肺結節(jié)指南與臨床實踐

肺結節(jié)最新指南與臨床實踐Fleischner2017guidelineforpulmonarynodules

byOnnoMetsandRobinSmithuis

theAcademicalMedicalCentre,AmsterdamandtheAlrijneHospital,Leiderdorp,theNetherlands2017年費萊舍爾學會：肺結節(jié)指南Introduction

FleischnerGuideline2017

Introduction介紹

Solidnodules

實性結節(jié)Subsolidnodules

亞實性結節(jié)Riskfactors

危險因素Notes

注意點PulmonaryNoduleMeasurements

肺結節(jié)的測量

Perifissuralnodules葉間裂旁結節(jié)

PublicationdateJuly1,2017PulmonarynodulesarefrequentlyencounteredincidentallyonchestCT.

Theroleoftheradiologististoseparatebetweenbenignandpossiblymalignantlesions,andadviseonfollow-upimagingoradditionalinvasiveimagingtechniques.Thisarticlesummarizesthebasicsofindeterminatepulmonarynodules,andpresentsthenewestmanagementrecommendationsoftheFleischnerSociety.2017年7月1日文章：肺結節(jié)是偶然胸部CT檢查中頻繁遇到的。放射學家的角色就是在良性灶或惡性灶二者間做出鑒別診斷，并提出影像學的隨訪或附加另外的有創(chuàng)性的介入技術。該文章概括了不能定性的肺結節(jié)的基本概念，介紹了由費舍爾學會推薦的最新的管理方法。Pulmonarynodulescanbedividedintosolidlesionsandsubsolidlesions,whichcanbefurthersubdividedintopart-solidandpuregroundglassnodules.Heresomedefinitions:Subsolidnodule(SSN)

ApulmonarynodulewithatleastpartialgroundglassappearanceGroundglass

Opacificationwithahigherdensitythanthesurroundingtissue,notobscuringunderlyingbronchovascularstructures肺結節(jié)分為實性病灶和亞實性病變。再進一步分為部分實性和純磨玻璃結節(jié)。也有做如下的定義：

*亞實性結節(jié)（SSN）：肺結節(jié)至少有一部分呈磨玻璃的表現(xiàn)。*磨玻璃：相比周圍組織為不透明性的高密度，但不遮擋支氣管血管結構。肺結節(jié)亞實性（SSN）實性部分實性（PSN）純磨玻璃（PGGN）中放2015年4月49卷4期（放射學分會心胸組專家共識）FleischnerGuideline2017IntroductionIn2017theupdatedFleischnerSocietyguidelinewaspublished[1].

Thesereplacetherecommendationsforsolid(2005)[2]andsubsolidpulmonarynodules(2013)[3].

Thesenewguidelinesshouldreducethenumberofunnecessaryfollow-upexaminationsandprovideclearmanagementdecisions.Nodulecharacterizationshouldbeperformedonthin-sliceCTimages≤1.5mm,sinceasmallsolidnodulemayappeartohavegroundglassdensityonathicksliceduetopartial-volumeeffect.費舍爾學會：2017年指南更新過的“2017年費舍爾學會肺結節(jié)指南”

已經(jīng)發(fā)布。它替換了以往推薦的實性結節(jié)（2005年）和亞實性肺結節(jié)（2013年）新的指南將減少不必要的隨訪檢查并提供了明確的管理決策。結節(jié)特征的評價需要薄層CT成像，即層厚要≤1.5mm,理由：小的實性結節(jié)在較厚的圖像上因部分容積效應可以類似于磨玻璃密度。SolidnodulesSolidpulmonarynodulescanrepresentvariousetiologies:benigngranulomasfocalscarintrapulmonarylymphnodesprimarymalignanciesmetastaticdisease.Perifissuralnodulesareaseparateentity,sincetheyusuallyrepresentintrapulmonarylymphnodes,whicharebenignandneednofollowup.

Theyarediscussedinthelastchapter.

