多层螺旋CT动态增强扫描在孤立性肺结节中的应用价值

目的对多层螺旋CT动态增强扫描在孤立性肺结节中的应用价值进行探讨。方法选取就诊于我院的单发孤立性肺结节患者60例,均给予多层螺旋CT动态扫描,对动态扫描增强后CT值改变情况、多层螺旋CT动态扫描与病理学诊断孤立性肺结节的结果进行比较。结果 1.恶性结节增强扫描后其CT值增高明显,显著高于良性结节,其差异具有统计学意义(P<0.05)。2.选择增强扫描后CT值改变≥20HU诊断为恶性结节,<20 HU诊断为良性结节,对CT增强扫描和病理学诊断在孤立性结节的诊断结果进行比较,未见明显统计学差异(χ2=1.40,P>0.05)。结论多层螺旋CT增强扫描对良恶性结节的诊断具有较高的应用价值,可以协助良恶性结节的鉴别诊断。     

多层螺旋CT动态增强扫描在孤立性肺结节中的应用价值

目的对多层螺旋CT动态增强扫描在孤立性肺结节中的应用价值进行探讨。方法选取就诊于我院的单发孤立性肺结节患者60例,均给予多层螺旋CT动态扫描,对动态扫描增强后CT值改变情况、多层螺旋CT动态扫描与病理学诊断孤立性肺结节的结果进行比较。结果恶性结节增强扫描后其CT值增高明显,显著高于良性结节,其差异具有统计学意义(P<0.05);选择增强扫描后CT值改变≥20HU诊断为恶性结节,<20HU诊断为良性结节,对CT增强扫描和病理学诊断在孤立性结节的诊断结果进行比较,未见明显统计学差异(χ2=1.40,P>0.05)。结论多层螺旋CT增强扫描对良恶性结节的诊断具有较高的应用价值。     

Evaluation of the solitary pulmonary nodule

The solitary pulmonary nodule represents a common diagnostic challenge for clinicians. While most are benign, a significant number represent early, potentially curable lung cancers. With the increased utilisation of chest computed tomography, solitary pulmonary nodules are increasingly being identified and with lung cancer screening programmes now on the horizon globally, it is crucial clinicians are familiar with the evaluation and management of solitary pulmonary nodules. Through the evaluation of patient risk factors combined with computed tomography characteristics of solitary pulmonary nodules, including size, growth rate, margin characteristics, calcification, density and location; a clinician can assess the risk of malignancy. This article provides an up to date review of the imaging features of both benign and malignant solitary pulmonary nodules to assist in the identification of nodules that require histological confirmation or ongoing surveillance. In addition, we summarise the newly updated Fleischner Society Guidelines that provide clinicians with a framework for the evaluation and management of solitary pulmonary nodules.     

Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography

BACKGROUND: The added value of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning as a function of pretest risk assessment in indeterminate pulmonary nodules is still unclear. OBJECTIVE: To obtain an external validation of the prediction model according to Swensen and colleagues, and to quantify the potential added value of FDG-PET scanning as a function of its operating characteristics in relation to this prediction model, in a population of patients with radiologically indeterminate pulmonary nodules. DESIGN, SETTING, AND PATIENTS: Between August 1997 and March 2001, all patients with an indeterminate solitary pulmonary nodule who had been referred for FDG-PET scanning were retrospectively identified from the database of the PET center at the VU University Medical Center. RESULTS: One hundred six patients were eligible for the study, and 61 patients (57%) proved to have malignant nodules. The goodness-of-fit statistic for the model (according to Swensen) indicated that the observed proportion of malignancies did not differ from the predicted proportion (p = 0.46). PET scan results, which were classified using the 4-point intensity scale reading, yielded an area under the evaluated receiver operating characteristic curve of 0.88 (95% confidence interval [CI], 0.77 to 0.91). The estimated difference of 0.095 (95% CI, -0.003 to 0.193) between the PET scan results classified using the 4-point intensity scale reading and the area under the curve (AUC) from the Swensen prediction was not significant (p = 0.058). The PET scan results, when added to the predicted probability calculated by the Swensen model, improves the AUC by 13.6% (95% CI, 6 to 21; p = 0.0003). CONCLUSION: The clinical prediction model of Swensen et al was proven to have external validity. However, especially in the lower range of its estimates, the model may underestimate the actual probability of malignancy. The combination of visually read FDG-PET scans and pretest factors appears to yield the best accuracy.     

