多层螺旋CT肺结节和血管的关系课件

1、Multi-detectorspiralCTstudyoftherelationshipsbetweenpulmonaryground-glassnodulesandbloodvesselsEurRadiol(2013)23:32713277第一页，共四十页。多层螺旋CT肺结节和血管的关系Abstract Objective:Toinvestigatetherelationshipsbetweenpulmo-naryground-glassnodules(GGN)andbloodvesselsandtheirdiagnosticvaluesindifferentiatingGGNs. Conc

2、lusion:DifferentGGNshavedifferentrelationshipswithvessels.UnderstandingandrecognisingcharacteristicGGN-vesselrelationshipsmayhelpidentifywhichGGNsaremorelikelytobemalignant.第二页，共四十页。多层螺旋CT肺结节和血管的关系KeyPoints Multi-detectorCToffersnewinformationaboutground-glassnodules. Differenttypesofground-glassnod

3、uleshavedifferentrelationshipswithvessels. Thismayhelpidentifywhichground-glassnodulesarelikelytobemalignant.第三页，共四十页。多层螺旋CT肺结节和血管的关系IntroductionWiththeextensiveacceptanceoflow-dosemulti-detectorspiralCTinlungcancerscreening,thenumberofdetectedGGNsorfocalground-glassopacities(fGGOs)hasdramaticallyin

4、creased.GGNscanresultfromneoplasms,suchaspulmonaryadenocarcinoma,orbenigndiseases,suchasfocalfibrosis,inflammationoralveolarhaemorrhage.第四页，共四十页。多层螺旋CT肺结节和血管的关系Inaddition,pre-invasiveabnormalities,includingatypicaladenomatoushyperplasia(AAH)andadenocarcinomainsitu(AIS).Ithasbeenreportedthatthepropor

5、tionofmalignancyinGGNsishigherthaninsolidpulmonarynodules(SPNs)andthemajorityofmalignantGGNsareadenocarcinoma.Duetoimagingresemblance,however,itisextremelychallengingtodifferentiatemalignantGGNsfromtheaforementionedbenigncounterparts.第五页，共四十页。多层螺旋CT肺结节和血管的关系 AccuratedifferentialdiagnosisofGGNswillas

6、sistphysicianstomaketreatmentdecisionsandimprovetreatmentoutcomesandprognosis. SeveralinvestigatorshavesuggestedthatanalysisofrelationshipsbetweenSPNsandsurroundingvesselscanhelppredictthelikelihoodofmalignancyinsuchnodules. TherelationshipbetweenGGNsandbloodvesselsremainsunknown.Whetherthisrelation

7、shipcanbeutilisedtofacilitatethediagnosisofmalignantGGNsisaworthyofinvestigation.第六页，共四十页。多层螺旋CT肺结节和血管的关系MaterialsandmethodsPatientsTheimagingdataofpatientswithpulmonaryGGNsreceivingthin-sectionmulti-detectorCTexaminationatourhospitalinJanuary2011throughNovember2012wereretrospectivelyreviewed.Allles

8、ionsweresolitaryandmostofthem(104/108)surgicallyresectedwithin2weeksafterCTscanning.第七页，共四十页。多层螺旋CT肺结节和血管的关系InclusioncriteriaTheGGNsizewaslessthan3cminthelargestdimension.ground-glassopacity(GGO)comprisedmorethan50%oftheareaofthelesiononCT.-Anareaofover50%GGOwassetasthecutoffvaluetoexcludesolid/semi

9、-solidlesions.-AlthoughsolidnodulesfrequentlyhadGGOcomponentsaroundtheirmargin,probablyrepresentingsurroundingoedemaormerelypooraerationofthesurroundinglungtissuesduetocompressionorretractionbynodules,thesenoduleshadalreadybeenwellinvestigatedusingCTandthereforewerenotthestudyobjects第八页，共四十页。多层螺旋CT肺

10、结节和血管的关系Ultimately,108patientswereenrolledintothisstudy,including38malesand70femaleswithmeanageof58.1812.89years(range,22to79years).43patientswereasymptomatic,28hadrespiratorysymptoms,and37hadlungcancerriskfactors,suchassmokingandfamilyhistory.第九页，共四十页。多层螺旋CT肺结节和血管的关系Accordingtopathologicalfindings,

11、GGNsweredividedintothreegroups:(1) Benigndiseasegroup(10cases),includingfournodulesdiagnosedwithacombinationofclinicalsymptomsandimagingpresentations(nodulesdisappearedorgraduallyreducedinsizeonmultiplefollow-upCTimaging)andsixnodulesconfirmedbypathologicalexamination(1caseofsclerosinghaemangiomaand

