肺結(jié)節(jié)最新指南與臨床實(shí)踐Fleischner2017guidelineforpulmonarynodules

byOnnoMetsandRobinSmithuis

theAcademicalMedicalCentre,AmsterdamandtheAlrijneHospital,Leiderdorp,theNetherlands2017年費(fèi)萊舍爾學(xué)會(huì)：肺結(jié)節(jié)指南Introduction

FleischnerGuideline2017

Introduction介紹

Solidnodules

實(shí)性結(jié)節(jié)Subsolidnodules

亞實(shí)性結(jié)節(jié)Riskfactors

危險(xiǎn)因素Notes

注意點(diǎn)PulmonaryNoduleMeasurements

肺結(jié)節(jié)的測(cè)量

Perifissuralnodules葉間裂旁結(jié)節(jié)

PublicationdateJuly1,2017PulmonarynodulesarefrequentlyencounteredincidentallyonchestCT.

Theroleoftheradiologististoseparatebetweenbenignandpossiblymalignantlesions,andadviseonfollow-upimagingoradditionalinvasiveimagingtechniques.Thisarticlesummarizesthebasicsofindeterminatepulmonarynodules,andpresentsthenewestmanagementrecommendationsoftheFleischnerSociety.2017年7月1日文章：肺結(jié)節(jié)是偶然胸部CT檢查中頻繁遇到的。放射學(xué)家的角色就是在良性灶或惡性灶二者間做出鑒別診斷，并提出影像學(xué)的隨訪或附加另外的有創(chuàng)性的介入技術(shù)。該文章概括了不能定性的肺結(jié)節(jié)的基本概念，介紹了由費(fèi)舍爾學(xué)會(huì)推薦的最新的管理方法。Pulmonarynodulescanbedividedintosolidlesionsandsubsolidlesions,whichcanbefurthersubdividedintopart-solidandpuregroundglassnodules.Heresomedefinitions:Subsolidnodule(SSN)

ApulmonarynodulewithatleastpartialgroundglassappearanceGroundglass

Opacificationwithahigherdensitythanthesurroundingtissue,notobscuringunderlyingbronchovascularstructures肺結(jié)節(jié)分為實(shí)性病灶和亞實(shí)性病變。再進(jìn)一步分為部分實(shí)性和純磨玻璃結(jié)節(jié)。也有做如下的定義：

*亞實(shí)性結(jié)節(jié)（SSN）：肺結(jié)節(jié)至少有一部分呈磨玻璃的表現(xiàn)。*磨玻璃：相比周圍組織為不透明性的高密度，但不遮擋支氣管血管結(jié)構(gòu)。肺結(jié)節(jié)亞實(shí)性（SSN）實(shí)性部分實(shí)性（PSN）純磨玻璃（PGGN）中放2015年4月49卷4期（放射學(xué)分會(huì)心胸組專家共識(shí)）FleischnerGuideline2017IntroductionIn2017theupdatedFleischnerSocietyguidelinewaspublished[1].

Thesereplacetherecommendationsforsolid(2005)[2]andsubsolidpulmonarynodules(2013)[3].

Thesenewguidelinesshouldreducethenumberofunnecessaryfollow-upexaminationsandprovideclearmanagementdecisions.Nodulecharacterizationshouldbeperformedonthin-sliceCTimages≤1.5mm,sinceasmallsolidnodulemayappeartohavegroundglassdensityonathicksliceduetopartial-volumeeffect.費(fèi)舍爾學(xué)會(huì)：2017年指南更新過的“2017年費(fèi)舍爾學(xué)會(huì)肺結(jié)節(jié)指南”

已經(jīng)發(fā)布。它替換了以往推薦的實(shí)性結(jié)節(jié)（2005年）和亞實(shí)性肺結(jié)節(jié)（2013年）新的指南將減少不必要的隨訪檢查并提供了明確的管理決策。結(jié)節(jié)特征的評(píng)價(jià)需要薄層CT成像，即層厚要≤1.5mm,理由：小的實(shí)性結(jié)節(jié)在較厚的圖像上因部分容積效應(yīng)可以類似于磨玻璃密度。SolidnodulesSolidpulmonarynodulescanrepresentvariousetiologies:benigngranulomasfocalscarintrapulmonarylymphnodesprimarymalignanciesmetastaticdisease.Perifissuralnodulesareaseparateentity,sincetheyusuallyrepresentintrapulmonarylymphnodes,whicharebenignandneednofollowup.

