偶发肺结节病的管理课件.ppt

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1、11/27/2022,.,1,Guidelines for Management of Incidental Pulmonary Nodules Detected on CT images: From the Fleischner Society 2017,11/27/2022,.,2,The Fleischner Society,Since then, new information has become available; therefore, the guidelines have been revised to reflect current thinking on nodule m

2、anagement.,Fewer follow-up examinations,A range of times,Immunocompromised patients,Primary cancers,Younger than 35 years,Increase the minimum threshold size,11/27/2022,.,3,The Guidelines,11/27/2022,.,4,The Guidelines,11/27/2022,.,5,General Recommendations,Thin sections,Coronal reconstructed,Sagitta

3、l reconstructed,11/27/2022,.,6,General Recommendations,Figure 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 component

4、s (arrow).,11/27/2022,.,7,General Recommendations,Figure 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).,11/27/2022,.,8,General Recommendation

5、s,Low-radiation,3mGy,Dose modulation,Iterative reconstruction,A similar technique be used to perform the follow-upexamination.,11/27/2022,.,9,General Recommendations,The average of long- and short-axis diameters.,Measurements shouldbe rounded to the nearest millimeter.,Volume thresholds of 100and 25

6、0 mm 3 are used for volumetryinstead of the 6- and 8-mm.,11/27/2022,.,10,Recommendations for Solid Lung Nodules,The Guidelines,11/27/2022,.,11,Recommendations for Solid Lung Nodules,Single solid noncal-cified nodules,(6mm),Low risk,High risk,Suspicious morphology,Upper lobe location,Optional CT at 1

7、2 months,Exception:thick sections or nervous patients.,11/27/2022,.,12,Recommendations for Solid Lung Nodules,Figure 3: Resection revealed invasive adenocarcinoma in the right lower lobe .,11/27/2022,.,13,Recommendations for Solid Lung Nodules,Single solid noncal-cified nodules,(6mm8mm),Low risk,Hig

8、h risk,Optional CT at 612 months,Optional CT at 1824 months,Optional CT at 1824 months,11/27/2022,.,14,Recommendations for Solid Lung Nodules,Figure 4: Transverse 1-mm CT section through the right upper lobe shows a 7-mm solid nodule and doesnt increase in 2 years.,11/27/2022,.,15,Recommendations fo

9、r Solid Lung Nodules,Single solid noncal-cified nodules,(8mm),Tissue sampling,As nodules become larger, their morphology becomes more distinct, and management should be strongly influenced by the appearance of the nodule rather than by size alone.,PET/CT,Optional CT at 3 months,Measurement of attenu

10、ation in solid nodules can be helpful to determine the presence of calcification or fat, either of whichcan have major diagnostic implications.,11/27/2022,.,16,Figure 5: (a) Lung window and (b) soft-tissue window 1-mm transverse CT sections show a smoothly marginated solid nodule (arrow) with intern

11、al fat and calcification, consistent with a hamartoma. No further CT follow-up is recommended for such findings.,Recommendations for Solid Lung Nodules,11/27/2022,.,17,Figure 6:(a) CT image shows a smoothly marginated solid nodule with central calcification, typical of a healed granuloma. No further

12、 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 Nodules,11/27/2022,.,18,Recommendations for Solid L

13、ung Nodules,Figure 7:Transverse 1-mm CT section through the left upper lobe shows a suspicious solid spiculated nodule (arrow). Surgery revealed invasive adenocarcinoma.,11/27/2022,.,19,Recommendations for Solid Lung Nodules,Figure 8:Transverse 1-mm CT sections obtained 10 months apart show a highly

14、 suspicious pattern of progressive thickening in the wall of a right lower lobe cyst (arrow). Resection revealed invasive adenocarcinoma.,11/27/2022,.,20,Recommendations for Solid Lung Nodules,Multiple solid noncal-cified nodules,(6mm),Low risk,High risk,Suspicious morphology,Upper lobe location,Opt

15、ional CT at 12 months,They most often represent either healed granulomata from a previous infection or intrapulmonary lymph nodes.,11/27/2022,.,21,Recommendations for Solid Lung Nodules,Multiple solid noncal-cified nodules,Metastases remain a leading consideration, particularly when the distribution

16、 of nodules has peripheral and/or lower zone predominance ,and metastases will grow perceptibly within 3 months.,Optional CT at 36 months,( At least one nodule 6 mm orlarger in diameter),Optional CT at 1824months,depend onestimated risk,An increase in risk for primary cancer, as the total nodule cou

17、nt increased from 1 to 4, but a decrease in risk for those with five or more nodules,most of which likely resulted from prior granu-lomatous infection.,11/27/2022,.,22,Recommendations for Solid Lung Nodules,Figure 9:CT image shows multiple solid nodules of varying size with lowerzone predominance (a

18、rrows) secondary to metastatic thyroid carcinoma.,11/27/2022,.,23,Recommendations for Solitary Subsolid Lung Nodules,The Guidelines,11/27/2022,.,24,Recommendations for Solitary Subsolid Lung Nodules,Solitary pure ground-glass nodules,(6mm),11/27/2022,.,25,Solitary pure ground-glass nodules,(610mm),O

