A diagram to understand the process of pulmonary nodule diagnosis and treatment
The above diagram is a mind map of the lung nodule management process, based on the comprehensive content of the 2016 Chinese Expert Consensus on Lung Nodules.
Doctor, what should I do if I find a lung nodule?
What should I do if I am told that there are nodules in my lungs after a physical examination? Is a lung nodule lung cancer? Should I follow up regularly or have surgery? Here are 12 common questions from patients, let’s hear how the respiratory doctors answer them!
1. I have been a smoker for a long time, and a month ago a physical examination revealed a small solid nodule in my left lung, about 8 mm, what should I do?
You have a long history of smoking, for your kind of nodules need close dynamic observation, you need to review the chest CT 3 months after the discovery of lung nodules, if they still persist, further PET-CT examination, non-surgical biopsy or surgical treatment is needed.
2.I already had a chest CT at my local hospital, why do I need to have another CT at your hospital?
The CT you had at the local hospital was a normal CT with 10 mm per level, but the CT you had at our hospital was a 256HR CT, also called high-resolution thin-layer CT, with 1 mm per level, which can be seen more clearly and can be reconstructed in three dimensions and multiple planes to understand the morphological characteristics of the nodule and its relationship with the surrounding blood vessels, so as to make a better diagnosis.
3.I have taken a chest CT which indicates a lung nodule, will it become cancer?
The malignant rate of lung nodules is about 20% (i.e., 2 out of 10 people); if a smoking man does not quit smoking in time after finding a lung nodule, the nodule will become malignant 20 times more often than a non-smoker.
4.I took a chest CT indicating that I have a lung nodule, do I have lung cancer?
Not necessarily. CT chest indicates lung nodules, which may be the following diseases.
①Benign tumors: including pulmonary malignancy, adenoma, lipoma, infectious granuloma, pulmonary tuberculosis, pneumosporidiosis, etc.
(ii) benign non-neoplastic diseases: occlusive fine bronchitis with mechanized pneumonia, lung abscess, silicosis, fibrous degeneration, hematoma, inflammatory pseudotumor, pulmonary infarction, etc.
③Malignant tumors: bronchial lung cancer (adenocarcinoma, squamous carcinoma, small cell lung cancer), carcinoid tumor, pulmonary lymphoma.
④Metastatic tumors: colon cancer, breast cancer, kidney cancer, head and neck tumors metastasized to the lung.
5.I had a high-resolution CT that said I have GGO nodules in my right lung, what are GGO nodules?
A pulmonary nodule is a nodular or round-like hyperdense shadow in the lung parenchyma that is less than 3 cm in diameter. Pulmonary nodules are classified into small pulmonary nodules and micronodules based on size; small nodules are nodules less than 1 cm in diameter and micronodules are nodules less than 5 mm in diameter. The size of the nodule correlates with the benignity of the nodule; the smaller the nodule, the more likely it is to be benign, and if the nodule is larger than 3 cm, it is called a mass and is mostly malignant.
Imaging physicians classify nodules into the following three categories according to their different imaging presentations.
① solid nodules, where the nodules are soft tissue dense.
(ii) ground glass nodules (GGO nodules) where the lesions are all ground glass-like in density.
(iii) mixed ground glass nodules, where the lesion is partly soft tissue density and partly ground glass-like density.
The relative proportion of soft tissue nodules that are malignant is high. Most of the mixed ground glass nodules are malignant and a few are benign. Pure ground glass nodules are more benign, some are inflammatory nodules, and some are malignant.
6, I have a 1.5 cm nodule in my right lung. The radiologist said I have a bad nodule and need surgery, I am a little scared, what should I do?
I read your CT film, the lung nodule is not neatly edged, has burrs and shallow lobes, it does tend to be malignant and needs radical surgery as soon as possible. However, you should not be afraid, you can choose the TV thoracoscopic technique of the hospital thoracic surgery, which can complete the removal of nodules through 1-3 small incisions in the chest wall, but because your nodules are relatively small, CT-guided lung nodule localization technique can be used to precisely locate the lesions before removal.