Theyarediscussedinthelastchapter.

Inanotherarticlewepresentedsomefeaturesthatcanhelptodifferentiatebetweenbenignandmalignantlesions(clickhere)Unfortunately,thereisconsiderableoverlapandoftennodefinitiveanswercanbegivenbasedonimagingmorphology.Follow-upisthereforeacommonlyusedstrategy.實(shí)性結(jié)節(jié)實(shí)性肺結(jié)節(jié)可有多種病因?qū)W：良性肉芽腫、局灶瘢痕、肺內(nèi)的淋巴結(jié)、原發(fā)性惡性腫瘤、轉(zhuǎn)移性病變。葉間裂周圍的結(jié)節(jié)是一單獨(dú)的小體，因?yàn)樗ǔ４矸蝺?nèi)的淋巴結(jié)而作為良性灶，不需隨訪（見后述）在另外的文章中我們提出一些影像學(xué)特點(diǎn)目的是用于幫助良惡病變間的鑒別，但遺憾的是有相當(dāng)大的重疊，故而不能根據(jù)影像形態(tài)學(xué)做出更明確的結(jié)論，因此隨訪仍是常用的策略。實(shí)性大小隨訪低風(fēng)險(xiǎn)低、高低風(fēng)險(xiǎn)低風(fēng)險(xiǎn)低風(fēng)險(xiǎn)高風(fēng)險(xiǎn)高風(fēng)險(xiǎn)高風(fēng)險(xiǎn)高風(fēng)險(xiǎn)多發(fā)單發(fā)多發(fā)多發(fā)單發(fā)不常規(guī)隨訪3-6個(gè)月CT，然后18-24個(gè)月CT不常規(guī)隨訪考慮3個(gè)月CT，PET-CT或活檢6-12個(gè)月CT，然后18-24個(gè)月CT選擇性的1年復(fù)查CT選擇性的1年復(fù)查CT6-12個(gè)月CT，然后考慮18-24個(gè)月CT3-6個(gè)月CT，然后考慮18-24個(gè)月CT3-6個(gè)月CT，然后考慮18-24個(gè)月CT3-6個(gè)月CT，然后18-24個(gè)月CT低風(fēng)險(xiǎn)高風(fēng)險(xiǎn)單發(fā)SubsolidnodulesMostsubsolidnodulesaretransientandtheresultofinfectionorhemorrhage.

However,persistentsubsolidnodulesoftenrepresentpathologyintheadenocarcinomatousspectrum.Noreliabledistinctioncanbemaderadiologically,althoughstudiessuggestthatlargersizeandasolidcomponentareassociatedwithmoreinvasivebehaviour.

Comparedtosolidlesions,persistentsubsolidnoduleshaveamuchslowergrowthrate,butcarryamuchhigherriskofmalignancy.

InastudybyHenschkeetal,part-solidnodulesweremalignantin63%,puregroundglassSSNsin18%andsolidnodulesonlyin7%[4].亞實(shí)性結(jié)節(jié)大部分的亞實(shí)性結(jié)節(jié)是一過性的并作為感染或出血的結(jié)果。然而，持續(xù)性的亞實(shí)性結(jié)節(jié)其病理學(xué)上多為肺腺癌之譜線。在放射學(xué)上，盡管一些研究提示：在較大的結(jié)節(jié)灶并伴實(shí)性成分及侵潤征象等，仍沒有更可靠的鑒別特征。與實(shí)性結(jié)節(jié)對(duì)比，持久性的亞實(shí)性結(jié)節(jié)盡管具有較緩慢的生長速度，但其更多見于惡性腫瘤。在Henschkeetal的研究中，惡性腫瘤的分別是：部分實(shí)性成分者為63%；純磨玻璃結(jié)節(jié)（SSNs）則為18%；實(shí)性結(jié)節(jié)僅7%。磨玻璃6-12月復(fù)查CT,若持續(xù)，則3、5年CT隨后的處理主要基于可疑結(jié)節(jié)隨訪單發(fā)亞實(shí)性結(jié)節(jié)無需隨訪部分實(shí)性多發(fā)性無需隨訪3-6月復(fù)查CT,若持續(xù)，則5年內(nèi)年度CT3-6月復(fù)查CT,若穩(wěn)定，則2年、4年CT3-6月復(fù)查CTSubsolidnodulesintheadenocarcinomatousspectrumwereformerlyknownasbronchoalveolarcarcinomaorBAC.

