1、肺癌是发病率和死亡率增长最快,对人群健康和生命威胁最大的恶性肿瘤之一。近50年来许多国家都报道肺癌的发病率和死亡率均明显增高,男性肺癌发病率和死亡率均占所有恶性肿瘤的第一位,女性发病率占第二位,死亡率占第二位。肺癌是可以预防的,也是可以控制的。可分为三级预防: 一级预防是病因干预:1.禁止和控制吸烟(长期大量吸烟者患肺癌的概率是不吸烟者的1020倍)。2.保护环境(城市居民肺癌的发病率比农村高)。3.职业因素的预防(减少职业致癌物的暴露);等等 二级预防是肺癌的筛查和早期诊断,达到肺癌的早诊早治;肺癌的早期往往表现为肺部结节。 三级预防为康复预防。患者黄某,女,60岁。胸部CT 影像学所见:左
2、肺上叶结节样高密度影,边界毛糙,大小约1.4*1.2cm。2014 年底行手术切除。手术病理:腺癌Ib期。0123456类别 1类别 2类别 3类别 4图表标题系列 1系列 2系列 3患者赵某,女,40岁。胸部CT 影像学所见:右肺下叶后外基底段可见一片状淡薄高密度影,直径约2.1cm,边界尚清。20145年初行手术切除。手术病理:腺癌Ib期。肺科临床实践中肺结节阴影是一个常见问题,出现频率由:原来的胸片发现的0.2%到现在肺癌低剂量CT筛查研究中的约4060%。Lung nodules are acommon problem in pulmonary practice.Estimates o
3、f their frequency range from 0.2% in older studies with chest radiographs toapproximately 4060% in lung cancer screening trials using low-dose computed tomography (CT) 肺结节(pulmonary nodule)为小的局灶性、类圆形、影像学表现密度增高的阴影,可单发或多发,直径 3cm,不伴肺不张、肺门肿大和胸腔积液。 孤立性肺结节(solitary pulmonary nodule ,SPN)经典定义:单发、圆形或类圆形、边界清
4、楚、无肺不张、直径 3cm的高密度阴影,周围完全由充气的肺组织包绕的肺部结节。 亚厘米级结节(subcentimeter nodules) :直径8mm 结节。形态可呈球形或非球形。两种形态均可见于恶性结节。肿块(masses):3cm 直径的病灶被称为肿块而不再称为结节。在明确诊断前原则上应认为恶性。1 Ost D, Fein AM, Feinsilver SH. Clinical practice: the solitary pulmonary nodule. N Engl J Med 2003;348:25352542.2 Gould MK, Fletcher J, Iannettoni
5、 MD, Lynch WR, Midthun DE, Naidich DP, Ost DE. Evaluation of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practiceguidelines (2nd edition). Chest 2007;132:108S130S. 3 Xu DM, van der Zaag-Loonen HJ, Oudkerk M, Wang Y. Smooth or attached solid indeterminate nod
6、ules detected at baseline CT screening in the nelsonstudy: cancer risk during 1 year of follow-up. Radiology 2009;250:264272.孤立性肺结节(SPN)非实性结节subsolid nodule纯磨玻璃密度结节 pure ground-glass nodule(pGGN)部分实性结节part-solid GGN实性结节solidary nodule(A)Ground-glass opacity(GGO). 磨玻璃影磨玻璃影 (B) Mixed ground glass and
7、solid nodule. 混合混合性结节性结节 (C) Solid lung nodule.实性结节实性结节毛玻璃成分为均匀的磨砂状阴影,有时可见小空泡征,通常这样的毛玻璃样结节进展很慢,或数年无变化,或仅表现为逐渐密实。这种影像特征在病理上往往对应为原位腺癌或不典型腺样增生。部分毛玻璃样结节可伴有空泡征、支气管造影征或微结节,其中实性成分往往为浸润性腺癌。5 mm 的实性成分以微浸润腺癌多见,或为预后良好的伏壁生长型。实性结节:致密均匀的小结节,如伴有分叶、刷状毛刺、胸膜牵扯征,则恶性可能性极大。由于病灶小,很难穿刺明确病理,且正电子发射体层摄影(PET)对于8 mm 的病灶,诊断的假阴性
8、率明显增高,因此随访中观察有无进展并结合影像学特征是临床上决定是否开胸探查的主要依据。值得注意的是,恶性实性结节的病理类型多为浸润性腺癌,以腺泡状、乳头状和实性亚型为主。在小结节病灶中即使是实性结节也极少见到鳞癌。右下肺实性结节,边缘锐利且有分叶, 构瘤,直径8 mm。随访过程中明显增大,手术病理:错构瘤。提示:即使良性病变也有增大的趋势。 年龄、职业、吸烟史、慢性肺部疾病史、个人和家族肿瘤史临床信息 结节大小、部位、边缘、内部特征、与支气管和血管的关系、生长速度影像学方法 Pro-GRP、NSE、CEA、CYFRA21-1、SCC等肿瘤标志物肿瘤风险低危中危高危大小年龄家族史吸烟史戒烟史慢阻