Inanotherarticlewepresentedsomefeaturesthatcanhelptodifferentiatebetweenbenignandmalignantlesions(clickhere)Unfortunately,thereisconsiderableoverlapandoftennodefinitiveanswercanbegivenbasedonimagingmorphology.Follow-upisthereforeacommonlyusedstrategy.實性結節(jié)實性肺結節(jié)可有多種病因學：良性肉芽腫、局灶瘢痕、肺內(nèi)的淋巴結、原發(fā)性惡性腫瘤、轉移性病變。葉間裂周圍的結節(jié)是一單獨的小體，因為它通常代表肺內(nèi)的淋巴結而作為良性灶，不需隨訪（見后述）在另外的文章中我們提出一些影像學特點目的是用于幫助良惡病變間的鑒別，但遺憾的是有相當大的重疊，故而不能根據(jù)影像形態(tài)學做出更明確的結論，因此隨訪仍是常用的策略。實性大小隨訪低風險低、高低風險低風險低風險高風險高風險高風險高風險多發(fā)單發(fā)多發(fā)多發(fā)單發(fā)不常規(guī)隨訪3-6個月CT，然后18-24個月CT不常規(guī)隨訪考慮3個月CT，PET-CT或活檢6-12個月CT，然后18-24個月CT選擇性的1年復查CT選擇性的1年復查CT6-12個月CT，然后考慮18-24個月CT3-6個月CT，然后考慮18-24個月CT3-6個月CT，然后考慮18-24個月CT3-6個月CT，然后18-24個月CT低風險高風險單發(fā)SubsolidnodulesMostsubsolidnodulesaretransientandtheresultofinfectionorhemorrhage.

However,persistentsubsolidnodulesoftenrepresentpathologyintheadenocarcinomatousspectrum.Noreliabledistinctioncanbemaderadiologically,althoughstudiessuggestthatlargersizeandasolidcomponentareassociatedwithmoreinvasivebehaviour.

Comparedtosolidlesions,persistentsubsolidnoduleshaveamuchslowergrowthrate,butcarryamuchhigherriskofmalignancy.

InastudybyHenschkeetal,part-solidnodulesweremalignantin63%,puregroundglassSSNsin18%andsolidnodulesonlyin7%[4].亞實性結節(jié)大部分的亞實性結節(jié)是一過性的并作為感染或出血的結果。然而，持續(xù)性的亞實性結節(jié)其病理學上多為肺腺癌之譜線。在放射學上，盡管一些研究提示：在較大的結節(jié)灶并伴實性成分及侵潤征象等，仍沒有更可靠的鑒別特征。與實性結節(jié)對比，持久性的亞實性結節(jié)盡管具有較緩慢的生長速度，但其更多見于惡性腫瘤。在Henschkeetal的研究中，惡性腫瘤的分別是：部分實性成分者為63%；純磨玻璃結節(jié)（SSNs）則為18%；實性結節(jié)僅7%。磨玻璃6-12月復查CT,若持續(xù)，則3、5年CT隨后的處理主要基于可疑結節(jié)隨訪單發(fā)亞實性結節(jié)無需隨訪部分實性多發(fā)性無需隨訪3-6月復查CT,若持續(xù)，則5年內(nèi)年度CT3-6月復查CT,若穩(wěn)定，則2年、4年CT3-6月復查CTSubsolidnodulesintheadenocarcinomatousspectrumwereformerlyknownasbronchoalveolarcarcinomaorBAC.

Thisterminologyshouldnolongerbeused.Anewpathology-basedclassificationforadenocarcinomawasintroducedin2011andthiscurrentclassificationmakesdistinctionbetween:Adenocacinomainsitu.Minimallyinvasiveadenocarcinoma.Invasiveadenocarcinoma.Transientsubsolidnodulesusuallyrepresentinfectionoralveolarhemorrhage.

Todifferentiatebetweentransientorpersistentsubsolidnodulesafollow-upCTshouldbeobtained.