Computer-aided diagnosis in lung nodule assessment

Computed tomography (CT) imaging is playing an increasingly important role in cancer detection, diagnosis, and lesion characterization, and it is the most sensitive test for lung nodule detection. Interpretation of lung nodules involves characterization and integration of clinical and other imaging information. Advances in lung nodule management using CT require optimization of CT data acquisition, postprocessing tools, and computer-aided diagnosis (CAD). The goal of CAD systems being developed is to both assist radiologists in the more sensitive detection of nodules and noninvasively differentiate benign from malignant lesions; the latter is important given that malignant lesions account for between 1% and 11% of pulmonary nodules. The aim of this review is to summarize the current state of the art regarding CAD techniques for the detection and characterization of solitary pulmonary nodules and their potential applications in the clinical workup of these lesions.     

Approach to a solid solitary pulmonary nodule in two different settings—“Common is common,rare is rare”

A new solid solitary pulmonary nodule (SPN) is a common feature in the daily practice of physicians, pulmonologists and thoracic surgeons. The etiology and consequently the diagnostic approach is very different in various parts of the world. Identification of malignant nodules is the universal goal to proceed to a potential curable therapy. In countries with a low incidence of inflammatory disease and a high incidence of lung cancer the diagnostic work up includes a positron emission tomography (PET) scan or PET-computer tomography (CT) as a main pillar. In countries with a high incidence of inflammatory and infectious disease and a low incidence in lung cancer this diagnostic work up needs to be adapted. In these settings a PET scan has a limited role and tissue diagnosis, whether with a trans-thoracic, trans-bronchial biopsy or a video-assisted wedge resection is the most targeted approach to determine or exclude malignancy. The evaluation of a solid SPN in the two different situations is outlined in our algorithm. Recommendations stress the value of clinical judgement in different settings, determination of probabilities of malignancy, cost-effective use of diagnostic tools and evaluation of various management alternatives according to the risk profile and the patients preferences.KEYWORDS : Solitary pulmonary nodule (SPN), diagnostic work up, lung neoplasms, inflammatory lung disease, algorithm     

Evaluation and management of solitary and multiple pulmonary nodules.

The evaluation and management of a patient with an SPN is guided by principles that were derived from earlier surgical studies. Stability or no growth for at least 2 years, the presence of calcium in characteristic patterns, and age less than 35 years without any associated risk factors are reliable indicators of a benign process. Fluoroscopy and localized tomography are helpful in evaluation of an SPN. If the nodule is still considered indeterminate, CT scanning, with the use of thin section cuts through the nodule, is now widely employed. If calcium is present in a characteristic pattern, the nodule is considered benign. If the nodule is very dense or more dense than a phantom reference nodule, the nodule has a high likelihood of being benign. Nodules that are less dense than the phantom nodule are indeterminate, and approximately 25% of these nodules will be benign. Computed tomography scan of the chest and upper abdomen is indicated in patients with a previous history of malignancy or when there is a high suspicion that the nodule is malignant. The further evaluation and management of SPNs that are indeterminate after CT examination are controversial. Some recommend tissue biopsy via transbronchoscopic or transthoracic approach, whereas others recommend immediate thoracotomy. Observation is indicated in certain situations when the chance of malignancy is quite low, the patient is not an operable candidate, or when the patient refuses further invasive evaluation. The physician's role in the management of a patient with an SPN is to educate and advise. The physician must be aware of the patient's anxieties, fears, and attitude and provide an opportunity for active participation by the patient in the decision-making process. Multiple pulmonary nodules are most commonly encountered in patients with metastatic disease to the lungs. Other less commonly encountered diseases that present as multiple pulmonary nodules include infections, arteriovenous malformations, Wegener's granulomatosis, and lymphoma. The evaluation and management of the patient with multiple pulmonary nodules are usually guided by the history, physical examination, and laboratory findings.     