9、肺职业暴露结节特征Midthun等发现:不同大小结节的恶性可能性比率为: 3 mm : 0.2% 47 mm : 0.9%, 820 mm : 18% 20 mm : 50%Midthun DE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with low dose spiral computed tomography. Lung Cancer 2003;41(suppl 2):S40.Wahidi MM, Govert JA, Goudar RK,
10、Gould MK, McCrory DC.Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2ndedition). Chest 2007;132:94S107S.7个CT肺癌筛查研究表明,不同大小的肺结节的恶性率为: 5 mm结节:01% 5- 10mm: 628% 1120mm : 3364% 20 mm : 6482% In seven studies of nodu
11、les detected in lung cancer screening trials, the prevalence of malignancy: 01% in patients with nodules less than 5 mm in diameter, 628% for 5- to 10-mm nodules, 3364% for 11- to 20-mm nodules, 6482% for nodules measuring greater than 20 mm 大部分恶性结节倍增时间30-400天2年随访病灶稳定,倍增时间至少730天倾向良性疾病 倍增时间小于7天,超过465
12、天倾向良性 直径小于1cm病灶较难评价 Radiographics. 2000;20:59-66Hasegawa M, Sone S, Takashima S, et al. Growth rate of small lung cancers detected on mass CT screening. Br J Radiol 2000;73: 1252 1259.Hasegawa et al在一个为期3年的结节筛查研究中的不同结节平均倍增时间(Mean volume doubling times)pGGN (纯磨玻璃结节 ) 813 days mGGN (混合性) 457 days SN (
13、实性) 149 daysSPN 部位良性结节分布无规律性 肺癌:右肺/左肺 1.5,上叶占70 IPF患者合并肺癌好发于下叶外周或发生纤维化部位 50腺癌位于外周,鳞癌多为中央型SPN边缘光滑:21恶性结节边界清,多见于转移瘤分叶:25良性结节有分叶,恶性组织生长非均质性不规则:倾向于恶性,可见于肉芽肿性疾病、类脂性肺炎等毛刺:恶性多见Solitary metastasis from bladder cancer(膀胱癌的孤立转移) in a 45-year-old woman. Chest CT scan shows a smoothly marginated, 1-cm periphera
14、l nodule.Metastatic disease was confirmed at resection. Solitary metastases account for 3%-5% of all resected solitary. 转移瘤的数占所有手术切除的孤立结节的3-5%。Non-small cell lung cancer(非小细胞肺癌) in a 63-year-old woman. Close-up chest CT scan of the right lung shows a lobulated(分叶) and spiculated(毛刺) nodule in the lo
15、wer lobe. 55良性结节有钙(中心性,分层,弥漫性,爆米花样,超过结节面 积10)。13肺癌有不同程度的钙化偏心样钙化。钙化钙化 良性见于错构瘤、脂肪瘤。恶性见于脂肉瘤、肾透明细胞癌脂肪密度脂肪密度 良性空洞:壁光滑、薄(16mm) 空洞空洞 为肿瘤内小的低密度影,多为23 mm大小,1个或多个。空泡征是未闭塞的小支气管或肺泡。多见于原位腺癌、不典型腺样增生或浸润腺癌。空泡征空泡征 指结节内见到充气的支气管,CT表现为气体密度小管影。有此征象的肿瘤比无此征象的相对恶性程度低。恶性SPN发生率:269 650。良性SPN发生率:00 59支气管充支气管充气征气征Granuloma (肉芽
16、肿肉芽肿)in an asymptomatic 64-year-old man. Close-up chest CT scan of the left lung shows a soft-tissue nodule with central calcification in the upper lobe. Chondrohamartoma (错构瘤)(错构瘤)in a 40-year-old man. Close-up chest CT scan of the right lung shows a lobulated nodule withcentral popcornlike calcifi
17、cation in the upper lobe.Typical pulmonary carcinoid tumor(肺类癌瘤)(肺类癌瘤) in a 68-year-old woman. Chest CT scan shows a lobulated lesion with scattered punctate calcifications(散在点状钙(散在点状钙化)化) in the left lower lobe.Non-small cell lung cancer(非小细非小细胞肺癌胞肺癌) in a 45-year-old woman. Close-up chest CT scan