Previously,itwasrecommendedtorepeatimagingafter3months,however,thisintervalhasbeenincreasedto12months.

Becauseoftheslowergrowthrate,thetotalfollow-upperiodforpersistentsubsolidnoduleshasbeenincreasedto5years.Theimagesshowa7mmpuregroundglasssubsolidnoduleintherightupperlobe.

Onfollow-upCTthisprovedtobeatransientsubsolidnodule.在肺腺癌中的亞實性結節(jié)即舊稱的支氣管肺泡癌或BAC。腺癌的新的病理學分類已在2011年公布：1、原位腺癌2、微侵潤腺癌3、侵潤性腺癌見左上圖短暫性的亞實性結節(jié)通常代表感染或肺泡出血。為了區(qū)分短暫性或持久性亞實性結節(jié)，需要CT隨訪證實。在以前，這種病灶推薦3個月復查。而現(xiàn)在復查間隔增加到12個月。處于較緩慢增長的原因，對恒定的亞實性結節(jié)的整個的隨訪時期，增加到5年。左下圖顯示：右上葉7mm純磨玻璃亞實性結節(jié)。隨訪CT證實為短暫性亞實性結節(jié)。Theseimagesshowapuregroundglasssubsolidnoduleintherightlowerlobe.

Thislesiondemonstratedgrowthinatwoyearintervalandprovedtobemalignantafterresection.RiskfactorsDefininghigh-orlow-riskiscurrentlymoredifficultthanitwasintheoldguideline.

Previouslyahigh-risksubjectwasidentifiedbasedonahistoryofheavysmoking,historyoflungcancerinafirst-degreerelativeorexposuretoasbestos,radonoruranium.Now,itisaimedfortoseparatehigh-risklesionsfromlow-riskonesbyconsideringmoreparametersthansubjectcharacteristicsalone(SeeTable).左圖顯示右下葉純磨玻璃亞實性結節(jié)。該病變隨訪兩年期間增大。手術證實為惡性。

危險因素定義高或低風險，目前要比舊的指南更困難。先前，被定義為高風險的因素是基于嚴重吸煙史，直系親屬肺癌史，接觸石棉、氡、鈾。而今，它是以區(qū)分高風險或低風險病灶為目的，則要考慮更多的參數(shù)而不是僅靠單一的某些因素。危險因素嚴重吸煙史暴露于石棉、氡、鈾肺癌家族史老齡性別（女多于男）種族（黑人、土著人、夏威夷人多于白種人）邊境投機商上葉部位多重性（結節(jié)少于5個，惡性幾率增加）肺氣腫和肺纖維化（特別是IPF）Sincetheseriskfactorsarenumerousandhavedifferenteffectsonthemalignancyrisk,itisproposedtoassessfinalriskcategoriesconcerningtheprobabilityofmalignancy[8](Table).NotesTheguidelinerecommendsfollow-upfornoduleswithanestimatedlungcancerriskofaround1%orgreater,whichisanarbitrarycut-off.Thelikelihoodofmalignancyisdifferentforanincidentallyfoundpulmonarynoduleinthelowerlobeofarelativelyyoungpatientcomparedtoanoduleintheupperlobeofahigh-riskheavysmoker,orinapatientwithaknownorsuspectedmalignancy.

