早期非小细胞肺癌外科治疗新进展

肺癌是恶性肿瘤患者首位的死亡原因,随着计算机断层扫描（computed tomography, CT）等影像筛查的普及,肺癌的疾病谱正在发生变化,以往以中央型局部晚期肺鳞癌为主,而目前肺癌疾病谱主要为以孤立性肺结节、磨玻璃结节、亚厘米结节等为影像学表现的早期肺腺癌。早期肺癌是目前临床研究的热点,本文将就早期肺癌外科治疗的多个方面进展进行述评。     

肺癌的早期筛查现状及进展

肺癌由于高发病率及高病死率,严重危害人民生命健康。在国际研究成果的基础上,结合我国实际,国内推出了《中国肺癌低剂量螺旋 CT 筛查指南》及《肺癌筛查与管理中国专家共识》,被国内医院及健康管理机构奉为圭 臬。他们指导国内的肺癌早期筛查,并进行全程健康管理。国内研究者在该指南基础上对影像检查的结果进行持 续评估,对肺结节的形态、位置、密度、边缘、空泡和血管生成等进行研究,进一步提高肺癌筛查的精确性。研究者将PET-CT,弥散加权核磁共振等方法应用到肺癌的早期筛查中,也提高了肺癌筛查的特异性。除影像检查外,ctDNA、支气管内镜和呼出气体检查等方法的研究也取得了不错的进展,为肺癌的筛查提供了备用方案。本文针对肺癌早期筛查的情况进行综述,以期最大限度地提高肺癌早期诊断的几率,降低肺癌的危害。     

肺结节评估四大指南比较分析

近20年来,随着计算机断层扫描(computed tomography,CT)技术的提高和肺癌高危人群筛查的普及,越来越多的肺部小结节被发现,然而肺结节的定性诊断仍有很多困难.肺结节是临床上一种常见的现象,恶性结节早期发病比较隐匿,如果不进行早期干预,其病程迅速、恶性程度强、预后差.如果能在早期阶段对病灶进行手术切除,将会明显改善肺癌患者的预后.目前针对肺结节的处理指南层出不穷,但各大指南均未达成统一的共识.本文拟对在国内影响最大的四个指南:美国国家综合癌症网络非小细胞肺癌(non-small cell lung cancer,NSCLC)临床实践指南、美国胸科医师协会肺癌诊疗指南、Fleischner-Society肺结节处理策略指南、肺结节的评估亚洲共识指南所推荐的肺结节诊断和处理策略进行介绍和分析.     

乌鲁木齐市社区肺癌高危人群低剂量螺旋CT筛查结果分析

[目的]对乌鲁木齐市城市社区40～69岁人群开展肺癌筛查,评价筛查效果.[方法]对问卷评估的11 512名肺癌高危人群低剂量螺旋CT检查.[结果]共完成肺癌CT筛查3436人,依从性为20.4％.共发现1294人有肺内结节(37.6％),367人有阳性结节(10.7％),可疑肺癌16例(0.46％).男性阳性结节的检出率高于女性.60～69岁年龄组在阳性结节、小结节、可疑肺癌的检出率都高于其他年龄组.[结论]低剂量螺旋CT适合肺癌的高危人群筛查,有助于早期发现肺内的阳性结节和相关疾病,60岁以上人群肺癌的筛查应该引起高度重视.     

低剂量多层螺旋CT对717例健康体检者的肺结节筛查分析

摘 要：［目的］ 评价低剂量多层螺旋CT进行健康体检人群早期肺结节筛查的特点。［方法］ 重庆市人民医院放射科2014年3月至2014年7月对已排除既往有恶性肿瘤病史的717例健康体检人员采用低剂量螺旋CT 进行早期肺结节筛查。［结果］ 筛检并经病理确诊肺结节117例(16.3%),结节类型中磨玻璃样结节34例,部分实性结节47例,实性结节36例,术后病理结果肉芽肿性结节94例,肺癌17例,错构瘤6例。肺结节的总检出率为16.3%。肺结节的总检出率男性高于女性,检出的肺结节中肺癌的总检出率男性高于女性。［结论］ 采用低剂量多层螺旋CT 进行肺结节筛查有助于肺结节的早期发现并提高肺癌的检出率。     

