>李单青</author><author>李力</author><author>徐晓辉</author><author>李龙芸</author></authors><translated-authors><author>G.U.O.Feng</author><author>ZhangZhiyong</author><author>C.U.I.Yushang</author><author>L.I.Shanqing</author><author>L.I.Li</author><author>X.U.Xiaohui</author><author>L.I.Longyun</author></translated-authors></contributors><auth-address>中国协和医科大学北京协和医院胸外科,北京,100730 中国协和医科大学北京协和医院呼吸内科,北京,100730</auth-address><titles><title>肺局限性磨玻璃样病灶的外科处理</title><secondary-title>中国肺癌杂志</secondary-title></titles><periodical><full-title>中国肺癌杂志</full-title></periodical><pages>739-741</pages><volume>11</volume><number>5</number><dates><year>2008</year></dates><isbn>1009-3419</isbn><urls><related-urls><url>/Periodical_zgfazz200805028.aspx</url></related-urls></urls><remote-database-provider>北京万方数据股份有限公司</remote-database-provider><language>chi</language></record></Cite></EndNote>[\o"郭峰,2008#30"22]。对于较小GGO手术切除方式肺段切除能否代替标准肺叶切除的争议,直径小于10mmGGO的患者行肺段切除和肺叶切除可取得一样的远期生存率且均无复发ADDINEN.CITE<EndNote><Cite><Author>Fukui</Author><Year>2010</Year><RecNum>44</RecNum><DisplayText><styleface="superscript">[20]</style></DisplayText><record><rec-number>44</rec-number><foreign-keys><keyapp="EN"db-id="2xp52rtw4x5rt5eseaw5vv23xe0rprp52etx"timestamp="1384944840">44</key></foreign-keys><ref-typename="JournalArticle">17</ref-type><contributors><authors><author>Fukui,T.</author><author>Mitsudomi,T.</author></authors></contributors><auth-address>DepartmentofThoracicSurgery,AichiCancerCenterHospital,1-1Kanokoden,Chikusa-ku,Nagoya,464-8681,Japan.</auth-address><titles><title>Smallperipherallungadenocarcinoma:clinicopathologicalfeaturesandsurgicaltreatment</title><secondary-title>SurgToday</secondary-title><alt-title>Surgerytoday</alt-title></titles><periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></periodical><alt-periodical><full-title>SurgToday</full-title><abbr-1>Surgerytoday</abbr-1></alt-periodical><pages>191-8</pages><volume>40</volume><number>3</number><edition>2010/02/25</edition><keywords><keyword>Adenocarcinoma/*diagnosis/pathology/*surgery</keyword><keyword>Humans</keyword><keyword>LungNeoplasms/*diagnosis/pathology/*surgery</keyword></keywords><dates><year>2010</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0941-1291</isbn><accession-num>20180071</accession-num><urls></urls><electronic-resource-num>10.1007/s00595-008-4100-4</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>[\o"Fukui,2010#44"20]，但基于样本含量等因素考虑此争议一直存在，目前美国国立癌症中心对于此项研究的结果还没有报道。日本临床肿瘤学组织也在计划进行一项对于2cm以下早期腺癌局部切除的研究。术中冰冻技术日益成熟，其对于1.1~1.5cm的结节灵敏度达94.1%，但报道称其对于5mm以下的结节的准确率并不十分令人满意ADDINEN.CITEADDINEN.CITE.DATA[\o"Marchevsky,2004#32"23]。对于GGO表现的早期肺癌患者，淋巴结的清扫术后是否辅助治疗尚无定论，需要大量样本及前瞻性研究作为客观证据。尽管目前GGO的认识及诊断有了很大提高，并取得了很大的临床效果，但因各地技术水平、医疗条件和国民健康意识的参差，我们与国际先进水平还有一定差距。因此我们需要深化医疗体制改革，提升医疗人员及国民素质，普及医学知识，落实询证医学及转化医学。相信未来我们对于GGO的认识将进一步提高，早期肺癌患者的生存率将进一步提高。参考文献ADDINEN.REFLIST[1]. 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