12、5casesofchronicinflammation).(2)Preinvasivediseasegroup(24cases),including7AAHsand17AISs.第十页，共四十页。多层螺旋CT肺结节和血管的关系(3)theinvasiveadenocarcinomagroup(74cases),confirmedpathologically,therewere39non-mucinousminimallyinvasiveadenocarcinomas(MIA)and35invasiveadenocarcinomas(IAC;specifically,13lepidicpredo

13、minantadenocarcinomas;19acinus-predominantadenocarcinomas;2papillary-predominantadenocarcinomasand1solidpredominantwithmucin粘蛋白(dnbi)production).第十一页，共四十页。多层螺旋CT肺结节和血管的关系CTimaginganalysis protocolparameters:0.625-mmsectionwidthwitha0.625-mmreconstructioninterval,pitchof0.984,120kVand250mA.Allimagesw

14、erereviewedwithahigh-resolution,2,0481,560pixel,standardlungwindow(ww,1,500HU;wl,-500HU)andmediastinalwindow(ww,350HU;wl,50HU) GGNscanbefurthersubdividedintomixedground-glassnodules(mGGNs)andpureground-glassnodules(pGGNs).ThepercentageoftheGGOcomponentwascalculatedasfollows:(DGGO-D)/DGGO100,whereDGG

15、OisthelargestdiameteroftheentirelesionandDisthelargestdiameterofthesolidcomponentwithinthelesion.第十二页，共四十页。多层螺旋CT肺结节和血管的关系 BloodvesselanalysiswasperformedintermsofvascularmorphologyandvascularrelationshipswithGGNlesions. thediameterofpulmonaryvesselsgraduallydecreasesfromthehilumtowardtheperiphery.

16、Ifthediameterofthevascularsegmentwithinlesionswaslargerthantheproximalsegmentorlesionvesselswereapparentlywiderthanothervesselsatthesamebranchlevel,thevesselwasdeemedasabnormalvascularbroadening. Thevesselswereconsideredtobedistortedorrigidiftravelingastrayfromtheexpectednormalcourse.第十三页，共四十页。多层螺旋C

17、T肺结节和血管的关系 Multiplesupplyingvessels,withdifferentoriginatingsources,convergingtowardalesion,wereprobablyindicativeofanincreasedbloodcirculationwithin. Tofurtherclarifyaffiliationsofsupplyingvessels,wetracedvascularcoursesslice-wisebackwardtomajorvesselsinthehilum. TherelationshipsbetweentheGGNsandsu

18、pplyingbloodvesselswereanalysedinaxialimages,MPRimagesCPRimages.第十四页，共四十页。多层螺旋CT肺结节和血管的关系theGGN-vesselrelationshipswerecategorizedintofourtypesaccordingtoimagingfeatures:typeI(pass-by),vesselspassedbyGGNswithoutdetectablesupplyingbranchestolesions.typeI第十五页，共四十页。多层螺旋CT肺结节和血管的关系typeII(pass-through),v

19、esselspassedthroughthelesionswithoutobviousmorphologicalchangesintravelingpathorsize.第十六页，共四十页。多层螺旋CT肺结节和血管的关系typeIII(distorted/dilated),vesselswithinlesionsweretortuousorrigidwithoutanincreaseinamount第十七页，共四十页。多层螺旋CT肺结节和血管的关系typeIV(complicated),morecomplicatedvasculatureotherthandescribedintheafore

20、mentionedtypeswithinGGNs,forinstance,coexistenceofirregularvasculardilationandvascularconvergencefrommultiplesupplyingvessels.第十八页，共四十页。多层螺旋CT肺结节和血管的关系Pathologicalanalysis ThepathologicaldiagnosisandcategorisationofAAH,AIS,MIAandIACweremadebasedonthenewpulmonaryadenocarcinomaclassification,2011editi

21、on. GGNswereresectedbyvideo-assistedthoracoscopyorthoracotomysurgery. Allhistologicalpreparationsandanalyseswereperformedbytwoseniorpathologists.Inthecaseofdisagreements,aconsensuswasreachedaftermutualdiscussionand/orconsultationwithathirdpathologist.第十九页，共四十页。多层螺旋CT肺结节和血管的关系StatisticalanalysisSPSS1

22、6.0forWindows,SPSS,Chicago,IllIndependentttestwasusedtocomparedifferentpathologicalgroups(benigndiseases,preinvasivediseasesandinvasiveadenocarcinoma)ofGGN.CorrelationsbetweenpathologicalfindingsofGGNsandGGN-vesselrelationshipswereexaminedusingSpearmansranktest.GGN-vesselrelationshipsbetweenMIAandIA

