偶发肺结节病的管理.ppt

Guidelines for Management of Incidental Pulmonary Nodules Detected on CT images:From the Fleischner Society 2017 5/26/20241.The Fleischner Society Since then,new information has become Since then,new information has become available;therefore,the guidelines have been available;therefore,the guidelines have been revisedrevised to reflect current thinking on nodule to reflect current thinking on nodule management.management.Fewer follow-up examinations ArangeoftimesChangeNot intended forImmunocompromised patientsPrimary cancersYounger than 35 yearsIncrease the minimum threshold size5/26/20242.The Guidelines5/26/20243.The Guidelines5/26/20244.General RecommendationsThin sections Coronal Coronal reconstructedreconstructedS Sagittal agittal reconstructedreconstructed5/26/20245.General RecommendationsFigure 1:(a)Transverse 5-mm CT section shows an apparently pure ground-glass nodule in the left lower lobe(arrow).(b)Transverse 1-mm CT section at the same level as a reveals that this is a suspicious part-solid nodule with cystic components(arrow).5/26/20246.General RecommendationsFigure 2:(a)Transverse 1-mm CT section shows a nodular opacity adjacent to the minor fissure(arrow).(b)Coronal reconstructed CT image shows that the opacity is a benign linear scar or lymphoid tissue(arrow).5/26/20247.General RecommendationsLow-radiation3mGyDose modulationIterative reconstructionA similar technique be used to perform the follow-upA similar technique be used to perform the follow-upexamination.examination.5/26/20248.General RecommendationsThe average of long-and short-axis diameters.Measurements shouldbe rounded to the nearest millimeter.Volume thresholds of 100and 250 mm 3 are used for volumetryinstead of the 6-and 8-mm.5/26/20249.Recommendations for Solid Lung NodulesThe Guidelines5/26/202410.Recommendations for Solid Lung NodulesSingle solid noncal-cified nodules(8mm)Tissue samplingAs nodules become larger,their As nodules become larger,their morphologymorphology becomes becomes more distinct,and management should be strongly more distinct,and management should be strongly influenced by the appearance of the nodule rather than by influenced by the appearance of the nodule rather than by size alonesize alone.PET/CTOptional CT at 3 monthsMeasurement of attenuationMeasurement of attenuation in solid nodules can be in solid nodules can be helpful to determine the presence of helpful to determine the presence of calcification or fatcalcification or fat,either of whicheither of whichcan have major diagnostic implications.can have major diagnostic implications.5/26/202415.Figure 5:(a)Lung window and(b)soft-tissue window 1-mm transverse CT sections show a smoothly marginated solid nodule(arrow)with internal fat and calcification,consistent with a hamartoma.No further CT follow-up is recommended for such findings.Recommendations for Solid Lung Nodules5/26/202416.Figure 6:(a)CT image shows a smoothly marginated solid nodule with central calcification,typical of a healed granuloma.No further CT follow-up is recommended for such nodules.(b)CT image shows a smoothly marginated solid nodule with laminar calcification,typical of a healed granuloma.No further CT follow-up is recommended for such findings.Recommendations for Solid Lung Nodules5/26/202417.Recommendations for Solid Lung Nodules Figure 7:Transverse 1-mm CT section through the left upper lobe shows a suspicious solid spiculated nodule(arrow).Surgery revealed invasive adenocarcinoma.5/26/202418.Recommendations for Solid Lung Nodules Figure 8:Transverse 1-mm CT sections obtained 10 months apart show a highly suspicious pattern of progressive thickening in the wall of a right lower lobe cyst(arrow).Resection revealed invasive adenocarcinoma.5/26/202419.Recommendations for Solid Lung NodulesMultiple solid noncal-cified nodules(6mm)Low riskHigh riskSuspiciousSuspicious morphology morphologyUpper lobeUpper lobe location locationOptional CT Optional CT at at 12 months12 months They most often represent either healed granulomata from a previous infection or intrapulmonary lymph nodes.5/26/202420.Recommendations