循环肿瘤细胞在早期肺癌诊疗中的研究进展

循环肿瘤细胞(circulating tumor cells, CTCs)作为液体活检的一种重要类型,在肺癌的筛查诊断、疗效评估、术后监测与预后判断等方面显示出越来越丰富的临床价值.随着对肺癌高危人群筛查工作的进展,大量肺小结节患者被检出,但是肺小结节不等于肺癌,而且据统计良性比例达90%-95%,这使得该部分患者在首次就诊时的良恶性鉴别诊断成为临床医生面临着的新的机遇与挑战.CTCs检测技术的不断进步与完善,是否可以在早期肺癌的鉴别诊断中发挥更大的作用,此外,它是否对早期肺癌手术治疗时的操作具有指导意义,这还需要进一步科研探索,以期将来实现临床转化.     

肺癌筛查与早期诊断:从影像学到生物标志物的进展

降低肺癌死亡率最有效的方法是早诊断、早治疗,但目前尚未有理想的肺癌筛查和早诊模式。近年来,为了提高肺癌的早期诊断率,降低肺癌患者死亡率,延长生存期,越来越多的研究探索可行、有效的早期诊断策略,并开发了多种早期肺癌风险人群的筛查方法,包括影像学筛查、支气管镜检查、液体活检以及挥发性有机化合物等。本文就肺癌筛查与早期诊断的影像及生物标志物层面的研究进展作一综述。     

人工智能在肺部肿瘤影像诊断中的研究进展

肺癌的早期发现、精确诊断对于患者的预后至关重要。影像学能够无创、全面地反映肿瘤的异质性,在肺癌诊断中发挥重要作用。海量影像数据的深入挖掘是影像医师面临的巨大挑战。人工智能(artificial intelligence,AI)擅长处理大批量、高维度的信息,用算法解析数据,既可以自动提取定量特征,也可以自动学习现有数据,从而对新数据进行预测。AI在影像处理领域得到快速发展,在肺结节检出、肺癌诊断等方面显示出较大的优势和应用前景。将AI与临床工作相结合有助于精准医疗的实施。本文对近年来AI在肺部肿瘤影像诊断领域的研究现状和进展予以概述。     

血清自身抗体联合低剂量螺旋CT在肺癌早期筛查中的价值

目的 探讨血清自身抗体检测联合低剂量螺旋CT（LDCT）在肺癌早期筛查中的可行性。方法 收集武汉大学人民医院体检中心体检人群12 568例体检资料,男7 453例、女5 115例,筛选出肺癌高危人群1 324例纳入本研究,该人群均进行胸部X线检查。随机选取443例患者采用低剂量螺旋CT检测;488例患者采用血清自身抗体进行检测;393例患者采用血清自身抗体联合低剂量螺旋CT检测。均随访一年,比较不同筛查方法对肺结节初筛阳性率及肺癌确诊率,早期肺癌筛查的敏感度及特异性。结果 血清自身抗体联合低剂量螺旋CT检测对于发现肺结节的初筛率、肺癌的确诊率及不同直径肺结节的检出率均明显高于低剂量螺旋CT组及血清自身抗体检测组（P<0.001）。血清自身抗体联合低剂量螺旋CT检测的特异性为89.1%,敏感度为88.4%,AUC为0.863。结论 血清自身抗体检测联合低剂量螺旋CT可明显提高高危人群早期肺癌筛查的确诊率,为寻找肺癌筛查路径提供理论依据。     

亚肺叶切除使老年早期肺癌患者术后生活质量更佳

随着胸部低剂量螺旋CT在老年人健康体检和高危人群肺癌筛查项目中的推广普及,越来越多的病灶小于2厘米的肺内微小结节或磨玻璃样病变被发现,而且双肺多发的肺内微小结节或磨玻璃样病变也日渐增多,其中有70％以上经过外科手术被证实为早期肺癌。早期肺癌标准的外科手术方式是以肺叶为基本单位的肺叶切除加淋巴结清扫。标准的肺叶切除手术对于60岁以上的老年肺癌患者的术后肺功能影响较大,以至于一些合并有COPD或低肺功能的老年肺癌患者不能够耐受肺叶切除手术。     