23、CdiseaseswerecomparedusingPearsonschi-squaredtest.Whentherewasanexpectedvalue1orapretestprobabilityclosetothetestlevel,Fishersexacttestwasusedinstead.StatisticalresultswereconsideredsignificantwhenthePvaluewaslessthan0.05.第二十页，共四十页。多层螺旋CT肺结节和血管的关系ResultsSize variation of GGN lesions TheaverageGGNsiz

24、einthebenigngroup,preinvasivegroupandadenocarcinomasgroupwas8.12.5mm,9.35.6mmand14.86.0mm,respectively. Nosignificantdifferencesexistedbetweenthepreinvasivegroupandthebenigngroup(t=0.64,p=0.53). However,thereweresignificantdifferencesbetweenbenignandpreinvasivegroupsandtheinvasiveadenocarcinomagroup

25、(t=6.31,p=0.00;t=3.98,p=0.00).第二十一页，共四十页。多层螺旋CT肺结节和血管的关系 Correlations between GGN-vessel relationships and pathological findings Of108GGNs,typeI,II,IIIandIVGGNvessellrelationshipswereobservedin9,58,21and20cases,respectively. thetypeIIGGN-vesselrelationshipwasthedominantrelationshipineachpathological

26、group,seenin9benign(90.0%),16preinvasive(66.7%)and33invasive(44.6%)GGNcases. 第二十二页，共四十页。多层螺旋CT肺结节和血管的关系comparedwiththelowincidenceoftypeIIIandIVrelationshipsinbenignandpreinvasivegroupsthecombinedincidenceoftypeIII(25.7%)andIV(25.7%)relationshipsintheinvasiveadenocarcinomagroupreached51.3%.第二十三页，共四十

27、页。多层螺旋CT肺结节和血管的关系MIA couldpresentfourtypes,withtypeIIasthemajortype (48.7%).ThecombinationoftypeIIandIVcomprised about80%oftheMIAsubgroup;forIAC,typeIIandIII hadthesameproportionof40%,hencethecombinationof 80%.StatisticalstudiesshowednodifferenceintypeIIbuta significantdifferencewasfoundintypeIIIand

28、IVbetween MIAandIAClesions(p=0.02).第二十四页，共四十页。多层螺旋CT肺结节和血管的关系Thevessel(s)travelingthroughGGNcouldbeartery(ies)(categoryA),vein(s)(categoryB),orartery(ies)andvein(s)(categoryC).TherewerenosignificantdifferencesandcorrelationsbetweenvascularcategoriesandGGNgroups(p=0.50and0.96,respectively).第二十五页，共四十页

29、。多层螺旋CT肺结节和血管的关系AfurtherexaminationofthecorrelationbetweenvascularcategoriesandGGNswithtypeIIIandIVrelationshipsdidnotgenerateanysignificantresults(p=0.70).第二十六页，共四十页。多层螺旋CT肺结节和血管的关系Discussion Solitarypulmonarynodules(SPNs)arecommonfindingsinCTexaminationsandcanbedividedintotwogroupsbasedondensityva

30、riation:solidnodulesandGGNs. In2011,theInternationalAssociationfortheStudyofLungCancer,theAmericanThoracicSocietyandtheEuropeanRespiratorySocietyproposedanewclassificationforlungadenocarcinomas. Inthenewclassificationsystem,thetermbronchioloalveolarcarcinoma(BAC)isnolongerused.TheformerBACconceptapp

31、licabletomultiplecategoriesinthenewclassificationsystem,suchasAIS,MIAandthemucinoussubtypeofadenocarcinoma.BothAISandAAHlesionsareclassifiedaspreinvasiveadenocarcinomaunderthenewclassificationsystem第二十七页，共四十页。多层螺旋CT肺结节和血管的关系 EarlystagelungcancersoftenpresentasGGNsinCTimages;thus,itisimportanttobefam

32、iliarwiththecharacteristicsofGGNswithmalignantpotential,astimelysurgicalresectionwillimprovepatientsurvivalandqualityoflife,andforpatientswithbenignGGNs,unnecessarysurgicalprocedurescanbeavoided.第二十八页，共四十页。多层螺旋CT肺结节和血管的关系 Clinicaldatahaveshownthatnodulesizeisanindependentpredictivefactorofmalignancy

33、,withsizeincreasingthelikelihoodofmalignancyincreasing,consistentwithourresultsthatthemeansizesofGGNsinbenign,preinvasiveandadenocarcinomagroupswere8.1mm,9.3mmand14.7mm. Clinicalexperiencehasdemonstratedthatsomecommonimagingfeaturesofmalignantnodules,suchaspleuralindentation,spiculationandlobulation

