肺结节指南与临床实践(1).pptx

中国石油中心医院 杨景震（2017-8）,肺结节最新指南与临床实践,注：内有动画制作，浏览时采用幻灯片放映模式,一、肺结节指南,二、图片展示,三、肺结节本院经典病例分享,内 容,四、附：教训篇,Fleischner 2017 guideline for pulmonary nodulesby Onno Mets and Robin Smithuis the Academical Medical Centre,Amsterdam and the Alrijne Hospital,Leiderdorp,the Netherlands,2017年费莱舍尔学会：肺结节指南,Introduction Fleischner Guideline 2017 Introduction介绍 Solid nodules 实性结节Subsolid nodules 亚实性结节Risk factors 危险因素Notes 注意点 Pulmonary Nodule Measurements 肺结节的测量 Perifissural nodules叶间裂旁结节,Publication date July 1,2017 Pulmonary nodules are frequently encountered incidentally on chest CT.The role of the radiologist is to separate between benign and possibly malignant lesions,and advise on follow-up imaging or additional invasive imaging techniques.This article summarizes the basics of indeterminate pulmonary nodules,and presents the newest management recommendations of the Fleischner Society.,2017年7月1日文章：肺结节是偶然胸部CT检查中频繁遇到的。放射学家的角色就是在良性灶或恶性灶二者间做出鉴别诊断，并提出影像学的随访或附加另外的有创性的介入技术。该文章概括了不能定性的肺结节的基本概念，介绍了由费舍尔学会推荐的最新的管理方法。,Pulmonary nodules can be divided into solid lesions and subsolid lesions,which can be further subdivided into part-solid and pure ground glass nodules.Here some definitions:Subsolid nodule(SSN)A pulmonary nodule with at least partial groundglass appearance GroundglassOpacification with a higher density than the surrounding tissue,not obscuring underlying bronchovascular structures,肺结节分为实性病灶和亚实性病变。再进一步分为部分实性和纯磨玻璃结节。,也有做如下的定义：*亚实性结节（SSN）：肺结节至少有一部分呈磨玻璃的表现。*磨玻璃：相比周围组织为不透明性的高密度，但不遮挡支气管血管结构。,肺结节,亚实性（SSN）,实性,部分实性（PSN）,纯磨玻璃（PGGN）,中放2015年4月49卷4期（放射学分会心胸组 专家共识）,Fleischner Guideline 2017,IntroductionIn 2017 the updated Fleischner Society guideline was published1.These replace the recommendations for solid(2005)2 and subsolid pulmonary nodules(2013)3.These new guidelines should reduce the number of unnecessary follow-up examinations and provide clear management decisions.Nodule characterization should be performed on thin-slice CT images 1.5 mm,since a small solid nodule may appear to have groundglass density on a thick slice due to partial-volume effect.,费舍尔学会：2017年指南,更新过的“2017年费舍尔学会肺结节指南”已经发布。它替换了以往推荐的实性结节（2005年）和亚实性肺结节（2013年）新的指南将减少不必要的随访检查并提供了明确的管理决策。结节特征的评价需要薄层CT成像，即层厚要1.5 mm,理由：小的实性结节在较厚的图像上因部分容积效应可以类似于磨玻璃密度。,Solid nodulesSolid pulmonary nodules can represent various etiologies:benign granulomas focal scar intrapulmonary lymph nodes primary malignancies metastatic disease.Perifissural nodules are a separate entity,since they usually represent intrapulmonary lymph nodes,which are benign and need no follow up.They are discussed in the last chapter.In another article we presented some features that can help to differentiatebetween benign and malignant lesions(click here)Unfortunately,there is considerable overlap and often no definitive answer can be given based on imaging morphology.Follow-up is therefore a commonly used strategy.,实性结节实性肺结节可有多种病因学：良性肉芽肿、局灶瘢痕、肺内的淋巴结、原发性恶性肿瘤、转移性病变。叶间裂周围的结节是一单独的小体，因为它通常代表肺内的淋巴结而作为良性灶，不需随访（见后述）,在另外的文章中我们提出一些影像学特点目的是用于帮助良恶病变间的鉴别，但遗憾的是有相当大的重叠，故而不能根据影像形态学做出更明确的结论，因此随访仍是常用的策略。,单发,Subsolid nodulesMost subsolid nodules are transient and the result of infection or hemorrhage.However,persistent subsolid nodules often represent pathology in the adenocarcinomatous spectrum.No reliable distinction can be made radiologically,although studies suggest that larger size and a solid component are associated with more invasive behaviour.Compared to solid lesions,persistent subsolid nodules have a much slower growth rate,but carry a much higher risk of malignancy.In a study by Henschke et al,part-solid nodules were malignant in 63%,pure groundglass SSNs in 18%and solid nodules only in 7%4.,亚实性结节大部分的亚实性结节是一过性的并作为感染或出血的结果。然而，持续性的亚实性结节其病理学上多为肺腺癌之谱线。在放射学上，尽管一些研究提示：在较大的结节灶并伴实性成分及侵润征象等，仍没有更可靠的鉴别特征。与实性结节对比，持久性的亚实性结节尽管具有较缓慢的生长速度，但其更多见于恶性肿瘤。在Henschke et al的研究中，恶性肿瘤的分别是：部分实性成分者为63%；纯磨玻璃结节（SSNs）则为18%；实性结节仅7%。,磨玻璃,6-12月复查CT,若持续，则3、5年CT,随后的处理主要基于可疑结节,随访,单发,亚实性结节,无需随访,部分实性,多发性,无需随访,3-6月复查CT,若持续，则5年内年度CT,3-6月复查CT,若稳定，则2年、4年CT,3-6月复查CT,Subsolid nodules in the adenocarcinomatous spectrum were formerly known as bronchoalveolar carcinoma or BAC.This terminology should no longer be used.A new pathology-based classification for adenocarcinoma was introduced in 2011 and this current classification makes distinction between:Adenocacinoma in situ.Minimally invasive adenocarcinoma.Invasive adenocarcinoma.,Transient subsolid nodules usually represent infection or alveolar hemorrhage.To differentiate between transient or persistent subsolid nodules a follow-up CT should be obtained.Previously,it was recommended to repeat imaging after 3 months,however,this interval has been increased to 12 months.Because of the slower growth rate,the total follow-up period for persistent subsolid nodules has been increased to 5 years.The images show a 7 mm pure groundglass subsolid nodule in the right upper lobe.On follow-up CT this proved to be a transient subsolid nodule.,在肺腺癌中的亚实性结节即旧称的支气管肺泡癌或BAC。腺癌的新的病理学分类已在2011年公布：1、原位腺癌2、微侵润腺癌3、侵润性腺癌 见左上图,短暂性的亚实性结节通常代表感染或肺泡