ForthisreasontheFleischnerguidelineforthemanagementofpulmonarynodulesseparateshigh-andlow-risk,anddoesnotapplytosubjectsyoungerthan35years,immunocompromisedpatientsorpatientswithcancer[1].惡性腫瘤的可能性評估低概率（＜5%）年輕不吸煙無先前癌結節(jié)小邊緣規(guī)則結節(jié)非上葉中概率（5-65%）具有高與低混合特征高概率（>65%）年老嚴重吸煙有先前癌結節(jié)大邊緣不規(guī)則結節(jié)位于上葉使用2017年費舍爾學會肺結節(jié)指南的注意點僅用于35歲及以上者不適用免疫功能低下者，或已患有確診性癌癥者使用薄層（低劑量）CT成像重組圖描述其特征和進行肺結節(jié)隨訪。結節(jié)的手工測量是基于結節(jié)的長軸和短軸徑線；選擇性地使用結節(jié)灶的容積測量，需保證隨訪期間的成像技術和軟件的恒定性。新的指南的風險分級是兩方面的綜合，即病人高危因素、肺結節(jié)的特征。而不同于單一分析低或高危因素的往年的文獻。PulmonaryNoduleMeasurementsIntheFleischnerguidelinesnoduledimensionscanbeobtainedusingeither2Dcalipermeasurementsor3Dnodulevolumetry.

Manual2Dcalipermeasurementsshouldbebasedontheaverageofthelong-andshort-axisdiametersofthenodule.

Theseshouldbeobtainedonthesametransverse,coronalorsagittalreconstructedimage,whicheverplanerevealsthegreatestdimensions[1].

Thisisnewcomparedtothepriorguideline,inwhichdimensionswereaverageddiametersintheaxialplaneonly[2].

Manual2Dcalipermeasurementsshouldberoundedtothenearestwholemillimeter.

Inpart-solidsubsolidnodulesboththetotalnoduleaswellasthesolidcomponentdimensionsshouldbemeasuredseparately,bothusingtheabovementionedaveragingtechnique.肺結節(jié)測量費舍爾指南中，對肺結節(jié)的大小可以通過2D卡尺測量，或者3D結節(jié)容積測量獲得。手動的2D卡尺測量應是以結節(jié)的最大長軸和短軸之和除以2，而獲得結節(jié)的平均大小。隨訪對比，應以同樣的軸位、冠狀、矢狀重組圖，選擇層面內(nèi)的最大徑。在對部分實性的亞實性結節(jié)測量，要對其實性及磨玻璃成分要分別測量。同先前的指南比較，結節(jié)的大小只是由軸位層面上的平均直徑表示。而新的2D手工卡尺測量應該是更接近實際的整體大?。╩m）Alesionwhichmeasures8×5mmhasanaverageof(8+5):2=6.5mm-roundedupto7mm最終測量：7mmPerifissuralnodules(PFN)Perifissuralnodulesareaseparateentity,andlikelyrepresentintrapulmonarylymphnodes.

Morphologicallythesearesolid,homogeneousnoduleswithasmoothmargin,andareovalorrounded,lentiformortriangularinshape.

Theirlocationiswithin15mmofthefissureorthepleura.Theymayormaynothavecontactwithaninterlobarseptum.

ThelatterdifferentiatesbetweenatypicalandatypicalPFN(seeFigure).

PFNscanshowsignificantgrowthratesonserialimaging,sometimescomparabletomalignantnodules.

Thisisnotatypicalsignofmalignancy,butmerelyaresultoftheirpresumedlymphaticorigin.典型的PFN不典型的PFN非PFN葉間裂周圍的結節(jié)葉間裂周圍的結節(jié)是單獨的實體，很可能是肺內(nèi)的淋巴結。在形態(tài)上，這些結節(jié)為實性、密度均勻，邊緣光滑，呈橢圓形或圓形、或凸透鏡狀或三角形。在PFN的位置上，胸膜或葉間裂位于其內(nèi)占據(jù)15mm。或伴/不伴隨與小葉間隔的接觸。多個PFN在系列成像上可能顯示其明顯的增長率，有時候酷似惡性結節(jié)。這并非典型的惡性特征，只不過提示為淋巴源性。Inscreeningsettingithasbeenshownthatnoneofthe919typicalandatypicalPFNswerefoundtobemalignantina5.5yearfollow-up[5].

ThisconfirmedpriorresultsofAhnetal.[6].