19、ptional CT at 612 months,Every 2 years thereafter until 5 years,Recommendations for Solitary Subsolid Lung Nodules,11/27/2022,.,26,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)

20、 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 aden

21、ocarcinoma, and continued yearly follow-up is recommended.,11/27/2022,.,27,Recommendations for Solitary Subsolid Lung Nodules,Figure 11: Resection revealed adenocarcinoma in situ (7mm) in the right upper lobe .,11/27/2022,.,28,Recommendations for Solitary Subsolid Lung Nodules,Figure 12: Resection r

22、evealed adenocarcinoma in situ (10mm) in the right upper lobe .,11/27/2022,.,29,Solitary pure ground-glass nodules,Optional CT at 6 months,(10mm orbubbly lucencies),Recommendations for Solitary Subsolid Lung Nodules,11/27/2022,.,30,Recommendations for Solitary Subsolid Lung Nodules,Figure 13: (a) A

23、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

24、evolved into a larger part-solid nodule. Surgical resection revealed stage 1A invasive lepidic predominant adenocarcinoma.,11/27/2022,.,31,Recommendations for Solitary Subsolid Lung Nodules,Figure 14: (a) Transverse 1-mm CT section through the left upper lobe shows an indeterminate 10-mm ground-glas

25、s nodule (arrow). (b) Follow-up CT image after 4 months shows interval resolution without treatment, consistent with a benign cause, such as focal infection.,11/27/2022,.,32,Solitary part-solid nodules,(6mm),Recommendations for Solitary Subsolid Lung Nodules,11/27/2022,.,33,( 6mm),Solid component6mm

26、,Optional CT at 36 months,Optional CT annually for a minimum of 5 years,PET/CTBiopsy Resection,Solitary part-solid nodules,Solid component 6mm,Suspicious morphology,A growing solid component,Solid component 8mm,Abundant evidence enables us to confirm that the larger the solid component, the greater

27、the risk of invasiveness and metastases.,Recommendations for Solitary Subsolid Lung Nodules,11/27/2022,.,34,Recommendations for Solitary Subsolid Lung Nodules,Figure 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

28、than 4 mm. (b) Follow-up CT section at 6-month follow-up shows complete resolution, consistent with a benign cause.,11/27/2022,.,35,Recommendations for Solitary Subsolid Lung Nodules,Figure 16:(a) Transverse 1-mm CT section through the superior segment of the right lower lobe shows a highly suspicio

29、us (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.,11/27/2022,.,36,Recommendations for Solitary Subsolid Lung

30、Nodules,Figure 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.,11/27/2022,.,37,Recommendations for Solitary Subsolid Lung Nodules,Figure 18: Transverse 1-mm CT section through the right lower lobe shows a 11-mm par

31、t-solid nodule. Follow-up image obtained 6 months after a shows progressive increase in the size of the solid component. Surgery revealed invasive adenocarcinoma.,11/27/2022,.,38,Multiple sub-solid lung nodules,Recommendations for Solitary Subsolid Lung Nodules,Infections,Optional CT at 36 months,Su

32、bsolid nodules6mm,At approximately2 and 4 years,No change,Subsolid nodules 6mm,The most suspicious nodule should guide management,11/27/2022,.,39,Recommendations for Solitary Subsolid Lung Nodules,Figure 19: (a) Transverse 1-mm CT section through the upper lobes shows multiple variablesized subsolid

33、 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

34、 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.,11/27/2022,.,40,Nodule Size and Morphology,Size is a dominant factor in management.,Marginal spiculation,11/27

35、/2022,.,41,Nodule Location,Lung cancers occur more frequently inthe upper lobes,with a predilection forthe right lung.,adenocarcinoma metastases,squamous cancers,intrapulmonary lymph nodes,periphery,pulmonary hila,perifissural or subpleural,11/27/2022,.,42,Nodule Growth Rate,Solid cancerousnodules,S

36、ubsolid cancerous nodules,(volume doubling times),(volume doubling times),100400 days,35 years,For this reason, longer initial follow-up intervals and longer total follow-up periods are recommended for subsolid nodules than for solid nodules.,11/27/2022,.,43,Emphysema and Fibrosis,Emphysema and Fibr

37、osis is also an independent risk factor.,11/27/2022,.,44,Age, Sex, Race and Family History,Lung 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

38、in black men and native Hawaiian men more danger when compared with that in white men .,11/27/2022,.,45,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-yea

39、rs or more.,Quitting smoking within the past 15 years.,11/27/2022,.,46,Invasive Diagnostic and Therapeutic Procedures,11/27/2022,.,47,Apical Scarring,Pleural and Subpleural apical scarring is extremely common.,A pleural-based configuration.,An elongated shape.,Straight or Concave margins.,The presen

40、ce of similar adjacent opacities.,11/27/2022,.,48,Perifissural Nodules,11/27/2022,.,49,Perifissural Nodules,Figure 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.,11/27/2022,.,50,Thank you!,/10/29,.,51,