Solitary pulmonary nodule: time to think small

The challenge presented by a solitary pulmonary nodule has faced physicians and patients since the advent of the chest radiograph. Is the nodule malignant or benign? When should something be done about it and what should that be? The majority of solitary nodules are benign, but the detection of a nodule may be the first and only chance for cure in the patient with lung cancer. The expanding availability and use of computed tomography are leading to increased numbers and decreased size of nodules detected. Surgical resection remains the most sensitive and specific method of analysis but introduces morbidity and mortality that may be unnecessary and avoidable. Advances in radiographic techniques have improved the ability to noninvasively identify whether a nodule is likely malignant or benign. Application of these techniques may ease the decision making and reduce the incision making.     

Managing solitary pulmonary nodules. The choice of strategy is a "close call"

The best approach to the initial management of solitary pulmonary nodules is controversial. Using decision analysis, we compared the average life expectancy produced by alternative strategies for managing the patient with a solitary pulmonary nodule: thoracotomy for diagnosis and potential resection (IMMEDIATE SURGERY); needle aspiration biopsy or bronchoscopy (BIOPSY) followed by either thoracotomy or extended observation, depending on the results of the biopsy; and serial chest films with thoracotomy if the nodule grows at a potentially malignant rate (OBSERVATION). IMMEDIATE SURGERY produced a slightly longer average life expectancy when the probability of cancer was very high; BIOPSY had a narrow advantage when the probability of cancer was intermediate; and OBSERVATION produced slightly longer average life-expectancy when the probability of malignancy was very low. But the differences between strategies were so small that, in most circumstances, the decision was a "close call." Therefore, when choosing between these management strategies, physicians should give greater weight to considerations besides life expectancy, and should encourage patients to actively participate in the decisions about how to manage their solitary pulmonary nodules.     

Radiologische Abklärung pulmonaler Rundherde

Solitary pulmonary nodules (SPN) are a frequent diagnostic problem in the clinical routine. The main aim of the management of patients with SPNs is to differentiate malignant from benign nodules with a high level of confidence. Knowledge of the pretest probability of malignancy is essential. Recently, the radiological morphology has been expanded to differentiate solid, semi-solid and ground glass nodules by the density in computed tomography (CT). In addition, diagnostic algorithms are well established for small SPNs ≤ 8 mm and normal sized SPNs > 8 mm in diameter. For normal SPNs the presence of homogeneous calcification and lack of growth are highly suggestive of a benign lesion. For the indeterminate small SPNs CT follow-up is recommended, at time intervals depending on the size, pretest probability for malignancy and CT morphology. Calculation of tumor doubling times with CT-based 3D volumetry of SPNs has recently been included in the clinical routine. For the indeterminate SPNs > 8 mm the management should be based on the pretest probability for malignancy, with CT follow-up, functional imaging, guided biopsy for fine tissue diagnostics and possibly surgical removal as diagnostic options.     

Evidence based imaging strategies for solitary pulmonary nodule

Solitary pulmonary nodule (SPN) is defined as a rounded opacity ≤3 cm in diameter surrounded by lung parenchyma. The majority of smokers who undergo thin-section CT have SPNs, most of which are smaller than 7 mm. In the past, multiple follow-up examinations over a two-year period, including CT follow-up at 3, 6, 12, 18, and 24 months, were recommended when such nodules are detected incidentally. This policy increases radiation burden for the affected population. Nodule features such as shape, edge characteristics, cavitation, and location have not yet been found to be accurate for distinguishing benign from malignant nodules. When SPN is considered to be indeterminate in the initial exam, the risk factor of the patients should be evaluated, which includes patients’ age and smoking history. The 2005 Fleischner Society guideline stated that at least 99% of all nodules 4 mm or smaller are benign; when nodule is 5-9 mm in diameter, the best strategy is surveillance. The timing of these control examinations varies according to the nodule size (4-6, or 6-8 mm) and the type of patients, specifically at low or high risk of malignancy concerned. Noncalcified nodules larger than 8 mm diameter bear a substantial risk of malignancy, additional options such as contrast material-enhanced CT, positron emission tomography (PET), percutaneous needle biopsy, and thoracoscopic resection or videoassisted thoracoscopic resection should be considered.     

