Abstract: Objective To investigate the imaging features, staging and its diagnostic value of pneumonia-type lung cancer. Methods The clinical, pathological and serial imaging data of 30 cases of pneumonia-type lung cancer confirmed by bronchoscopic biopsy, puncture biopsy, open lung biopsy and surgery were retrospectively analyzed, and their imaging features were summarized, and they were staged according to imaging morphology, and their application values in imaging diagnosis were evaluated. Results Among the 30 cases of pneumonia-type lung cancer, 21 cases were fine bronchoalveolar carcinoma and 9 cases were adenocarcinoma. The imaging manifestations were divided into 6 types: simple ground glass density shadow in 2 cases, coexistence of ground glass density shadow and nodules in 5 cases, solid shadow in lobes and lung segments in 5 cases, solid shadow in lobes or lung segments with vacuolation and honeycomb in 8 cases, solid shadow combined with fibrosis and mass in 6 cases, and mixed shadow in 4 cases. The dynamic changes in the imaging of lung cancer with pneumonia were as follows: (1) the scope of lesions gradually expanded; (2) the morphology of lesions gradually progressed from simple ground glass shadow or solid shadow to combined nodules, fibrosis, honeycomb and mass; (3) cancerous lymphangitis, mediastinal lymph node metastasis and distant metastasis could even appear. Conclusion The imaging pattern of pneumonia-type lung cancer can be various, and when it is manifested as simple ground glass shadow or lobe lung segment shadow, the diagnosis is more difficult; however, its dynamic imaging performance has certain characteristics, which reflects its pathological change process to a certain extent, and when the lesion develops into solid lesion combined with vacuole, fibrosis, honeycomb or even mass, its imaging performance is more characteristic, which can suggest the diagnosis when combined with clinical. Lei Zhidan, Department of Radiology, Henan Provincial People’s Hospital
Keywords: pneumonia type lung cancer; imaging diagnosis; pathology; application study
The imaging types of pneumonia type carcinoma of lung and the imaging diagnostic clinical value
LEI Zhi-dan, JIA Wu-lin, REN Ying, SHI Da-peng, WEN Ze-jun, MA Xi-tao
(Department of Radiology, the People’s Hospital of Henan Province, Zhengzhou 450003, China)
Abstract: Objective To discuss the image features and the imaging types of pneumonia type carcinoma of lung(PTCL), and investigate it’s Methods The clinical, pathological and serial imaging materials of 30 cases’ PTCL which were proved by bronchoscopic biopsy or aspiration biopsy The clinical, pathological and serial imaging materials of 30 cases’ PTCL which were proved by bronchoscopic biopsy or aspiration biopsy or open-lung biopsy were retrospectively analyzed. The PTCL were divided into six kinds of types and the clinical application of imaging diagnosis were investigated. The major imaging features of PTCL were①2 cases’ PTCL showed as simple ground-glass opacities.②5 patients coexisted ground-glass opacities and nodes.③5 cases were found with simple pulmonary ③5 cases were found with simple pulmonary segmental and pulmonary lobar consolidations.④8 cases’ PTCL had not only pulmonary segmental and pulmonary lobar consolidations but also vacant vesicle and honeycomb shadows.⑤6 cases’ patients were found with consolidations, fibroses and masses.6 4 cases The features of it’s imaging morphologic dynamic changing were①the range of shadows was gradually expanded. ②the types of PTCL were progressed from ground-glass opacities or consolidations to nodes, fibroses, honeycomb The types of PTCL were progressed from ground-glass opacities or consolidations to nodes, fibroses, honeycomb shadows and masses. The diagnosis is very hard when it express simple ground-glass opacities or simple consolidations. But the imaging morphologic dynamic changing of PTCL possess relative imaging feature. When it expresses vacant vesicles, nodes, fibroses, honeycomb shadows and masses, it’s imaging feature is relative typical. In combination with clinical materials, the PTCL can be diagnosed.
Key words: pneumonia type carcinoma of lung; imaging diagnosis; pathology; applied studies.
pathology ; applied studies
Pneumonia type carcinoma of the lung (PTCL) is not rare, but it has been poorly reported in China [1-4], and its imaging resemblance to pneumonia and lack of clinical specificity make the diagnosis difficult [5]. We collected 30 cases of PTCL with complete imaging, clinical and pathological data from 1997 to 2006 and conducted a retrospective comprehensive analysis, aiming to investigate the basis of imaging staging, morphological features of each type, dynamic changes and the diagnostic value of staging on PTCL, so as to improve the correct diagnosis rate of this disease.