Thisterminologyshouldnolongerbeused.Anewpathology-basedclassificationforadenocarcinomawasintroducedin2011andthiscurrentclassificationmakesdistinctionbetween:Adenocacinomainsitu.Minimallyinvasiveadenocarcinoma.Invasiveadenocarcinoma.Transientsubsolidnodulesusuallyrepresentinfectionoralveolarhemorrhage.

Todifferentiatebetweentransientorpersistentsubsolidnodulesafollow-upCTshouldbeobtained.

Previously,itwasrecommendedtorepeatimagingafter3months,however,thisintervalhasbeenincreasedto12months.

Becauseoftheslowergrowthrate,thetotalfollow-upperiodforpersistentsubsolidnoduleshasbeenincreasedto5years.Theimagesshowa7mmpuregroundglasssubsolidnoduleintherightupperlobe.

Onfollow-upCTthisprovedtobeatransientsubsolidnodule.在肺腺癌中的亞實(shí)性結(jié)節(jié)即舊稱的支氣管肺泡癌或BAC。腺癌的新的病理學(xué)分類已在2011年公布：1、原位腺癌2、微侵潤腺癌3、侵潤性腺癌見左上圖短暫性的亞實(shí)性結(jié)節(jié)通常代表感染或肺泡出血。為了區(qū)分短暫性或持久性亞實(shí)性結(jié)節(jié)，需要CT隨訪證實(shí)。在以前，這種病灶推薦3個(gè)月復(fù)查。而現(xiàn)在復(fù)查間隔增加到12個(gè)月。處于較緩慢增長的原因，對(duì)恒定的亞實(shí)性結(jié)節(jié)的整個(gè)的隨訪時(shí)期，增加到5年。左下圖顯示：右上葉7mm純磨玻璃亞實(shí)性結(jié)節(jié)。隨訪CT證實(shí)為短暫性亞實(shí)性結(jié)節(jié)。Theseimagesshowapuregroundglasssubsolidnoduleintherightlowerlobe.

Thislesiondemonstratedgrowthinatwoyearintervalandprovedtobemalignantafterresection.RiskfactorsDefininghigh-orlow-riskiscurrentlymoredifficultthanitwasintheoldguideline.

Previouslyahigh-risksubjectwasidentifiedbasedonahistoryofheavysmoking,historyoflungcancerinafirst-degreerelativeorexposuretoasbestos,radonoruranium.Now,itisaimedfortoseparatehigh-risklesionsfromlow-riskonesbyconsideringmoreparametersthansubjectcharacteristicsalone(SeeTable).左圖顯示右下葉純磨玻璃亞實(shí)性結(jié)節(jié)。該病變隨訪兩年期間增大。手術(shù)證實(shí)為惡性。

危險(xiǎn)因素定義高或低風(fēng)險(xiǎn)，目前要比舊的指南更困難。先前，被定義為高風(fēng)險(xiǎn)的因素是基于嚴(yán)重吸煙史，直系親屬肺癌史，接觸石棉、氡、鈾。而今，它是以區(qū)分高風(fēng)險(xiǎn)或低風(fēng)險(xiǎn)病灶為目的，則要考慮更多的參數(shù)而不是僅靠單一的某些因素。危險(xiǎn)因素嚴(yán)重吸煙史暴露于石棉、氡、鈾肺癌家族史老齡性別（女多于男）種族（黑人、土著人、夏威夷人多于白種人）邊境投機(jī)商上葉部位多重性（結(jié)節(jié)少于5個(gè)，惡性幾率增加）肺氣腫和肺纖維化（特別是IPF）Sincetheseriskfactorsarenumerousandhavedifferenteffectsonthemalignancyrisk,itisproposedtoassessfinalriskcategoriesconcerningtheprobabilityofmalignancy[8](Table).NotesTheguidelinerecommendsfollow-upfornoduleswithanestimatedlungcancerriskofaround1%orgreater,whichisanarbitrarycut-off.Thelikelihoodofmalignancyisdifferentforanincidentallyfoundpulmonarynoduleinthelowerlobeofarelativelyyoungpatientcomparedtoanoduleintheupperlobeofahigh-riskheavysmoker,orinapatientwithaknownorsuspectedmalignancy.