False-Negative Results in Lung Cancer Screening—Evidence and Controversies

Identifying false-negative cases is an important quality metric in lung cancer screening, but it has been infrequently and variably reported in previous studies. Although as a proportion of all screening participants, false-negative cases are uncommon, such cases may constitute a substantial proportion of all lung cancers diagnosed (up to 15%) within a screening program.This article reviews the impact and causes of false-negative lung cancer screening tests, including those related to radiologic evaluation, nodule management protocols, and management decisions made by multidisciplinary teams. Following a review of data from international screening studies, this article discusses the controversies within the screening literature surrounding the definition and classification of a false-negative lung cancer screening test and how data on false-negative rates should be captured and recorded. Challenges, such as avoiding overly cautious surveillance of lung nodules while minimizing overdiagnosis and investigation of indolent or benign lesions, are considered. Finally, the advantages and disadvantages of different approaches to dealing with false-negative results in lung cancer screening are discussed.     

Physicians' Knowledge and Practice of Lung Cancer Screening: A Cross-Sectional Survey Comparing General Practitioners,Thoracic Oncologists,and Pulmonologists in France

BackgroundScreening for lung cancer by low-dose computed tomography scan (LDCTS) has been demonstrated to reduce lung cancer–specific and overall mortality rates in high-risk individuals. From trial to clinical practice, it is crucial to obtain an accurate level of knowledge of the physicians who will recruit patients for a screening program. The actual current practice and knowledge of practitioners are unknown. This could be critical to develop dedicated continuous medical education programs.Materials and MethodsThree groups of French physicians—pulmonologists (PUs), thoracic oncologists (TOs), and general practitioners (GPs)—were surveyed through a dedicated questionnaire on lung cancer screening.ResultsA total of 242 physicians answered the questionnaire; 81% of TOs knew that LDCTS showed efficacy for screening lung cancer compared with 52% of PUs and 18% of GPs (P < .0001). Approximately one third of physicians recommended lung cancer screening in daily practice at the time of the survey, including 53% of PUs, 34% of TOs, and 20% of GPs (P < .001). However, 94% of GPs, 44% of PUs, and 33% of TOs used inappropriate tests, mainly chest radiography. Most GPs proposed screening for all smokers, whereas PUs and TOs reserved screening for heavy smokers (P = .040). Most PUs and TOs recommended annual LDCTS (76%), whereas the majority of GPs sent patients for screening tests every 3 to 5 years (93%; P < .0001).ConclusionsThese results highlight the interest of physicians for lung cancer screening; meanwhile, our data stress the need for appropriate medical education and recommendations based on available evidence.     

多层螺旋CT在早期肺癌筛查中的临床应用价值

目的 探讨多层螺旋CT扫描技术在早期肺癌筛查中的临床价值.方法 选取早期肺癌患者160例,进行多层螺旋CT扫描诊断,观察CT片中患者肺部轮廓及病灶扫描图像,将CT诊断结果与病理检查结果比较,研究多层螺旋CT扫描技术在早期肺癌筛查中的准确率.结果 多层螺旋CT扫描能清晰显示患者胸部各叶细节结构,肺部轮廓、病灶形状等.160例早期肺癌患者中,经过多层螺旋CT扫描诊断确诊151例,准确率为94.37％,与病理检查结果相比较,差异无统计学意义(P＞0.05);72例周围型肺癌患者中,确诊71例,准确率98.61％;88例中央型肺癌中,确诊80例,准确率为90.90％.多层螺旋CT诊断周围型肺癌、中央型肺癌准确率差异有统计学意义(P＜0.05).结论 多层螺旋CT扫描技术下,肺部组织轮廓、病灶显示清晰,在早期肺癌筛查中准确率较高,值得推广使用.但在中央型肺癌早期筛查时漏诊率相对较高,需要采用病理检查等其他方式辅助诊断,提高准确率.     

New Subsolid Pulmonary Nodules in Lung Cancer Screening: The NELSON Trial

Introduction

Low-dose computed tomography (LDCT) lung cancer screening is recommended in the United States. While new solid nodules after baseline screening have a high lung cancer probability at small size and require lower size cutoff values than baseline nodules, there only is limited evidence on management of new subsolid nodules.

