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How to judge the appearance of ground glass nodules in the lungs?

 Last Update: 2021-09-29
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Primary lung cancer (referred to as lung cancer) is common worldwide, currently one of the highest cancer incidence and mortality, is divided into non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) Clinically, NSCLC proportion It is as high as 80-85%, and about 70% of patients are locally advanced or late at the time of diagnosis
.

Lung adenocarcinoma is the most common histological type of NSCLC, accounting for more than 50%.

Figure 1 There are ground glass nodules in the lungs with unclear peripheral edges

Ground-glass nodules are pathologically closely related to lung adenocarcinoma.
So, does CT show that ground-glass nodules must be lung adenocarcinoma?

1.
What is a "ground glass nodule"?

1.
What is a "ground glass nodule"? 1.
What is a "ground glass nodule"?

Ground-glass nodule (GGN) is a focal cloud-like density increase in the lung, including lesions with clear and unclear boundaries, but can show the texture of blood vessels and bronchus.
This is a typical chest CT The image is called a ground glass nodule, which is like a piece of ground glass over the lung tissue
.

Pathological manifestations include thickening of alveolar walls, collapse of alveolar cavity, decreased air content, and the appearance of cells, exudate and tissue fragments

Ground-glass nodule (GGN) is a focal cloud-like density increase in the lung, including lesions with clear and unclear boundaries, but can show the texture of blood vessels and bronchus.

In recent years, with the widespread development of chest computed tomography (CT) examinations, more and more asymptomatic ground-glass nodules in the lung have been discovered
.

The characteristics of the affected population are East Asians, non-smokers, females and younger age

In recent years, with the widespread development of chest computed tomography (CT) examinations, more and more asymptomatic ground-glass nodules in the lung have been discovered

GGN is a non-specific imaging manifestation.
Both benign and malignant lung lesions can be shown as ground glass nodules on chest CT, which can be seen in atypical adenomatous hyperplasia and adenocarcinoma, including carcinoma in situ and microinvasive carcinoma , And benign lesions such as inflammation, local hemorrhage and pulmonary fibrosis
.

It can be seen that there are malignant and benign lesions of ground glass nodules in the lung, which means that ground glass nodules do not represent lung cancer

GGN is a non-specific imaging manifestation.

Since GGN is closely related to early lung cancer, its differential diagnosis and treatment are particularly important
.

2.
Differentiation of benign and malignant lung "ground glass nodules"

2.
Differentiation of benign and malignant “ground glass nodules” in lung 2.
Differentiation of benign and malignant “ground glass nodules” in lung

CT is the preferred method of displaying GGN
.

For the differentiation of benign and malignant GGN, it is necessary to make a correct diagnosis and comprehensive analysis based on the size, shape, margin and tumor-lung interface of the nodule, the characteristics of the internal density of the nodule, the characteristics of the internal structure, the structure around the tumor, and the follow-up observation of the lesion.

CT is the preferred method of displaying GGN

1.
Nodule appearance evaluation

1.
Nodule appearance assessment 1.
Nodule appearance assessment As the volume of the nodule increases, the probability of malignancy or infiltration of GGN increases; the overall shape of most malignant GGNs is round or quasi-circular, and the edges of the nodules are mostly divided.
Leaf-shaped, or with burr sign (also known as spinous protrusion), nodules have clear but irregular edges, and the tumor-lung interface is clear, rough and even burrs
.

2.
Internal features of nodules

2.
Internal features of nodules .
2.
Internal features of nodules .
High GGN density and unevenness indicate a high possibility of malignancy; most of the persistent GGNs are malignant or have a tendency to develop malignantly
.
The average CT value of GGN is of great value for differential diagnosis.
High density has a high probability of malignancy, and low density has a small probability of malignancy.
At the same time, it needs to be combined with nodule size and morphological changes to make a comprehensive judgment
.

3.
About enhancement

3.
Regarding enhancement 3.
Regarding enhancement, CT enhancement scan is generally not recommended for pGGN, while mGGN, nodules that are closely related to pulmonary blood vessels or suspected of lymph node metastasis are recommended for chest CT enhancement scan
.

