Jinhua’s A is my classmate’s eldest sister. A few days ago, because the classmate’s lover found out that lung nodule was an early stage lung cancer, her sister remembered that she also found a lung nodule 2 years ago, but I haven't reviewed it, and I'm afraid I might get lung cancer, so I came to my clinic for a review. Let’s take a look at the CT images of her plain scan:
The posterior ground glass nodule of the right upper lobe of the upper lobe
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img and high density
see not only the whole edge, it seems fine burrs
overall outline clear
has microvascular signs
There is a slight stretch in the chest cavity
the lesion is not comfortable from the small span 1span scanMost likely it is malignant. Let's look at other small nodules in her other parts:
There is another ground glass nodule in the posterior segment of the upper lobe, about 5-6 mm, low density, tumor lung border clear, consider dysplasia or adenocarcinoma in situ is likely, but the current risk is low
There is also a tiny nodule in the posterior right upper lobe, about 1-2 mm, of low density High, the tumor lung boundary is clear, considering the possibility of adenocarcinoma in situ, the current risk is low
So what about the details of the further target scanning of these 3 nodules?
The main lesion is ground glass, but there are obvious blood vessels entering the lesion (orange arrow)
img It is clear that
has obvious leaf signs (brick-colored arrows) and ground glass components (green arrows) and solid components (pink arrows) _p117p _p117p The above figure also shows that the lesion has obvious lobular signs (brick arrow), ground glass component (green arrow) and solid component (pink arrow)
The density is messy and the outline is clear
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The figure above shows that the microvessels have vascular curvature, which is not clear from the lesion, and the solid component is relatively high
The post-processed and reconstructed image shows clearer information, showing the main lesion (hereinafter referred to as lesion A) lobes (brick arrow) and ground glass (green arrow) ) And solid components (pink arrows)
The lesion is adjacent to the pleura, and the density is disordered
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Stretching (blue arrow)
3D reconstruction shows that the lesion is round and round
0 span1 span Called B lesions) still show light ground glass nodules,At most it is adenocarcinoma in situ, and the possibility of dysplasia is high
. Another lesion (referred to as lesion C below) is shown above, and the density is high, which may be adenocarcinoma in situ , It may also be micro-invasive adenocarcinoma. If a single such lesion is not necessarily malignant, but because there are A and B lesions, the lesion is also very likely to be malignant. If it is malignant, the density is higher than that of the B lesion, and the risk is slightly higher than that of the B lesion.
In summary, the risk of disease Xuan A is high, basically it should be invasive adenocarcinoma, because it is so small, it is mixed ground glass, and the solid component is relatively high, so it may be at least acinar type Mainly (may also contain higher-risk subtypes) with adherent components (because of ground glass components, although the proportion is small); B lesions are considered to have a high possibility of dysplasia, and adenocarcinoma in situ cannot be ruled out. If there is no A in , It can be followed up safely; C lesions are considered at least in situ adenocarcinoma, and may also be micro-invasive adenocarcinoma because of the higher density. If the disease is A, it is too young and can be followed up. Fortunately, the three lesions are in the posterior upper lobe, so if the posterior upper lobe resection is done, all the current lesions can be resolved at one time. So I recommend that it be operated on as soon as possible. The purpose of sharing this case today is not here, but we will watch her film 2 years ago to see the evolution of the lesion and give us thoughts. Let’s take a look at the film 2 years ago:
The lesion A shown above was very light, with a triangular shape and blurry edges. It was actually more like a local inflammatory lesion.
The picture above is lesion B. Compared with this year, there is no big change. The diameter and density contours are similar, indicating that the lesion is more stable.Relatively indolent
The above picture shows the C lesion, which is also a small nodule, and there is no obvious change.
was performed by another hospital in the city at that time. The imaging report at that time only mentioned a ground glass nodule about 5 mm in the upper right lobe. The description did not mention the other two lesions. I suspect that it was only concerned at the time. The lesion was B lesion. After the patient moved in, we performed a "single-port thoracoscopic resection of the posterior right upper lobe plus lymph node sampling" after preoperative preparation. The following is the postoperative pathology report:
Because the lesion B was too light and the lesion C was too small, we did not find the specimen for a long time. Because I was sure that they were all in the back section, I did a back section resection anyway, so I didn't continue to look for it. It is not surprising that lesion A is invasive adenocarcinoma, but it is a little surprising that it contains micropapillary components! At that time, it was easier to explain afterwards that the lesion developed from such a thin, tiny ground glass nodule, and more like a benign lesion, to a typical invasive adenocarcinoma within 2 years.