for Solid Lung NodulesMultiple solid noncal-cified nodulesMetastases remain a leading consideration,particularly Metastases remain a leading consideration,particularly when the distribution of nodules has when the distribution of nodules has peripheralperipheral and/or and/or lower zonelower zone predominance,and metastases will grow predominance,and metastases will grow perceptibly perceptibly within 3 months.within 3 months.Optional CT at 36 months(At least one nodule 6 mm or(At least one nodule 6 mm orlarger in diameter)larger in diameter)Optional CT at 1824monthsdepend onestimated riskAn increase in risk for primary cancer,as the total nodule An increase in risk for primary cancer,as the total nodule count increased from count increased from 1 to 41 to 4,but a decrease in risk for those,but a decrease in risk for those with with five or morefive or more nodules,most of which likely resulted nodules,most of which likely resulted from from prior granu-prior granu-lomatous infectionlomatous infection.5/26/202421.Recommendations for Solid Lung Nodules Figure 9:CT image shows multiple solid nodules of varying size with lowerzone predominance(arrows)secondary to metastatic thyroid carcinoma.5/26/202422.Recommendations for Solitary Subsolid Lung NodulesThe Guidelines5/26/202423.Recommendations for Solitary Subsolid Lung NodulesSolitary pure ground-glass nodules(6mm)5/26/202424.Solitary pure ground-glass nodules(610mm)Optional CT Optional CT at at 612 months612 monthsEvery Every 2 years 2 years thereafter until thereafter until 5 years5 yearsRecommendations for Solitary Subsolid Lung Nodules5/26/202425.Recommendations for Solitary Subsolid Lung Nodules Figure 10:Transverse 1-mm CT sections through the right lower lobe.(a)A well-defined 6-mm groundglass nodule(arrow)can be seen.(b)Image obtained more than 2 years after a shows a subtle increase in the size of the nodule(arrow).This finding was confirmed by noting the slightly altered relationship to adjacent vascular structures.Findings are consistent with adenocarcinoma in situ or minimally invasive adenocarcinoma,and continued yearly follow-up is recommended.5/26/202426.Recommendations for Solitary Subsolid Lung NodulesFigure 11:Resection revealed adenocarcinoma in situ(7mm)in the right upper lobe.5/26/202427.Recommendations for Solitary Subsolid Lung NodulesFigure 12:Resection revealed adenocarcinoma in situ(10mm)in the right upper lobe.5/26/202428.Solitary pure ground-glass nodulesOptional CT at 6 months(10mm orbubbly lucencies)Recommendations for Solitary Subsolid Lung Nodules5/26/202429.Recommendations for Solitary Subsolid Lung Nodules Figure 13:(a)A 1-mm transverse CT image through the right midlung shows a 10-mm pure ground-glass nodule(arrow).(b)CT image in the same location as a at 15-month follow-up shows only a very subtle increase in opacity.(c)CT image in the same location as a and b a further 10 months after b shows the nodule has evolved into a larger part-solid nodule.Surgical resection revealed stage 1A invasive lepidic predominant adenocarcinoma.5/26/202430.Recommendations for Solitary Subsolid Lung NodulesFigure 14:(a)Transverse 1-mm CT section through the left upper lobe shows an indeterminate 10-mm ground-glass nodule(arrow).(b)Follow-up CT image after 4 months shows interval resolution without treatment,consistent with a benign cause,such as focal infection.5/26/202431.Solitary part-solid nodules(6mm)Recommendations for Solitary Subsolid Lung Nodules5/26/202432.(6mm)Solid componentSolid component6mm6mmOptional CT at 36 monthsOptional CT annually Optional CT annually for a minimum of 5 yearsfor a minimum of 5 yearsPET/CTPET/CTBiopsy Biopsy ResectionResectionSolitary part-solid nodulesSolid componentSolid component 6mm6mmSuspicious Suspicious morphologymorphologyA growing A growing solid componentsolid componentSolid component Solid component 8mm 8mm Abundant evidence enables us to confirm that the larger the solid component,the greater the risk of invasiveness and metastases.Recommendations for Solitary Subsolid Lung Nodules5/26/202433.Recommendations for Solitary Subsolid Lung NodulesFigure 15:(a)Transverse 1-mm CT section through the right upper lobe shows a 6-mm part-solid nodule with a solid component(arrow)smaller than 4 mm.