Micronodules Detected on Computed Tomography During the National Lung Screening Trial: Prevalence and Relation to Positive Studies and Lung Cancer

IntroductionIn the National Lung Screening Trial (NLST) all cases with a 4-mm nodule (micronodule) and no other findings were classified as a negative study. The prevalence and malignant potential of micronodules in the NLST is evaluated to understand if this classification was appropriate.Methods and MaterialsIn the NLST a total of 53,452 participants were enrolled with 26,722 undergoing low-dose computed tomography (CT) screening. To determine whether a micronodule developed into a lung cancer, a list from the NLST database of those participants who developed lung cancer and had a micronodule recorded was selected. The CT images of this subset were reviewed by experienced, fellowship-trained thoracic radiologists (R.F.M., C.C., P.M.B., and D.R.A.), all of whom participated as readers in the NLST.ResultsThere were 26,722 participants who underwent CT in the NLST, of which 11,326 (42%) participants had at least one CT with a micronodule. Five thousand five hundred sixty (49%) of these participants had at least one positive CT examination, of which 409 (3.6%) subsequently were diagnosed with lung cancer. Of the 409 lung cancer cases with a micronodule recorded, there were 13 cases in which a micronodule developed into lung cancer. Considering the 13 cases, they represent 1.2% (13 of 1089) of the lung cancers diagnosed in the CT arm of the NLST and 0.11% (13 of 11,326) of the total micronodule cases. Additionally they represent 0.23% (13 of 5560) of the micronodule and at least one positive CT examination cases and 3.2% (13 of 409) of the micronodule cases diagnosed with lung cancer. The average size of the nodule at baseline (recorded as maximum diameter by perpendicular diameter) was 3.0 × 2.5 mm (ranges 2 x 4 mm and 2 x 4 mm) and at the positive CT the nodule was 11.1 × 8.6 mm (ranges, 6 x 20 mm and 5 x 14 mm); a difference of average change in size of 8.1 × 6.1 mm. The average number of days from first CT with a micronodule recorded to positive CT was 459 days (range, 338 – 723 days), the mean time from first CT with micronodule to lung cancer diagnosis was 617 days (range, 380 – 1140 days) and the mean time from positive CT to lung cancer diagnosis was 160 days (range, 18 – 417 days). Histologically, there was one small cell carcinoma and 12 non–small cell with stages of IA in 8 (62%), stage IB in 2 (15%), and 1 each stage IIIA, IIIB, and IV. The overall survival of NSCLC cases with a micronodule was not significantly different than the survival of the CT subset diagnosed with NSCL (p = 0.36).ConclusionsMicronodules are common among lung cancer–screened participants and are capable of developing into lung cancer; however, following micronodules by annual CT screening surveillance is appropriate and does not impact overall survival or outcome.     

238 例女性肺癌纤维支气管镜检查的早期诊断探讨

目的:分析女性肺癌的诊断方法和危险因素,探讨早期肺癌诊断的途径。方法:收集2005年1 月至2008年12月本院呼吸内科纤维支气管镜（纤支镜）检查病例238 例,结合临床资料分析比较纤支镜下肺癌表现与临床影像学表现、女性罹患肺癌的主要危险因素及病理类型的关系。两组资料比较采用χ2检验。结果:年龄49岁以下组腺癌为主要病理类型,60岁以上组鳞癌为主要病理类型。纤支镜下表现分为增生型、浸润型、外压型、正常型。其中增生型与鳞癌相关,影像学表现以肿块为主,主要危险因素为吸烟;浸润型与腺癌相关,影像学表现以胸腔积液为主,主要危险因素为室内油烟吸入。结论:对长期接触室内油烟和烟草暴露女性,尤其存在多项危险因素的女性应该定期进行低剂量CT（LDCT）筛查,发现异常及时行纤支镜检查和组织细胞学检查是确诊早期肺癌的有效途径。      

低剂量螺旋CT对肺癌高危人群早期筛查的临床研究

目的 探讨低剂量螺旋CT对筛查早期肺癌的临床价值.方法 回顾性分析7052例肺癌高危人群分别接受DR胸片及低剂量螺旋CT肺部扫描的影像学资料.结果 7052例肺癌高危人群受检者经低剂量螺旋CT扫描,共筛查出肺结节共1527例,其中经病理确诊肺癌共96例,肺癌总体检出率为1.36%,高于DR的检出率(0.52%),差异具有统计学意义(P<0.05).结论 低剂量螺旋CT能够提高肺内非钙化结节的检出率,对早期诊断肺癌具有重要的临床价值.