Itisassumedthatthisbenignetiologycanbeextrapolatedtoclinicalsubjects,whichissupportedbyyetunpublisheddatainroutine-careclinicalCTimaging[7].Thecurrentlyavailableguidelinesrecommendthatwhensmallnoduleshaveaperifissuralorotherjuxtapleurallocationandamorphologyconsistentwithanintrapulmonarylymphnode,follow-upCTisnotrecommended,eveniftheaveragedimensionexceeds6mm.Perifissurallylocatednodulesthatdonotconformtothemorphologiccharacteristicsshouldberegardedasnon-PFNnodules(Figure)anddoesrequirefollow-up.處于葉間裂旁的結節(jié)，它不符合PFN的形態(tài)特點，應被列為非PFN結節(jié)（左下圖）并需要隨訪。作者的919個典型的或不典型的PFNs在隨訪5.5年后沒有一個發(fā)現(xiàn)是惡性的病灶。這也證實之前Ahnetal的研究結果。假如該良性病因如果為臨床學科所接受，那么將是對至今還沒有出版的臨床CT成像常規(guī)護理一書的支持。Incidentalperifissuralnodulesonroutinechestcomputedtomography:lungcancerornot?

byMetsetal.

[Unpublisheddata.Submitted]當前的能查到的多數(shù)指南中建議：當葉間裂周圍或鄰近胸膜部位發(fā)現(xiàn)小結節(jié)并且其形態(tài)與肺內(nèi)淋巴結一致時，即使平均大小超過6mm,也不推薦對其做CT隨訪。GuidelinesforManagementofIncidentalPulmonaryNodulesDetectedonCTImages:FromtheFleischnerSociety2017July2017Volume284,Issue1Publishedin:HeberMacMahon;DavidP.Naidich;JinMoGoo;KyungSooLee;AnnN.C.Leung;JohnR.Mayo;AtulC.Mehta;YoshiharuOhno;CharlesA.Powell;MathiasProkop;GeoffreyD.Rubin;CorneliaM.Schaefer-Prokop;WilliamD.Travis;PaulE.VanSchil;AlexanderA.Bankier;Radiology