Management strategy of solitary pulmonary nodules

Solitary pulmonary nodules (SPNs) are increasingly detected with the widespread use of chest computed tomography (CT) scans. The management of patients with SPN should begin with estimating the probability of cancer from the patient’s clinical risk factors and CT characteristics. The decision-making process need to incorporate the probability of cancer, the potential benefits and harms of surgery, the accuracy of the available diagnostic tests and patient preferences. For patients with a very low probability of cancer, careful observation with serial CT is warranted. For patients in the intermediate range of probabilities, either CT-guided fine-needle aspiration biopsy (FNAB) or positron emission tomography (PET), is recommended. For those with a high probability of cancer, surgical diagnosis is warranted.KEYWORDS : Solitary pulmonary nodule (SPNs), ground-glass opacity (GGO), subcentimeter nodules, management strategyLung cancer is currently the leading cause of cancer deaths worldwide (1). Clinically, most patients are diagnosed at an advanced stage, with only about 15% have the opportunity of surgical resection. Early detection followed by surgical resection of stage I lung cancer may lead to a 5-year survival rate of 54-73%, while those with stage IV diseases have a 5-year survival rate of only 2% (2,3). With the established role of low-dose helical computed tomography (CT) screening for lung cancer (4-6), and the wide application of high-resolution CT, solitary pulmonary nodules (SPNs) are increasingly detected (7). Accurate assessment, proper treatment and timely surgical resection of malignant pulmonary nodules will be highly beneficial to the survival of patients with lung cancer. By reviewing the latest literature, combined with our experience in the clinical management of SPNs, we summarized the relevant clinical problems and treatment strategies in this review.     

High diagnostic yield from transbronchial biopsy of solitary pulmonary nodules using low‐dose CT‐guidance

Background and objective: The diagnostic yield from fluoroscopy‐guided bronchoscopic transbronchial biopsy of small solitary pulmonary nodules is low. The hypothesis tested in the present study was that the diagnostic yield can be significantly increased by combining flexible bronchoscopy with CT‐guidance using a dedicated low‐dose protocol. Methods: CT‐guided transbronchial biopsies were performed in 15 patients with a newly diagnosed solitary peripheral pulmonary nodule and negative conventional bronchoscopic biopsies under fluoroscopic guidance. For imaging, a multi‐detector helical CT unit, adjusted at 120 kV, 15 mAs/slice, 4 × 5 mm collimation, 10 mm reconstructed slice thickness and a maximal scan length of 150 mm, was used. After advancing the biopsy forceps towards the lesion, a CT scan was obtained. When the tip of the forceps reached or penetrated the lesion a biopsy was taken, otherwise the procedure was repeated with a maximum of eight attempts. The effective radiation dose was calculated. Results: The average diameter of the nodules was 23 ± 6 mm (mean ± SD) with a maximum distance to the parietal pleura of 18 mm (mean 6.5 mm). A mean of 4.1 (range 2–8) CT scans was performed to localize the lesion. In four patients, the forceps only reached the periphery of the nodule. In one patient, the nodule was missed in all attempts. Histology was malignant in eight patients and benign in four patients. In three patients, biopsy results were false negative (benign or non‐specific instead of malignant). The overall diagnostic yield was 73%. Complications consisted of two pneumothoraces, one of which necessitated a chest tube. Mean effective radiation dose was 0.55 mSv (range 0.3–1.0). Conclusions: CT‐guided transbronchial biopsy can be a valuable diagnostic tool in evaluating solitary pulmonary nodules. This applies for selected patients when other diagnostic methods are either unavailable or inappropriate. The diagnostic yield is high and, when a low‐dose protocol is used, radiation exposure can be kept at a minimum.     

