肺纯磨玻璃结节的高分辨率CT表现与临床病理学及基因特征

目的探讨肺纯磨玻璃结节的高分辨率CT表现与临床病理学及基因特征。方法回顾性纳入2014年4月~2019年4月在解放军总医院海南医院胸外科行手术切除的86例肺纯磨玻璃结节(pGGOs)患者，其中男性30例，女性56例，年龄21~78岁。分析其围手术期资料，根据术后5年生存率的不同将浸润性腺癌(IA)作为IA组，将微浸润性腺癌、原位腺癌及不典型腺瘤样增生设为对照组。其中IA组患者41例，对照组45例(微浸润性腺癌患者25例，原位腺癌患者14例，不典型腺瘤样增生患者6例)。比较IA组和对照组的高分辨率CT影像特点，组织病理学特征及基因突变情况。结果两组患者在一般资料方面差异无统计学意义(P>0.05)，在手术方式上的差异有统计学意义(P=0.001)，IA组患者更多接受肺叶切除术，对照组患者更多行亚肺叶切除术。两组患者在pGGOs的直径、体积及质量差异有统计学意义(P < 0.001)，在平均CT值和转化密度上差异无统计学意义(P>0.05)。ROC曲线分析，以10.8 mm为临界值鉴别肺IA组和对照组，敏感度为58.5%，特异度为84.4%，曲线下面积(AUC)为0.753。体积的临界值为870 mm3，AUC为0.773，诊断敏感度52.5%，特异性95.2%。质量的临界值为306.9 mg，AUC为0.769，诊断敏感度53.7%，特异性93.3%。反映边缘特征方面，在分叶和毛刺上有统计学差异，而在pGGOs的形状、胸膜牵拉征和血管集束征等方面差异并无统计学意义(P>0.05)。基因突变状态方面，对照组8例检测患者中有2例EGFR基因突变，IA组中20例检测患者中有9例EGFR突变，两组基因突变差异无统计学意义(P>0.05)。结论肺纯磨玻璃结节的病理表现多样，结合高分辨率CT影像特征及图像分析有助于对其定性诊断并指导后续随访策略及制定手术方案。对于直径大于10.8 mm、体积大于870 mm3及质量大于306.9 mg的纯磨玻璃结节，伴有分叶征、毛刺征等恶性影像学特征，应积极微创手术，手术方式根据影像学及患者意愿，主要以亚肺叶切除联合淋巴结活检术，可获得令人满意的预后效果。 

High resolution computed tomography findings,clinicopathological features and genetic characteristics of pure ground-glass opacity of the lung

ObjectiveTo analyze the high resolution computed tomography findings, clinicopathological features and genetic characteristics of pure ground-glass opacities of the lung.MethodsThe retrospective study included 86 patients with pGGOs who underwent surgical resection in the thoracic surgery department of hainan hospital of PLA general hospital from April 2014 to April 2019, including 30 males and 56 females, with the age from 21 to 78 years old. The perioperative data were analyzed to distinguish HRCT imaging features, histopathological features and gene mutations in the invasive adenocarcinoma group (IA) and the control group (MIA, AIS and AAH) according to the different survival.ResultsA total of 86 patients with pGGOs were enrolled, including 41 in group IA and 45 in control group, including 25 in MIA, 14 in AIS and 6 in AAH. The difference of general data between the two groups was not significant(P>0.05). However, there was a significant difference in surgical procedure (P=0.001). Patients in the IA group were more likely to receive lobectomy, while those in the control group were more likely to receive sublobectomy. The differences of diameter, volume and mass of pGGOs between the two groups were significant (P < 0.001), but no significant differences in mean CT value and conversion density (P>0.05). According to ROC curve analysis, the lung IA group and the control group were identified with a critical value of 10.8 mm, with a sensitivity of 58.5%, specificity of 84.4% and AUC of 0.753. The critical values of volume and AUC were 870 mm3 and 0.773, respectively. The diagnostic sensitivity was 52.5% and the specificity was 95.2%. The critical value of mass was 306.9 mg, the AUC value was 0.769, the diagnostic sensitivity was 53.7% and the specificity was 93.3%. There were significant differences in lobules and burrs, but no significant differences in pGGOs shape, pleural traction and vascular cluster. In terms of gene mutation status, 2 of the 8 patients in the control group had EGFR gene mutation, and 9 of the 20 patients in the IA group had EGFR mutation. The difference of gene mutation between the two groups was not significant (P>0.05).ConclusionIn summary, the pathological manifestations of pure ground glass nodules in lungs are diverse. Combining HRCT image features and image analysis can help to make a qualitative diagnosis and guide subsequent follow-up strategies and formulate surgical plans. For pure ground glass nodules with a diameter greater than 10.8 mm, a volume greater than 870 mm3, and a mass greater than 306.9 mg, with malignant imaging features such as lobular signs and burr signs, minimally invasive surgery should be actively performed. The surgical method is based on imaging and patient wishes. Sublobar resection combined with lymph node biopsy can achieve satisfactory prognosis.