4.
Follow-up of lesions

4.
Lesion follow-up 4.
Lesion follow-up Regular follow-up comparison of the external and internal features of the nodule is also of great significance for the diagnosis of benign and malignant
.
When (1) GGN increases, (2) GGN is stable and the density increases, (3) GGN is stable or increases and presents a realistic component, (4) GGN decreases but the solid component increases, (5) GGN has glitches , Lobes or pleural depression, suggesting malignant GGN
.
Figure 2 Invasive adenocarcinoma of the left lower lobe of the left lung, the lesion showed irregular GGN manifestations, with clear borders, with burrs and lobular signs .
Figure 2 The invasive adenocarcinoma of the anterior segment of the right left upper lobe of the lung, showing irregular GGN manifestations in the axial view, with clear borders.
There are signs of lobules and pleural depression.
3.
Should “ground glass nodules” be found immediately for surgery? 3.
Do you need immediate surgery if you find "ground glass nodules"? The Cardiothoracic Group of the Radiology Branch of the Chinese Medical Association formulated the "Expert Consensus on Image Processing of Subsolid Lung Nodules".
The consensus proposes that GGN can be processed only after the probability of malignancy is estimated.
Consider the three categories of benign GGN and difficult-to-identify pulmonary nodules .
1.
Consider malignant GGN 1.
Consider malignant GGN .
Malignant GGN with greater power should be surgically removed as soon as possible; GGN with low power but prone to malignancy can be followed up for 3 months.
If the CT appearance of persistent pGGN is lobulated Surgical resection is recommended for frizzy edges, uneven internal density, or vacuole signs; surgical resection is recommended for no change or increase in mGGN follow-up .
2.
Consider benign GGN 2.
Considering benign GGN, it is recommended to review after 3 months; if the patient is severely anxious, anti-inflammatory treatment can be performed under the guidance of a doctor, and follow-up after review after 1 month .
3.
Difficult pulmonary nodules 3.
Follow-up observation is recommended for difficult pulmonary nodules .
The specific follow-up principles need to be determined based on the size of the nodule, CT signs and dynamic changes .
(1) For isolated pGGN with a diameter of ≤5mm, follow-up is continued until it disappears.
If the nodule becomes larger and the density becomes larger, surgical resection is considered .
(2) Isolated pGGN with diameter> 5mm, long-term follow-up

.
If there is a pGGN with a diameter> 10mm, an average CT value> -600HU, with a lobulated appearance and a vacuole sign inside, it is considered malignant and surgical resection is recommended
.
(3) For isolated mGGN, follow-up review until it disappears; if the nodule is unchanged or enlarged, it is considered malignant and surgical resection is recommended
.
(4) For pGGN with multiple occurrences and clear boundaries, a conservative plan will be adopted to continue follow-up until the nodules disappear.
If the nodules increase, enlarge, or become denser, consider local surgical resection of the lesion with obvious changes
.
(5) For multiple GGN with prominent lesions, follow-up 3 months after the first examination.
If malignant signs appear, local surgical resection is recommended
.
In short, the discovery of ground-glass lung nodules must undergo a comprehensive analysis of imaging performance and make a correct diagnosis and give the correct treatment, which is of great significance for reducing the burden on patients and improving the prognosis
.

references:

1.
Jiang Gening, Chen Chang, Zhu Yuming, et al.
Shanghai Pulmonary Hospital: Consensus on the diagnosis and treatment of ground-glass nodules in early lung adenocarcinoma (first edition).
Chinese Journal of Lung Cancer, 2018, 21(3): 147-159.
] doi :10.
3779/j.
issn.
1009-3419.
2018.
03.
05

2.
Ji Yu, Li Desheng, Zhang Haiping, et al.
Multivariate logistic regression analysis for the discrimination of benign and malignant ground glass density shadows in the lung[J].
Journal of Clinical Pulmonology, 2016(7): 1313-1317.

3.
Cardiothoracic Group of Chinese Medical Association Radiology Branch.
Expert consensus on image processing of subsolid lung nodules[J].
Chinese Journal of Radiology, 2015, 49(004):254-258.

4.
Du Fenghua, Min Xuhong, Mei Xiaodong.
Application and drug resistance mechanism of targeted therapy drugs for lung adenocarcinoma[J].
Journal of Clinical Pulmonology, 2018, 23(1)

5.
Lung Cancer Group, Chinese Association of Respiratory Diseases, Expert Group of China Alliance for Lung Cancer Prevention and Treatment.
Chinese Expert Consensus on the Diagnosis and Treatment of Lung Nodules[J].
Chinese Journal of Tuberculosis and Respiratory, 2015, 38(004):249-254.

Image Source:

1.
Wu Guiquan, Jiang Tianqiang, Yang Caiying.
Study on CT imaging manifestations and differential diagnosis of 64 patients with ground glass density nodules in lung[J].
Chinese Journal of CT and MRI,2021,19(09):48-50.

2.
Zhou Guoping, Zhu Bin, Wang Lan, Wang Xiaoling.
The application value of multi-slice spiral CT three-dimensional reconstruction technology in the differential diagnosis of ground-glass density nodular lung cancer[J].
Zhejiang Traumatic Surgery,2021,26(04):767-769.

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