孤立性肺结节危险因素及良恶性预测模型

目的分析孤立性肺结节的危险因素并探讨肺部结节良恶性预测模型。 方法收集雅安市人民医院2017年1月至2018年8月经胸外科手术切除且有明确病理诊断的112例孤立性肺结节患者的临床资料。回顾性分析其年龄、性别、吸烟史、肿瘤家族史、既往肿瘤史、血清癌胚抗原(CEA)、神经元特异性烯醇化酶(NSE)、细胞角蛋白19片段(CYFRA21-1),以及肺部结节密度、直径、位置、分叶、毛刺、胸膜凹陷征、血管集束征、空泡征、空气支气管征、钙化等影像学特征。根据病理诊断分为良性、恶性两组,进行单因素分析,将单因素分析中有显著性差异的临床信息纳入Logistic回归分析,筛选出恶性结节的独立危险因素并建立预测模型。 结果单因数分析中年龄、既往肿瘤史、CEA、CYFRA21-1、结节密度、分叶、毛刺、胸膜凹陷征、血管集束征、空泡征、钙化征有统计学差异(P<0.05)。Logjistic回归分析显示患者年龄、CEA、CYFRA21-1、磨玻璃密度、分叶为恶性结节的独立危险因素。恶性肺部结节的预测模型公式为：P＝e^x/(1+e^x),x＝-8.816+(3.018×密度)+(0.073×年龄)+(0.482×CEA)+(0.426×CRFRA21-1)+(1.421×分叶)。 结论患者年龄、血CEA、血CYFRA21-1、磨玻璃密度、分叶为恶性结节的独立危险因素,预测模型对恶性肺结节有较好的敏感性及特异性,诊断准确性较高。     

肺部孤立小结节47例临床分析

目的分析47例肺部孤立小结节的临床表现和胸部CT特点判断肺部孤立小结节的良恶性。方法回顾分析我院治疗的47例肺部孤立小结节患者。结果 47例患者中恶性肿瘤28例(59.7%),良性肿瘤12例(25.5%),结核瘤7例(14.9%)。无症状和仅有咳嗽咳痰症状者31例(65.9%)。胸部CT影像中恶性肿瘤结节多边界不清,密度不均、有毛刺、分叶、胸膜皱缩。良性肿瘤结节边界清,密度均匀。结核钙化比率比较高。结论加强肺癌高危人群的普查、监测是发现早期肺癌的途径,结合临床表现和胸部CT特点,是鉴别诊断的最好方法。     

人工智能在肺结节良恶性鉴别诊断中的价值分析

目的评价人工智能(artificial intelligence, AI)风险评估对肺结节良恶性鉴别诊断的价值。 方法收集2018年8月至2019年12月唐都医院行胸部CT检查，发现肺结节患者310例，将患者CT影像数据DICOM文件拷贝输入到"FACT人工智能"软件系统对结节进行分析，获得结节的部位、数量、特征(磨玻璃、亚实性、实性)、大小、密度、以及恶性风险概率AI值和Lung-rads分级；其中39例肺结节经过多学科讨论，建议采用外科手术、经皮肺穿刺或者支气管镜下活检等，271例患者进行随访。 结果31例肺结节病理诊断良性14例，分别为结核8例，隐球菌2例，炎性结节4例；恶性25例，分别肺鳞癌2例，腺癌23例。进一步分析，恶性病变的AI风险概率明显高于良性病变(P<0.05)；结节AI风险概率与肺结节特点(磨玻璃、亚实性、实性)显著相关(P<0.05)，而与数量及边缘毛刺征无显著相关性(P>0.05)；肺结节特点(磨玻璃、亚实性、实性)在良恶性之间存在显著性差异(P<0.05)，而密度和体积之间在在良恶性之间无显著性差异(P>0.05)。肺结节Lung-rads分级与AI风险概率之间具有显著的相关性(P<0.05)。 结论依据人工智能自动分析良恶性概率AI值对肺结节良恶性鉴别诊断具有一定的价值，值得临床借鉴。     