1 Data and methods
Among the 30 cases of PTCL, 4 cases were associated with emaciation, poor appetite, and hyperemesis. The physical examination of 13 cases could be heard in wet stalls and 5 cases could be heard in Velcro woven J flute maple a frightened ESR: 66~85mm/h, CEA was positive in 5 cases. Pulmonary function tests 7 cases had mild restrictive ventilation disorders.
1.2 Imaging methods All 30 cases had X-ray chest films, CT and HRCT imaging data, of which 26 cases had serial imaging data. The conventional X-ray machine and Direct View CR 950 system from KODAK were used for chest radiography, and the CT machine was Shimadzu S8000 conventional CT and GE Light speed 4.0 multilayer spiral CT. 10 mm layer thickness and layer spacing were used for conventional CT in 6 cases, and 2 mm layer thickness and 10 mm layer spacing were used for high-resolution scanning in 3 of them. 21 cases had both plain and spiral CT. All the spiral CT cases had both plain and HRCT examinations. The plain layer thickness was 7.5 mm, the pitch factor was 1.5:1, the reconstruction interval was 5 mm, the standard algorithm reconstruction, the matrix was 512×512, the range was from the entrance of the thorax to the base of the lung, and the lung window and the mediastinal window were observed.
1.3 Analysis method Three experienced radiologists carefully analyzed the various signs of 30 cases of PTCL and summarized and analyzed them, then compared the imaging manifestations of 7 cases of open lung biopsy and 11 cases of surgical PTCL with their pathological and clinical data with respiratory and pathologists to discuss their imaging characteristics and the value of clinical application of imaging diagnosis.
2 Results
2.1 Site and extent of lesions Lesions were divided into limited and diffuse distribution, located in each segment of the left and right lung lobes, respectively, and the specific manifestations are shown in Table 1.
Table 1 Distribution characteristics of 30 cases of PTCL (cases)
Purely ground glass Ground glass density shadow Single lung lobe or lung lobe, lung segment solid lesion Solid lesion and mixed
Glass density shadow Coexisting with nodules Segmental solid shadow With vacuoles and honeycomb masses Shadow
Restricted distribution 1 5 4 6 6 3
Diffuse distribution 1 0 1 2 0 1
2.2 Imaging characteristics of lesion morphology According to the morphological characteristics of PTCL images, there were 6 types of lesions, namely: (1) 2 cases of simple ground glass density shadow [Figure 1a, Figure 1b], which showed a limited distribution of lamellar, large lamellar and diffuse distribution of mildly increased density shadows with blurred edges, and the blood vessels and bronchi within the shadow were not covered. (2) The coexistence of ground glass density shadow and nodules in five cases was characterized by higher density central lobar nodules, alveolar nodules and interstitial nodules within the ground glass density shadow [Figure 2a, Figure 2b]. (3) Five cases of solid shadows in lobes or lung segments alone [Figure 3a, Figure 3b] were mainly solid shadows distributed along lobes and lung segments, with higher density than ground glass shadows, obscuring blood vessels and bronchi with irregular morphology, and partially negative and partially positive tumor-lung interface signs. (4) Eight cases of solid lung lobes and segments with vacuolation and honeycomb, showing vacuolation and honeycomb shadows within solid shadows. (5) Six cases of PTCL had solid lesions combined with fibrosis and masses in the lungs [Figure 4a, Figure 4b, Figure 4c], which showed soft tissue masses within solid shadows, with fibrous cords located at the edges of the masses or around the solid shadows. (6) Four cases of mixed shadows showed the coexistence of four or more of the above shadows.
2.3 Dynamic changes of lesions Among the serial imaging data of 26 cases of PTCL, 21 cases had CT examinations 1, 3 and 6 months after the onset of the disease, and 5 cases had only 1 CT and chest film review 1, 3 and 6 months after the onset of the disease. (1) Lesion extent: The extent of limited lesions in 15 cases had different degrees of enlargement, among which the progression of simple ground glass density shadow and solid shadow was significant. (2) Morphology of lesions: Among the 21 cases in the series of CT data, the morphology of PTCL was changed in 19 cases, in order of progression from simple ground glass density shadow, ground glass density shadow with nodule, simple solid shadow in lobe lung segment, solid shadow in lobe lung segment with vacuole and honeycomb to ground glass density shadow combined with nodule, simple solid shadow, solid shadow with vacuole and honeycomb, solid shadow with fibrotic mass and mixed shadow. (3) Lymphatic metastases: Among the CT follow-up cases, cancerous lymphangitis was seen in 5 cases, and hilar and/or mediastinal lymph node metastases were seen in 3 cases. (4) Other metastases: among 21 cases of PTCL with serial CT data, 3 cases had pleural metastases, 1 case had chest wall metastases, and 1 case had pericardial metastases.
