2017 Fleischner指南:肺部CT偶发结节的处理

2017年2月,Fleischner学会发布了CT检出肺部偶发性结节的管理指南,该指南的主要目的是减少针对CT检出肺部偶发性结节不必要的随访检查,为放射科和临床医师更好的管理该类患者提供指导,以下是指南的主要建议。

2017 Fleischner指南:肺部CT偶发结节的处理

2017 Fleischner指南:肺部CT偶发结节的处理

2017 Fleischner指南:肺部CT偶发结节的处理

2017 Fleischner指南:肺部CT偶发结节的处理

孤立性肺结节

建议1:孤立性非钙化实性结节

➤  <6 mm的实性结节的低危患者不需进行常规随访(1C等级;强推荐,低或非常低质量证据)。

➤  <6 mm的实性结节的高危患者不需进行常规随访;但是,对于一些形态可疑,上叶位置或两者兼具的<6 mm的实性结节,12个月进行随访(2A等级;弱推荐,高质量证据)。

➤  对于6~8 mm的孤立性非钙化实性结节的低危患者,根据体积、形态和患者偏好,可在6~12个月进行初始随访检查(1C等级;强推荐,低或非常低质量证据)。

➤  对于6~8 mm的孤立性非钙化实性结节的高危患者,建议在6~12个月进行初始随访检查,在18~24个月再进行随访检查(1B等级;强推荐,中质量证据)

➤  对于>8 mm的孤立性非钙化实性结节,考虑3个月时进行随访,可结合PET和CT(PET/CT)、组织、样本、或其中一组;以上任何选择可依据结节体积、形态,合并症和其他因素(1A等级;强推荐,高质量证据)。

推荐2:多发性非钙化实性结节

➤  对于直径<6 mm的多发性非钙化实性结结节,不建议进行常规随访(等级2B;弱推荐,中质量证据)。

➤  对于至少有1个结节直径>6 mm的多发性钙化实性结节,建议在3~6个月时进行随访,然后根据风险在18~24个月考虑是否进行第2次随访(1B等级;强推荐,中质量证据)。

亚实性肺结节

推荐3:孤立性纯磨玻璃结节

➤  对于直径<6 mm的孤立性纯磨玻璃结节,不建议进行常规随访(1B等级;强推荐,中质量证据)。

➤  对于直径≥6 mm的孤立性纯磨玻璃结节,建议在6~12个月进行随访,之后每2年进行随访,直至5年(1B等级;强推荐,中质量证据)。

推荐4:孤立性部分实性结节

➤  对于直径<6 mm的孤立性部分实性结节,不推荐进行常规随访(等级1C;强推荐,低或非常低质量证据)。

➤  对于直径≥6 mm的孤立性部分实性结节,考虑在3~6个月进行短期随访以评估结节的持续性。对形态可疑的结节(如分叶边缘或囊性成分),实性成分增长,或实性成分>8 mm,建议进行PET/CT、活检或切除(1B等级;强推荐,中质量证据)。

推荐5:多发亚实性结节

➤  对于结节<6 mm的多发亚实性结节,须考虑感染的病因。若在3~6个月进行初始随访后病灶仍存在,考虑在2和4年时进行随访以确定结节的稳定性(等级1C;强推荐,低或非常低质量证据)。

➤  对于至少有1个结节直径>6 mm的多发性亚实性结节患者,治疗决策应根据最可疑的结节。在这种情况下,考虑感染性病因。若3~6个月后仍然存在,考虑多发原发性腺癌(等级1C;强推荐,低或非常低质量证据)。

【以上中文译文及中文图片均来源——医脉通呼吸科 公众号

【图解部分】

Figure 1: (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.【图1(a)(b)肺窗和软组织窗1mm的CT横断面显示平滑边缘实性结节(箭头),内部脂肪和钙化,错构瘤,没有进一步的CT随访建议。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 2: (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.【图2:(a)CT图像显示边界清楚的结节,中央钙化,典型的愈合肉芽肿。如此结节不建议进一步CT随访。(b)CT显示边界清楚的实性结节,斑片状钙化,典型的愈合肉芽肿。如此发现,不建议没有进一步的CT随访。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 3: (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).【图3:(a)轴位5mm层厚 CT显示左肺下叶似乎是纯GGO(箭头)。(b)同一水平的轴位1mm层厚的CT显示,是一个可疑的部分实性结节,伴有囊性部分(箭头)。】