甲状腺疾病影像学检查方法及临床应用

甲状腺非侵入性检查手段包括超声、核素显像(单光子显像和正电子断层显像)、CT以及MRI.超声是一种无损伤、操作简便、价格低廉的检查方法,因而是甲状腺疾病尤其是甲状腺结节的首选影像检查方法,彩色多普勒血流成像(CDFI)和超声指导下的细针穿刺活检的应用,为甲状腺结节良、恶性的鉴别诊断提供了可能.核素显像(包括SPECT和PET)是一种功能显像.99mTcO4-是最常用的功能显像剂,131I主要用于分化型甲状腺癌.FDG PET一般不用于甲状腺疾病术前,但甲状腺癌术后考虑转移而131I扫描结果阴性时,可以考虑应用.临床上,CT常作为甲状腺疾病的第二线影像学检查方法.MRI技术本身有许多特点,但在甲状腺疾病而言,并不比CT优越.     

18FDG-positron emission tomography/computed tomography (PET/CT) scanning in thyroid nodules with nondiagnostic cytology

Objective To assess the role of positron emission tomography/computed tomography (PET/CT) scans with ¹⁸FDG (¹⁸FDG‐PET/CT) in the evaluation of thyroid nodules with nondiagnostic cytology. Subjects and methods Eighty‐eight patients with a single euthyroid nodule and repeatedly nondiagnostic ultrasound‐guided fine‐needle cytology (US‐FNC) were enrolled in the present study. Nodules concentrating ¹⁸FDG were considered positive (i.e. suspicious for malignancy). Histological findings were obtained after surgery in all patients. Results None of 41 patients with negative ¹⁸FDG‐PET/CT scan had a final histological diagnosis of malignancy (i.e. no false‐negative results). Twenty‐nine patients with final histological diagnosis of thyroid cancer had positive ¹⁸FDG‐PET/CT scan. Eighteen patients with final histological diagnosis of benign lesions (including four with follicular adenomas) also had positive ¹⁸FDG‐PET/CT scans. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were 100%, 69%, 79%, 62% and 100%, respectively. Conclusions A negative ¹⁸FDG‐PET/CT scan accurately excludes malignancy in thyroid nodules with non‐diagnostic US‐FNC procedures. Histology is still necessary to distinguish benign from malignant disease in ¹⁸FDG‐PET/CT‐positive nodules, but unnecessary surgery could have been reduced from 88 to 41 cases (46%) in our series.     

Diagnostic approach to solitary pulmonary nodule

The solitary pulmonary nodule is a common radiologic abnormality that is often detected incidentally. Many malignant and benign diseases can present as a solitary pulmonary nodule on a chest roentgenogram. It is important to differentiate malignant nodules from benign nodules in the least invasive way and to make as specific and an accurate diagnosis as possible. In this paper, a diagnostic approach to the solitary pulmonary nodule was discussed.     

Usefulness of positron emission tomography-computed tomography in respiratory medicine

The introduction of positron emission tomography (PET) into the management of neoplastic disease in respiratory patients signified an important change from classic algorithms based exclusively on anatomic information obtained through computed tomography (CT). Non-small cell lung cancer and solitary pulmonary nodule were the 2 diseases in which metabolic PET imaging offered the highest diagnostic yield, as has been evident since the inclusion of this technology among the services available within the Spanish national health service. However, a number of limitations were encountered in relation to the lack of anatomic definition in PET imaging, as had been described in the literature. The appearance in 2001 of hybrid PET-CT devices has not only helped remedy those defects, but has also made it possible to combine anatomic and metabolic information in a single image, making this hybrid technology the most valuable tool in the current diagnostic arsenal.