2017,284,228-243.DOI:10.1148/radiol.20171616592017bytheRadiologicalSocietyofNorthAmerica,Inc./doi/abs/10.1148/radiol.2017161659Apictureisworthathousandwords一幅圖勝千言接下來就以近期刊在Radiology上的一篇文獻中的13個病例的26幅圖為例，學習一下偶然發(fā)現(xiàn)的肺結節(jié)影像學特點及對待原則。Figure1:(a)Lungwindowand(b)soft-tissuewindow1-mmtransverseCTsectionsshowasmoothlymarginatedsolidnodule(arrow)withinternalfatandcalcification,consistentwithahamartoma.NofurtherCTfollow-upisrecommendedforsuchfindings.這樣的結節(jié)不推薦CT隨訪含鈣化、脂肪：肺錯構瘤Figure2:(a)CTimageshowsasmoothlymarginatedsolidnodulewithcentralcalcification,typicalofahealedgranuloma.NofurtherCTfollow-upisrecommendedforsuchnodules.(b)CTimageshowsasmoothlymarginatedsolidnodulewithlaminarcalcification,typicalofahealedgranuloma.NofurtherCTfollow-upisrecommendedforsuchfindings.這兩例結節(jié)不推薦CT隨訪中央鈣化、層狀鈣化：為愈合后的肉芽腫Figure3:(a)Transverse5-mmCTsectionshowsanapparentlypureground-glassnoduleintheleftlowerlobe(arrow).(b)Transverse1-mmCTsectionatthesamelevelasarevealsthatthisisasuspiciouspart-solidnodulewithcysticcomponents(arrow).軸位5mm層厚顯示左下肺病變似乎為純磨玻璃結節(jié)同水平的軸位1mmCT如圖，可疑為部分實性結節(jié)伴囊性成分。Figure4:(a)Transverse1-mmCTsectionshowsanodularopacityadjacenttotheminorfissure(arrow).(b)CoronalreconstructedCTimageshowsthattheopacityisabenignlinearscarorlymphoidtissue(arrow).軸位1mm層厚CT顯示結節(jié)密度緊鄰于小裂。冠狀重組CT圖顯示該密度為良性線樣瘢痕或淋巴樣組織。Figure6:Transverse1-mmCTsectionthroughtheleftupperlobeshowsasuspicioussolidspiculatednodule(arrow).Surgeryrevealedinvasiveadenocarcinoma.Figure5:CTimageshowsasolidtriangularsubpleuralnodule(arrow)withalinearextensiontothepleuralsurface,typicalofanintrapulmonarylymphnode.NoCTfollow-upisrecommendedforsuchfindings.軸位1mm層厚顯示左上肺一周邊針狀結節(jié)，手術證實侵潤性腺癌。實性三角形胸膜下結節(jié)并線樣延伸至胸膜表面，此為典型的肺內(nèi)淋巴結。這種表現(xiàn)不推薦做CT隨訪。Figure7:Transverse1-mmCTsectionsobtained10monthsapartshowahighlysuspiciouspatternofprogressivethickeninginthewallofarightlowerlobecyst(arrow).Resectionrevealedinvasiveadenocarcinoma.軸位1mm層厚的圖像，間隔10個月后顯示右下葉囊壁明顯增厚。手術及病理為侵潤性腺癌。必須重視這樣的特殊肺癌（囊性肺癌）Figure8:CTimageshowsmultiplesolidnodulesofvaryingsizewithlowerzonepredominance(arrows)secondarytometastaticthyroidcarcinoma.Figure9:Transverse1-mmCTsectionsthroughtherightlowerlobe.(a)Awell-defined6-mmground-glassnodule(arrow)canbeseen.(b)Imageobtainedmorethan2yearsafterashowsasubtleincreaseinthesizeofthenodule(arrow).Thisfindingwasconfirmedbynotingtheslightlyalteredrelationshiptoadjacentvascularstructures.Suchsubtleprogressioncanbedetectedonlybyusing1-mmcontiguoussections.Findingsareconsistentwithadenocarcinomainsituorminimallyinvasiveadenocarcinoma,andcontinuedyearlyfollow-upisrecommended.CT圖顯示下葉多發(fā)性結節(jié)，源自甲狀腺癌的轉移瘤。1、軸位1mmCT圖見右肺下葉。左圖：6mm磨玻璃結節(jié)。右圖：2年

后顯示輕度增大。2、這種增大，可通過結節(jié)與鄰近血管的關系得到驗證。3、這種輕度的進展只能通過1mm的連續(xù)層面才能觀察到。4、這些表現(xiàn)符合肺腺癌（原位癌或微浸潤腺癌），并且推薦對

其做年度隨訪。Figure10:(a)A1-mmtransverseCTimagethroughtherightmidlungshowsa10-mmpureground-glassnodule(arrow).(b)CTimageinthesamelocationasaat15-monthfollow-upshowsonlyaverysubtleincreaseinopacity.(c)CTimageinthesamelocationasaandbafurther10monthsafterbshowsthenodulehasevolvedintoalargerpart-solidnodule.Surgicalresectionrevealedstage1Ainvasivelepidicpredominantadenocarcinoma.圖A）右中肺1mm軸位圖顯示一10mm純磨玻璃結節(jié)。圖B）15個月后，同層面軸位圖顯示該結節(jié)僅僅輕微的密度上的增高。圖C）又10個月后，同層軸位圖顯示該結節(jié)發(fā)展有較大的部分實性結節(jié)。手術及病理：1A期浸潤性鱗狀上皮癌Figure11:(a)Transverse1-mmCTsectionthroughtheleftupperlobeshowsanindeterminate10-mmground-glassnodule(arrow).(b)Follow-upCTimageafter4monthsshowsintervalresolutionwithouttreatment,consistentwithabenignca