ForthisreasontheFleischnerguidelineforthemanagementofpulmonarynodulesseparateshigh-andlow-risk,anddoesnotapplytosubjectsyoungerthan35years,immunocompromisedpatientsorpatientswithcancer[1].惡性腫瘤的可能性評(píng)估低概率（＜5%）年輕不吸煙無先前癌結(jié)節(jié)小邊緣規(guī)則結(jié)節(jié)非上葉中概率（5-65%）具有高與低混合特征高概率（>65%）年老嚴(yán)重吸煙有先前癌結(jié)節(jié)大邊緣不規(guī)則結(jié)節(jié)位于上葉使用2017年費(fèi)舍爾學(xué)會(huì)肺結(jié)節(jié)指南的注意點(diǎn)僅用于35歲及以上者不適用免疫功能低下者，或已患有確診性癌癥者使用薄層（低劑量）CT成像重組圖描述其特征和進(jìn)行肺結(jié)節(jié)隨訪。結(jié)節(jié)的手工測(cè)量是基于結(jié)節(jié)的長軸和短軸徑線；選擇性地使用結(jié)節(jié)灶的容積測(cè)量，需保證隨訪期間的成像技術(shù)和軟件的恒定性。新的指南的風(fēng)險(xiǎn)分級(jí)是兩方面的綜合，即病人高危因素、肺結(jié)節(jié)的特征。而不同于單一分析低或高危因素的往年的文獻(xiàn)。PulmonaryNoduleMeasurementsIntheFleischnerguidelinesnoduledimensionscanbeobtainedusingeither2Dcalipermeasurementsor3Dnodulevolumetry.

Manual2Dcalipermeasurementsshouldbebasedontheaverageofthelong-andshort-axisdiametersofthenodule.

Theseshouldbeobtainedonthesametransverse,coronalorsagittalreconstructedimage,whicheverplanerevealsthegreatestdimensions[1].

Thisisnewcomparedtothepriorguideline,inwhichdimensionswereaverageddiametersintheaxialplaneonly[2].

Manual2Dcalipermeasurementsshouldberoundedtothenearestwholemillimeter.

Inpart-solidsubsolidnodulesboththetotalnoduleaswellasthesolidcomponentdimensionsshouldbemeasuredseparately,bothusingtheabovementionedaveragingtechnique.肺結(jié)節(jié)測(cè)量費(fèi)舍爾指南中，對(duì)肺結(jié)節(jié)的大小可以通過2D卡尺測(cè)量，或者3D結(jié)節(jié)容積測(cè)量獲得。手動(dòng)的2D卡尺測(cè)量應(yīng)是以結(jié)節(jié)的最大長軸和短軸之和除以2，而獲得結(jié)節(jié)的平均大小。隨訪對(duì)比，應(yīng)以同樣的軸位、冠狀、矢狀重組圖，選擇層面內(nèi)的最大徑。在對(duì)部分實(shí)性的亞實(shí)性結(jié)節(jié)測(cè)量，要對(duì)其實(shí)性及磨玻璃成分要分別測(cè)量。同先前的指南比較，結(jié)節(jié)的大小只是由軸位層面上的平均直徑表示。而新的2D手工卡尺測(cè)量應(yīng)該是更接近實(shí)際的整體大小（mm）Alesionwhichmeasures8×5mmhasanaverageof(8+5):2=6.5mm-roundedupto7mm最終測(cè)量：7mmPerifissuralnodules(PFN)Perifissuralnodulesareaseparateentity,andlikelyrepresentintrapulmonarylymphnodes.

Morphologicallythesearesolid,homogeneousnoduleswithasmoothmargin,andareovalorrounded,lentiformortriangularinshape.

Theirlocationiswithin15mmofthefissureorthepleura.Theymayormaynothavecontactwithaninterlobarseptum.

ThelatterdifferentiatesbetweenatypicalandatypicalPFN(seeFigure).

PFNscanshowsignificantgrowthratesonserialimaging,sometimescomparabletomalignantnodules.

Thisisnotatypicalsignofmalignancy,butmerelyaresultoftheirpresumedlymphaticorigin.典型的PFN不典型的PFN非PFN葉間裂周圍的結(jié)節(jié)葉間裂周圍的結(jié)節(jié)是單獨(dú)的實(shí)體，很可能是肺內(nèi)的淋巴結(jié)。在形態(tài)上，這些結(jié)節(jié)為實(shí)性、密度均勻，邊緣光滑，呈橢圓形或圓形、或凸透鏡狀或三角形。在PFN的位置上，胸膜或葉間裂位于其內(nèi)占據(jù)15mm。或伴/不伴隨與小葉間隔的接觸。多個(gè)PFN在系列成像上可能顯示其明顯的增長率，有時(shí)候酷似惡性結(jié)節(jié)。這并非典型的惡性特征，只不過提示為淋巴源性。Inscreeningsettingithasbeenshownthatnoneofthe919typicalandatypicalPFNswerefoundtobemalignantina5.5yearfollow-up[5].