This case brings us a lot of thinking:
1. The guide always tells us that lung nodules smaller than 5 mm (and some smaller than 6 mm) do not need follow-up: First, the Fisher guide That's how it is said, and it is also copied by the domestic guide. But is it really unnecessary? I have always opposed it. There should be no nodules in the lungs. Isn't it abnormal to find nodules smaller than 5 mm? Shouldn't tumors grow from small to large? It’s hard to be 3 centimeters as soon as it comes out,No follow-up is obviously unscientific (although they are all evidence-based, they are all true science). The development process of the A lesion in this case tells us that even small, light, inflammatory lung nodules must be followed up! If the interval does not need to be 3-6 months, it can be once a year or every two years, then listen to it. If this case was not because of her sister's operation, she would not follow-up for reexamination, and come back to see if she had symptoms a few years later, the consequences would be disastrous! (Click on the link to my previous point of view: (1) So many lung nodules follow-up guidelines, who should I listen to? (2) Small lung nodule follow-up guidelines); : According to the principle, lesion A is still ground glass nodule, and it is so small. Although the solid component feels a little too much, it is not too dense. The typical solid component is only higher than ground glass, but more solid than completely solid. Still low. I don’t know whether according to the current lung cancer treatment guidelines, it is considered that the actual proportion is greater than 50% or less than 50%, because clinical ambiguities are often encountered, and the guidelines cannot be fully applied. If this kind of lesion is wedge-cut first, and it is reported as invasive adenocarcinoma, do you need to cut the lobe again? We performed segmental resection, which is a compromise operation. Intraoperative freezing is reported as invasive adenocarcinoma, and there is no specific subtype. The phone said there was a little micropapillary component. However, paraffin pathology reported that micropapillae accounted for 5%. For this type of classification, is lung segment enough? Do I need to have another lobectomy? According to my personal understanding, we carried out sampling of lymph nodes and collected 10 lymph nodes, all of which were negative. Groups 10-12 have been collected, and the mediastinal lymph nodes also have groups 4 and 7. What may be missed are groups 8 and 9 that were not sampled. However, because the tumor is small and it is in the upper lobe, the lymph nodes in the lower mediastinum do not necessarily need to be removed. Of (Japanese Studies). In addition, there is dissemination in the lungs, and it has to be disseminated to parts other than the posterior segment at a long distance, before it may be different from lobectomy. So I think the lung segment is enough. Of course, if the collected lymph nodes are positive, that is another matter. What do you think of teachers?
3. Because it contains high risk factors,Micropapillary subtype accounts for 5%. Do you need adjuvant treatment after surgery? This is also a question. According to the current guidelines for postoperative adjuvant treatment of lung cancer, stage Ia certainly does not require postoperative adjuvant treatment, but the guidelines do not distinguish whether there are high-risk factors As well as pathological subtypes, they are differentiated in stage Ib. EGFR-negative patients have high-risk factors that can be treated with postoperative adjuvant chemotherapy , and positive postoperative TKI treatment. Of course, the proportion of micropapillae in this case is only 5%, and it may in fact not require postoperative adjuvant treatment. But I was thinking, what if the micropapillary type is the main type? Do we need postoperative adjuvant treatment?
4. Whether the multiple nodules in the lung are multiple primary or spread and metastasis in the lung: In this case, the A lesion is the main lesion and contains high-risk subtypes. Whether the B and C lesions should be considered as lung The possibility of internal transfer or dissemination? Cheng Ran, because the lesions are small or weak, we did not specifically target the pathological results of lesions B and C, but individual analysis should consider multiple primary cancers. One is because the main lesion was too small 2 years ago, and there are no women who are under adulthood. , Just gave birth to a baby? Second, the pathological types of the other two lesions were examined from the image, and at most they were slightly infiltrated, and they were probably just adenocarcinoma in situ and dysplasia. But this is still an aspect that needs to be considered, especially if this is the first time this year, there is no comparison of the film two years ago.
So, I think: 1. As long as lung nodules are found, they have to be followed up . Thinking is going to happen; 2. Patients in stage Ia do not need adjuvant treatment after surgery. It is recommended to consider subtypes and development speed. Squamous cell carcinoma and adenocarcinoma should also be distinguished, not just non-small cell lung cancer is so general; 3. In the design of multiple nodules surgery, we must pay attention to preserving as much lung function as possible.You can't just follow the guidelines thoroughly, excessively and rigidly. Just like this example, in fact, the probability that she will develop new lung nodules in the future is quite high. She is only 51 years old. How will she grow in the future? Now that 3 nodules have been found, why do you think it is impossible for her to grow a fourth? Even the 5th, 6th, and 7th?
The number of multiple lung nodules and multiple primary lung cancers is increasing. The test is whether our doctor’s concept can keep up with the times. The update of guidelines and norms really needs to speed up the follow-up, clinical experience It is also very important. After all, if you have to promote evidence-based evidence, it is too slow! Time does not wait for me! ! !
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