2.4 Pathological manifestations of lesions (1) Two cases with simple ground glass density shadow and five cases with ground glass density shadow with nodules had been misdiagnosed as interstitial pneumonia and underwent open lung biopsy. The pathological manifestations were as follows: (1) in the case of simple ground glass density shadow, the cancer cells grew along the alveolar wall and the mucus secreted by them partially filled the alveolar cavity, and the growth of the cancer cells along the alveolar wall caused irregularity in the alveolar cavity; (2) in the three cases of ground glass density shadow with nodules, the pathological changes of ground glass density shadow were the same as those of simple ground glass density shadow, while the nodules were completely filled with cancer cells or mucus in the center of the lobules and alveolar cavity and the growth of cancer cells in clusters in the interval. (2) Two patients with biopsy-confirmed solid shadows in simple lung segments, two patients with solid lung segments with vacuoles and honeycombs, four patients with solid combined with fibrosis and masses, and three patients with mixed shadows were operated on. The postoperative pathological manifestations were as follows: (1) the mucus secreted by the cancer cells and cancer cells in the solid shadow of simple lung segments mostly or completely filled the alveolar lumen and spread along the alveolar pores and fine bronchi. The pathology of four cases of solid lesions with fibrosis and masses was that, in addition to mass-like tumor tissue, the air cavity around the masses was mostly or completely filled with cancer cells, mucus and blood cells secreted by cancer cells, and obvious fibroplasia was seen; (4) In addition to the above pathological changes in three cases of mixed shadows, one case was seen to have inflammatory exudate around the lesion. In addition to the above pathological changes, one case had inflammatory exudate around the lesion, and the other case was filled with blood cells.
3 Discussion
3.1 Imaging manifestations and staging of PTCL PTCL refers to lung cancer that is mainly manifested by lobe and segmental shadows and ground glass density shadow on imaging, and is a special form of peripheral lung cancer [1. 2]. According to the imaging manifestations, Xie Min [3] classified it into three types, and such classification has a certain role in clinical work. However, with the widespread clinical use of spiral CT and HRCT, it is easier to show occult site lesions, subtle lung lesions and ground glass density shadow, thus further understanding of the imaging manifestations of PTCL is needed. At the same time, a more scientific staging is urgently needed as the clinical study of PTCL is further deepened. By analyzing and summarizing the X-ray, CT and HRCT data of 30 cases of PTCL in our group, we believe that the typing of PTCL should be considered in combination with clinical, imaging manifestations, treatment plan and prognosis. The distribution of lesions can be divided into limited and diffuse types, and the imaging pattern should be divided into 6 types, namely, simple ground glass density shadow, ground glass density shadow with nodules, simple solid shadow in lung lobes and segments, solid shadow in lung lobes and segments with vacuoles and honeycomb, solid shadow combined with fibrosis and masses, and mixed shadow type. Therefore, the classification is based on the distribution, morphological changes and dynamic changes of imaging manifestations, which is more suitable for people’s observation and recognition habits, and thus more suitable for clinical diagnosis, treatment work and prognosis.
3.2 Pathological basis of PTCL PTCL is mostly adenocarcinoma and fine bronchoalveolar carcinoma. 21 cases of fine bronchoalveolar carcinoma and 9 cases of adenocarcinoma were found in our group, which is similar to the literature [4]. Xie Min [3] analyzed 14 cases of PTCL and concluded that the cancer cells had three types of growth patterns, i.e., full growth, mural growth, and little full growth with severe interstitial lung damage and infiltration, and the pathology of 7 open lung biopsies and 11 surgical cases in this group revealed that the cancer cells grew along the alveolar wall, filled the alveolar cavity, and grew in clusters in the interval in a manner similar to that reported by Xie Min. However, this could not be a sufficient reason for the “pneumonia”-like change of the tumor. In this paper, we showed that the main reasons for the “pneumonia”-like changes were related to the growth pattern of cancer cells, the growth site, the filling of alveolar cavity by mucus secreted by cancer cells, the proliferation of fibrous tissue, combined bleeding and secondary infection. The main mechanisms are: (i) two cases of ground glass density shadow were closely related to partial filling of alveolar cavity and deformation of alveolar structure [6.7]; (ii) five cases of central lobular nodules and alveolar nodules were complete filling of mucus or cancer cells in the alveoli within the primary lobules and alveoli, and this change was similar to that reported by Jung [7]; (iii) interstitial nodules were related to the growth of cancer cells in clusters within the interstitium; (iv) lobe lung segment shadow was related to The pathological basis was the spread of tumor tissue in the alveolar cavity and the formation of a mass, and the surrounding solid lesions were the result of filling of the alveolar cavity around the mass with cancer tissue, hemorrhage and secondary infection. The above pathological basis is not identical to the mechanism of PTCL described by Ping Li et al [4], which may be related to the different sample sizes studied by both. However, with more in-depth research on PTCL, the mechanism will be more perfect.