ThisconfirmedpriorresultsofAhnetal.[6].

Itisassumedthatthisbenignetiologycanbeextrapolatedtoclinicalsubjects,whichissupportedbyyetunpublisheddatainroutine-careclinicalCTimaging[7].Thecurrentlyavailableguidelinesrecommendthatwhensmallnoduleshaveaperifissuralorotherjuxtapleurallocationandamorphologyconsistentwithanintrapulmonarylymphnode,follow-upCTisnotrecommended,eveniftheaveragedimensionexceeds6mm.Perifissurallylocatednodulesthatdonotconformtothemorphologiccharacteristicsshouldberegardedasnon-PFNnodules(Figure)anddoesrequirefollow-up.處于葉間裂旁的結(jié)節(jié)，它不符合PFN的形態(tài)特點(diǎn)，應(yīng)被列為非PFN結(jié)節(jié)（左下圖）并需要隨訪。作者的919個(gè)典型的或不典型的PFNs在隨訪5.5年后沒有一個(gè)發(fā)現(xiàn)是惡性的病灶。這也證實(shí)之前Ahnetal的研究結(jié)果。假如該良性病因如果為臨床學(xué)科所接受，那么將是對(duì)至今還沒有出版的臨床CT成像常規(guī)護(hù)理一書的支持。Incidentalperifissuralnodulesonroutinechestcomputedtomography:lungcancerornot?

byMetsetal.

[Unpublisheddata.Submitted]當(dāng)前的能查到的多數(shù)指南中建議：當(dāng)葉間裂周圍或鄰近胸膜部位發(fā)現(xiàn)小結(jié)節(jié)并且其形態(tài)與肺內(nèi)淋巴結(jié)一致時(shí)，即使平均大小超過6mm,也不推薦對(duì)其做CT隨訪。GuidelinesforManagementofIncidentalPulmonaryNodulesDetectedonCTImages:FromtheFleischnerSociety2017July2017Volume284,Issue1Publishedin:HeberMacMahon;DavidP.Naidich;JinMoGoo;KyungSooLee;AnnN.C.Leung;JohnR.Mayo;AtulC.Mehta;YoshiharuOhno;CharlesA.Powell;MathiasProkop;GeoffreyD.Rubin;CorneliaM.Schaefer-Prokop;WilliamD.Travis;PaulE.VanSchil;AlexanderA.Bankier;Radiology