18、of the right lung reveals amorphous calcification(不规则钙化)(不规则钙化) in the nodule, a pattern that is typical of malignancy. Hamartoma (错构瘤错构瘤)in an asymptomatic man. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat(不均匀的边界清晰的病灶伴有多发小点状的钙化和脂
19、肪密度)(不均匀的边界清晰的病灶伴有多发小点状的钙化和脂肪密度). (b) Photograph of a resected specimen demonstrates a yellowish, glistening, lobular cut surface, a finding that is consistent with fat. (c) Photomicrograph (original magnification, x100; hematoxylineosin stain) helps confirm the presence of adipose tissue (arrow) an
20、d shows epithelial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma.Aspergillus infection(曲霉菌感染)(曲霉菌感染) in a 48-year-old man with leukemia. Close-up chest CT scan of the right lung shows a thin-walled cavit
21、ary nodule.Squamous cell lung cancer(鳞状细(鳞状细胞癌)胞癌) in a 60-year-old woman. Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodule in the lower lobe. I型:支气管被SPN截断II型:支气管进入SPN呈锥状中断型:支气管在SPN内呈长段开放状,并可进一步分叉型:支气管紧贴SPN边缘走行,管腔形态正常V型:支气管紧贴SPN边缘走行,管腔受压变扁 Clinical Radiology (
22、2004) 59, 11211127结核球鳞癌腺癌炎性假瘤恶性肿瘤The nodule was a sclerosing haemangioma as proven by pathological examination.病理证实为硬化型血管瘤。恶性结节最常见的肿瘤一支气管关系是I型,其次为型,型仅见于恶性SPN,V型最少见;良性结节最常见的是V型,其次为I型(结核球),未见到型。型可见于恶性和良性SPN,但前者的支气管形态僵硬,管腔保持通畅甚或轻度扩张;后者支气管形态柔软,走向自然,管腔扩张度不如恶性肿瘤,并常见支气管有多个树枝状分又及支气管呈断续状表现。恶性结节良性结节恶性结节增强超过良性
23、结节 CT净增值低于15HU倾向于良性CT净增值超过25HU,清除值5-31HU倾向恶性Adenocarcinoma (腺癌)in 67-year-old man shows net enhancement of 25 H and washout of 5-31 H at dynamic helical CT and positive uptake at integrated PET/CT. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 16-mm nodule (arrow ) in lef
24、t upper lobe has lobulated and speculated marginMacMahon H, MB, BCh, BAO. Austin JH, MD Gamsu G, MD Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society Radiology 2005; 237:395400 2005年Fleischner学会SPN指南NaidichDP , Bankier AA , MacMahon H
25、Recommendations for the Management of Subsolid Pulmonary Nodules Detected at CT: A Statement from the Fleischner Society, Radiology, 2013, 266: 304-317, 2013年Fleischner学会非实性结节指南孤立的部分实性结节,特别是实性成分5 mm的病变,3个月后复查发现病变增大或没有变化时,应考虑其为恶性可能。理由: (1) 大量研究证明,不管结节大小,部分实性结节较纯磨玻璃结节及实性结节恶性可能性大!因而需要更加积极的诊断 (2) 虽然GGN病变内实性成分的增多强烈提示病变为浸润性腺癌,但内部实性成分5 mm的病变例外,因为这些病变常常被证实是AIS(adenocarcinoma in situ原位腺癌)或MIA(minimally invasive adenocarcinoma微浸润腺癌),提示保守处理。