3.3 Dynamic changes of PTCL In 26 cases of PTCL with series of imaging data, 18 patients received anti-inflammatory or anti-tuberculosis treatment, but the lesions all had different degrees of expansion, and most of the lesion morphology developed from simple to complex and atypical to typical, in addition, 6 cases had lymph node metastasis, 4 cases had pleural or chest wall metastasis, and 1 case had pericardial metastasis. The characteristics of metastasis were similar to those reported by Run-Ming Li [9]. From the above dynamic changes combined with Akira’s view [10], it can be shown that (1) PTCL should be considered when ground glass shadows progress to ground glass shadows with nodules or to solid shadows, or even to solid plus fovea, solid plus mass, and mixed shadows; (2) PTCL should also be considered when simple solid lesions progress to solid plus fovea, mass, and mixed shadows; (3) when various types of The evolution of the imaging morphology of PTCL reflects, to a certain extent, its pathological progression characteristics.
3.4 Diagnostic significance of PTCL imaging staging and issues to be noted in imaging diagnosis
3.4.1 Diagnostic significance of imaging fractionation Through the imaging morphology and pathology control study of PTCL and the observation of 26 patients’ series data, it strongly indicates that the imaging morphology of PTCL is more diverse, and it is difficult to diagnose purely ground glass shadow and solid shadow, but when ground glass shadow or solid shadow and vacuolation, honeycomb, fibrosis, mass or even mixed shadow, it has certain tumor characteristics If the lesion gradually progresses from simple ground glass shadow or solid shadow to combined nodule, fibrosis, honeycomb and mass, or even cancerous lymphangitis, hilar mediastinal lymph node metastasis or distant metastasis, PTCL can be diagnosed, and biopsy can be recommended for further confirmation. Therefore, combined with its imaging morphological evolution characteristics, it can be considered that the imaging staging of PTCL can more scientifically reflect the imaging characteristics of the lesion at different stages, and provide the right direction for the thinking of imaging diagnosis.
3.4.2 Issues to be noted in imaging diagnosis Because of the difficulty in the diagnosis of PTCL, combined with this study we put forward the following considerations: ① Shi Mulan et al [11] considered that hollow vesicular and foveal shadows within solid shadows and perifocal ground glass shadows are more reliable for the diagnosis of PTCL, so when there are solid shadows with hollow vesicles, foveae and mixed shadows, the diagnosis should be suggested; ② attention should be paid to the short-term follow-up of lesions observation, suggesting the diagnosis as early as possible, the recommended review time is 1, 3, 6 months, preferably within 3 months can be found, and should not exceed 6 months, so as not to delay the disease; ③ imaging examination should be comprehensive, should include X-ray chest film, CT and HRCT, high spatial resolution of ordinary plain film, high density resolution of CT, HRCT shows the fine structure of PTCL better, especially for interstitial changes The combination of the three imaging data can comprehensively reflect the imaging features of PTCL; ④While observing lung lesions, indirect signs should also be observed, such as whether there is enlargement of lymph nodes in the hilum, mediastinum and upper and lower clavicular regions, and whether there are metastatic lesions in the pericardium, pleura and thoracic spine of the chest wall; ⑤When analyzing the imaging features, it is also necessary to consider them in combination with symptoms, signs and laboratory tests, especially In particular, symptoms such as irritating dry cough, blood in sputum and white foamy sputum, as well as laboratory tests such as sputum examination and tumor marker test are more important.
In summary, ground glass density shadow, ground glass density shadow with nodules, solid lung segment shadow, solid lung segment shadow with vacuoles and honeycomb, solid segment shadow combined with mass and fibrosis, mixed coexistence of these shadows and dynamic changes of lesions are the basic imaging features of PTCL, especially solid lung segment shadow with vacuoles and honeycomb, solid segment shadow combined with mass and fibrosis, mixed shadows and dynamic progressive manifestations have characteristics. Combined with the clinical can suggest the diagnosis.
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