Figure 4: (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).【图4:(a)轴位1mm层厚CT断面显示毗邻与叶间裂的小结节(箭头)。(b)冠状重建CT图像显示不透明度影为良性线状瘢痕或淋巴组织(箭头)。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 5: 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.【图5:CT显示胸膜下三角形实性结节(箭头),并有细线延伸至胸膜表面,典型的肺内淋巴结。如此发现,不建议CT进一步随访。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 6: Transverse 1-mm CT section through the left upper lobe shows a suspicious solid spiculated nodule (arrow). Surgery revealed invasive adenocarcinoma.【图6:轴位1mm层厚的CT断面显示左肺上叶可疑的毛刺的实性结节(箭头)。手术显示浸润性腺癌。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 7: 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.【图7:轴位1mm层厚CT断面显示,相隔10个月,右肺下叶囊性病变的囊壁,高度可疑进展性增厚(箭头)。术后示浸润性腺癌。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 8: CT image shows multiple solid nodules of varying size with lower zone predominance (arrows) secondary to metastatic thyroid carcinoma.【图8:CT图像显示下肺区多个大小不等的实体结节(箭头),继发于转移性甲状腺癌。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 9: 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. Such subtle progression can be detected only by using 1-mm contiguous sections. Findings are consistent with adenocarcinoma in situ or minimally invasive adenocarcinoma, and continued yearly follow-up is recommended.【图9:通过右肺下叶的轴位1mm层厚CT断面。(a)显示一个边界清晰的6毫米的GGN(箭头)。(b)超过2年后获得的图像显示结节的大小略有增加(箭头)。邻近血管结构的轻微改变证实了这一发现。这种轻微的进展只能通过1mm层厚的连续层面才能发现。如此发现可能是原位癌或微浸润腺癌,建议继续每年随访。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 10: (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.【图10:(a)1mm轴位CT图像显示右中肺10mm的纯GGN(箭头)。(b)在15个月后随访的同一位置CT图像显示,不透明度仅有非常细微的增加。(c)在B后10个月,CT图像显示结节已发展成较大的部分实体结节。手术切除显示为1A期浸润性鳞状上皮癌。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 11: (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.【图11:(a)轴位1mm层厚的CT断面显示左肺上叶,模糊的10mmGGN(箭头)。(b)4个月后CT随访图像显示,未经治疗病变吸收了,考虑良性病因,如局灶性感染。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 12: (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.【图12:(a)轴位1mm层厚CT断面显示,右上叶一6mm部分实性结节,实性部分小于4mm(箭头)。(b)6个月CT随访显示病变完全吸收,考虑良性病变。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 13: (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.【图13:(a)轴位1mm层厚的CT断面显示右肺下叶背段高度可疑(大,磨玻璃样,和实性形态)部分实性结节(箭头)。(b)3个月后随访CT图像显示实性部分大小进展性增大。手术显示浸润性腺癌。】

2017 Fleischner指南:肺部CT偶发结节的处理

Figure 14: (a) Transverse 1-mm CT section through the upper lobes shows multiple variable-sized 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 3–6 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.【图14:(a)轴位1mm的CT断面显示双侧地方大学不等亚实性结节,至少包括左肺上叶一个高度可疑(大的、磨玻璃样、实性形态)部分实性病变;最初的随访建议3-6个月。(b)同一检查更靠下的层面右肺上叶显示一个高度可疑分叶状10mmGGN(箭头),同样建议随访。如此表现,最可能是多灶性原发性腺癌。】

Leave a Comment

电子邮件地址不会被公开。 必填项已用*标注