(b)Follow-up CT section at 6-month follow-up shows complete resolution,consistent with a benign cause.5/26/202434.Recommendations for Solitary Subsolid Lung NodulesFigure 16:(a)Transverse 1-mm CT section through the superior segment of the right lower lobe shows a highly suspicious(large size,ground-glass appearance,and solid morphology)part-solid nodule(arrow).(b)Follow-up image obtained 3 months after a shows progressive increase in the size of the solid component.Surgery revealed invasive adenocarcinoma.5/26/202435.Recommendations for Solitary Subsolid Lung NodulesFigure 17:Transverse 1-mm CT section through the right lower lobe shows a 10-mm part-solid nodule with a solid component smaller than 5 mm.5/26/202436.Recommendations for Solitary Subsolid Lung NodulesFigure 18:Transverse 1-mm CT section through the right lower lobe shows a 11-mm part-solid nodule.Follow-up image obtained 6 months after a shows progressive increase in the size of the solid component.Surgery revealed invasive adenocarcinoma.5/26/202437.Multiple sub-solid lung nodulesRecommendations for Solitary Subsolid Lung NodulesInfectionsOptional CT at 36 monthsSubsolid nodulesSubsolid nodules6mm6mmAt approximatelyAt approximately2 and 4 years2 and 4 yearsNo changeNo changeSubsolid nodulesSubsolid nodules 6mm6mmThe most suspicious noduleThe most suspicious nodule should guide management should guide management5/26/202438.Recommendations for Solitary Subsolid Lung NodulesFigure 19:(a)Transverse 1-mm CT section through the upper lobes shows multiple variablesized subsolid nodules bilaterally,including at least one highly suspicious(large size,ground-glass appearance,and solid morphology)part-solid lesion in the left upper lobe(arrow).Initial follow-up would be appropriate in 36 months.(b)A more inferior section from the same examination shows another highly suspicious lobulated 10-mm ground-glass nodule in the right upper lobe(arrow),which would also warrant follow up.The findings are most consistent with multifocal primary adenocarcinoma.5/26/202439.Nodule Size and MorphologySize is a dominant factor in management.Marginal spiculation5/26/202440.Nodule LocationLung cancers occur more frequently inthe upper lobes,with a predilection forthe right lung.adenocarcinoma metastasessquamous cancersintrapulmonary lymph nodesperipherypulmonary hila perifissural or subpleural5/26/202441.Nodule Growth Rate Solid cancerousnodules Subsolid cancerous nodules(volume doubling times)(volume doubling times)(volume doubling times)(volume doubling times)100400 days35 yearsFor this reason,longer initial follow-up intervals and longer total follow-up periods are recommended for subsolid nodules than for solid nodules.5/26/202442.Emphysema and FibrosisEmphysema and Fibrosis is also an independent risk factor.5/26/202443.Age,Sex,Race and Family HistoryLung cancer is still relatively rare in individuals younger than 35 years.A significantly higher risk in women withground-glass(nonsolid)nodules.Family history of lung cancer is a risk factor.Lung cancer in black men and native Hawaiian men more danger when compared with that in white men.5/26/202444.Tobacco Cigarette smoking has been establishedas the major risk factor for lung cancer andwith a 10-to 35-fold increased risk when compared with that in nonsmokers.Smoking history of 30 pack-years or more.Quitting smoking within the past 15 years.5/26/202445.Invasive Diagnostic and Therapeutic Procedures5/26/202446.Apical Scarring Pleural and Subpleural apical scarring is extremely common.A pleural-based configuration.An elongated shape.Straight or Concave margins.The presence of similar adjacent opacities.5/26/202447.Perifissural Nodules5/26/202448.Perifissural NodulesFigure 20:CT image shows a solid triangular subpleural nodule(arrow)with a linear extension to the pleural surface,typical of an intrapulmonary lymph node.No CT follow-up is recommended for such findings.5/26/202449.Thank you!5/26/202450.5/26/202451.