34、,areseldomseeninveryearlystagemalignantGGNs.第二十九页，共四十页。多层螺旋CT肺结节和血管的关系 Thisdemandsfurtherinvestigationofthisparticularabnormalimagingfindingtominimisemisdiagnosis.InthemanagementofGGNsinourpatients,clinicalguidelinesfromtheFleischnerSocietyandNationalComprehensiveCancerNetwork(NCCN)werereferenced. E

35、achindividualcasewasdiscussedbyamultidisciplinaryteam,includingdiagnosticradiologists,thoracicsurgeonsandpathologists,togenerateconsequentmanagementstrategies. Allpatientsreceivedadequatefollow-upobservationwith/withoutsupportiveorantiinflammatorytreatment,whichexplainedthefactthatfourGGNsdisappeare

36、dpriortothenextscheduledCTexamination.第三十页，共四十页。多层螺旋CT肺结节和血管的关系 Exceptforthesefourcaseswithoutbiopsy,nodularlesionsintheremaining104patientsweresurgicallyremovedbecauseofthecontinuousincreaseinsizeand/ormassonfollow-upimagingstudies. ConsideringthedramaticallyincreasingincidenceoflungcancerinChina,p

37、atientsandphysiciansareveryalerttoitandthetreatmentmightbemoreaggressivethaninWesterncountries.第三十一页，共四十页。多层螺旋CT肺结节和血管的关系 Tumourbiologystudieshaverevealedthatvasculatureremodellingorneoangiogenesisisoneoftheinitiatingeventsoccurringintheearlystageoftumourdevelopment.Therefore,analysisofGGNsandrelate

38、dbloodsupplyingvesselscouldprovideinformationonGGNdifferentiation. SmallbloodvesselsandtherelationshipsbetweenvesselsandlesionscanbereadilyrevealedandevaluatedinCTimagesacquiredwithmodernmulti-detectorscanners,especiallywhenimagingdataarepost-processedusingadvancedcomputertechniques,includingMPRandC

39、PR. ManystudieshavedemonstratedthatrelationshipsbetweenSPNsandvessels,especiallythevascularconvergencesign(VCS),arevaluableforestimationofthemalignancypotentialofSPNs第三十二页，共四十页。多层螺旋CT肺结节和血管的关系 SomestudiesindicatedthatdiseaseprogressionfromAAH,AIS,MIAtoIACisacomplicated,polygene-involveddynamicproces

40、s.MIAorIACmaygraduallydevelopfromAAHandAIS.InterstitialfibrehyperplasiawithinlesionsisthemaincontributingfactortotypeIIIandIVvascularmorphologicalchanges. theformationmechanismofVCS,leadingtotheconclusionthatthecourseofadjacentvesselsissubjecttolesions,especiallywhendiseasesinfiltratethebronchiovasc

41、ularbundleandinterlobularsepta第三十三页，共四十页。多层螺旋CT肺结节和血管的关系 Asaresult,involvedvesselsmightappeardistorted,rigidorconcentratedtowardsthelesion. Thus,itisreasonabletopostulate假设(jish)thatthevascularconvergencesigncommonlyseeninSPNs. Actually,thetypeIVGGN-vesselrelationshipresemblesVCStosomedegree. Theinv

42、asiveadenocarcinomagroupiscomposedoftwosubgroups,MIAandIAC.SubgroupanalysisshowedMIAandIAChaddifferentpatternsofGGN-vesselrelationships.第三十四页，共四十页。多层螺旋CT肺结节和血管的关系 TypeIIIvascularmorphologicalchangeswereobservedmoreoftenintheIACthanMIAsubgroup,indicatingthatwithincreasingmalignancy,fibrehyperplasiast

43、imulatedbymalignanttissuesmaybecomemoresevere,andsubsequentlyimpactsonvasculaturebecomeaggravated. Furthermore，tumourmetabolismisfasterthaninnormaltissues;therefore,thebloodsupplydemandedbytumoursismuchhigherthaninnormaltissues. Thesemechanismsindirectlyleadtovesselproliferationandirregularluminaldi

44、lation.第三十五页，共四十页。多层螺旋CT肺结节和血管的关系 Somestudieshaveshownthatendogenousand/orextrinsictumorangiogenesisandneovascularisationcouldbethedrivingfactorsofvascularabnormalitiesobservedinmalignantearlystage. AsaCTimagingsign,VCSdescribesarelationshipbetweenSPNsandvessels,oneormultiplevesselsconcentratingtowardsandpassingthroughlesionsorbeingtruncatedattheedgeoflesions.第三十六页