2017,284,228-243.DOI:10.1148/radiol.20171616592017bytheRadiologicalSocietyofNorthAmerica,Inc./doi/abs/10.1148/radiol.2017161659Apictureisworthathousandwords一幅圖勝千言接下來就以近期刊在Radiology上的一篇文獻(xiàn)中的13個(gè)病例的26幅圖為例，學(xué)習(xí)一下偶然發(fā)現(xiàn)的肺結(jié)節(jié)影像學(xué)特點(diǎn)及對(duì)待原則。Figure1:(a)Lungwindowand(b)soft-tissuewindow1-mmtransverseCTsectionsshowasmoothlymarginatedsolidnodule(arrow)withinternalfatandcalcification,consistentwithahamartoma.NofurtherCTfollow-upisrecommendedforsuchfindings.這樣的結(jié)節(jié)不推薦CT隨訪含鈣化、脂肪：肺錯(cuò)構(gòu)瘤Figure2:(a)CTimageshowsasmoothlymarginatedsolidnodulewithcentralcalcification,typicalofahealedgranuloma.NofurtherCTfollow-upisrecommendedforsuchnodules.(b)CTimageshowsasmoothlymarginatedsolidnodulewithlaminarcalcification,typicalofahealedgranuloma.NofurtherCTfollow-upisrecommendedforsuchfindings.這兩例結(jié)節(jié)不推薦CT隨訪中央鈣化、層狀鈣化：為愈合后的肉芽腫Figure3:(a)Transverse5-mmCTsectionshowsanapparentlypureground-glassnoduleintheleftlowerlobe(arrow).(b)Transverse1-mmCTsectionatthesamelevelasarevealsthatthisisasuspiciouspart-solidnodulewithcysticcomponents(arrow).軸位5mm層厚顯示左下肺病變似乎為純磨玻璃結(jié)節(jié)同水平的軸位1mmCT如圖，可疑為部分實(shí)性結(jié)節(jié)伴囊性成分。Figure4:(a)Transverse1-mmCTsectionshowsanodularopacityadjacenttotheminorfissure(arrow).(b)CoronalreconstructedCTimageshowsthattheopacityisabenignlinearscarorlymphoidtissue(arrow).軸位1mm層厚CT顯示結(jié)節(jié)密度緊鄰于小裂。冠狀重組CT圖顯示該密度為良性線樣瘢痕或淋巴樣組織。Figure6:Transverse1-mmCTsectionthroughtheleftupperlobeshowsasuspicioussolidspiculatednodule(arrow).Surgeryrevealedinvasiveadenocarcinoma.Figure5:CTimageshowsasolidtriangularsubpleuralnodule(arrow)withalinearextensiontothepleuralsurface,typicalofanintrapulmonarylymphnode.NoCTfollow-upisrecommendedforsuchfindings.軸位1mm層厚顯示左上肺一周邊針狀結(jié)節(jié)，手術(shù)證實(shí)侵潤性腺癌。實(shí)性三角形胸膜下結(jié)節(jié)并線樣延伸至胸膜表面，此為典型的肺內(nèi)淋巴結(jié)。這種表現(xiàn)不推薦做CT隨訪。Figure7:Transverse1-mmCTsectionsobtained10monthsapartshowahighlysuspiciouspatternofprogressivethickeninginthewallofarightlowerlobecyst(arrow).Resectionrevealedinvasiveadenocarcinoma.軸位1mm層厚的圖像，間隔10個(gè)月后顯示右下葉囊壁明顯增厚。手術(shù)及病理為侵潤性腺癌。必須重視這樣的特殊肺癌（囊性肺癌）Figure8:CTimageshowsmultiplesolidnodulesofvaryingsizewithlowerzonepredominance(arrows)secondarytometastaticthyroidcarcinoma.Figure9:Transverse1-mmCTsectionsthroughtherightlowerlobe.(a)Awell-defined6-mmground-glassnodule(arrow)canbeseen.(b)Imageobtainedmorethan2yearsafterashowsasubtleincreaseinthesizeofthenodule(arrow).Thisfindingwasconfirmedbynotingtheslightlyalteredrelationshiptoadjacentvascularstructures.Suchsubtleprogressioncanbedetectedonlybyusing1-mmcontiguoussections.Findingsareconsistentwithadenocarcinomainsituorminimallyinvasiveadenocarcinoma,andcontinuedyearlyfollow-upisrecommended.CT圖顯示下葉多發(fā)性結(jié)節(jié)，源自甲狀腺癌的轉(zhuǎn)移瘤。1、軸位1mmCT圖見右肺下葉。左圖：6mm磨玻璃結(jié)節(jié)。右圖：2年

后顯示輕度增大。2、這種增大，可通過結(jié)節(jié)與鄰近血管的關(guān)系得到驗(yàn)證。3、這種輕度的進(jìn)展只能通過1mm的連續(xù)層面才能觀察到。4、這些表現(xiàn)符合肺腺癌（原位癌或微浸潤腺癌），并且推薦對(duì)

其做年度隨訪。Figure10:(a)A1-mmtransverseCTimagethroughtherightmidlungshowsa10-mmpureground-glassnodule(arrow).(b)CTimageinthesamelocationasaat15-monthfollow-upshowsonlyaverysubtleincreaseinopacity.(c)CTimageinthesamelocationasaandbafurther10monthsafterbshowsthenodulehasevolvedintoalargerpart-solidnodule.Surgicalresectionrevealedstage1Ainvasivelepidicpredominantadenocarcinoma.圖A）右中肺1mm軸位圖顯示一10mm純磨玻璃結(jié)節(jié)。圖B）15個(gè)月后，同層面軸位圖顯示該結(jié)節(jié)僅僅輕微的密度上的增高。圖C）又10個(gè)月后，同層軸位圖顯示該結(jié)節(jié)發(fā)展有較大的部分實(shí)性結(jié)節(jié)。手術(shù)及病理：1A期浸潤性鱗狀上皮癌Figure11:(a)Transverse1-mmCTsectionthroughtheleftupperlobeshowsanindeterminate10-mmground-glassnodule(arrow).(b)Follow-upCTimageafter4monthsshowsintervalresolutionwithouttreatment,consistentwithabenignca