7.Who belongs to the high-risk group of lung cancer?
Generally speaking, those who are over 50 years old and meet at least one of the following risk factors.
①People aged 40 years or older.
②Smokers, including passive smokers.
③Males.
④History of occupational exposure (asbestos, beryllium, uranium, radon, etc. exposure).
⑤ those with a history of malignancy or family history of lung cancer.
⑥Nodule size of 1 cm or more with burr-like, lobulated or hairy glass-like changes.
(7) accompanied by chest pain, cough, unexplained blood in sputum, weight loss, and other symptoms.
8.Why there are so many lung cancers at present, and they become late stage once detected?
The early diagnosis rate of lung cancer is extremely low, and the 5-year survival rate is only 15.6%. Early stage lung cancer is often manifested as lung nodules, but the current treatment level is difficult to make timely and accurate judgment on most lung nodules; at the same time, there is a lack of scientific differential diagnosis methods for nodules, resulting in delayed diagnosis and loss of surgery opportunities.
9.Doctor, I heard that radiation is harmful to human body, you still let me do CT regularly, will it hurt my body?
With the progress of CT technology and the popularity of low-dose spiral CT, a limited CT scan within 1 year should be safe. Studies have shown that less than 100msv has no effect on the body. 1 course of radiation therapy has a dose of at least 2000msv, 1 low dose CT has a radiation dose of about 1msv, and 1 conventional dose CT has a radiation dose of 3-5msv. the positive detection rate of lung nodules on CT scan is 24.2%, which is 3 times higher than that of chest X-ray (6.9%) (chest X-ray is easily missed). Therefore, CT is a safe and effective means of follow-up.
10.Is there any other means of examination for lung cancer other than plain CT scan of the chest?
In fact, to identify benign and malignant small lung nodules, it is better to do a CT enhancement of the chest, which is an important means to identify benign and malignant tumors. In addition, if lung cancer exists in human body, certain substances in blood will be increased, which we call tumor markers, such as CEA (carcinoembryonic antigen), NSE (neuron-specific enolase), cytokeratin 19 fragment, etc. Of course, sometimes tumor marker tests may be false negative or false positive, in other words, sometimes a mild increase may not necessarily mean lung cancer, and some lung cancer patients have normal tumor marker test results, so they need to combine with other means.
11.Doctor, my mother found a 5cm solid mass in the upper lobe of her right lung with shallow lobulated and burred margins and exceptionally high tumor marker CEA, the doctor suggested to perform CT-guided percutaneous lung puncture, my mother is 75 years old, can it be done?
From the imaging performance of the mass, it tends to be malignant. It is necessary to clarify the pathology as soon as possible, because the pathology type is different and the treatment means are also different. From the tumor markers, it is predicted that your mother may have adenocarcinoma, because CEA is predominantly elevated in lung adenocarcinoma, NSE is predominantly elevated in small cell lung cancer, and squamous carcinoma patients have significantly abnormal elevation of squamous carcinoma-related antigen and cytokeratin 19 fragment. From the treatment point of view, if your mother is really adenocarcinoma, considering her age, she cannot tolerate surgery or radiotherapy, she can choose targeted drug therapy, but targeted drug therapy requires genetic testing first.
CT-guided percutaneous lung aspiration is an important diagnostic method for pulmonary diseases, which is a means of diagnosis and differential diagnosis with the assistance of CT scan, negative pressure suction or cutting biopsy of intra-pulmonary lesions through an extracorporeal puncture needle or biopsy gun to obtain lesions and send them for examination. It has the advantages of high accuracy, small trauma, few complications and low cost. The highest incidence of complications is pneumothorax and bleeding. According to relevant reports, the incidence of pneumothorax is 12.9% to 26.6%, and the incidence of hemoptysis is about 4% to 27%, most of which can be absorbed by patients without treatment. Your mother’s lesion is large and close to the chest wall, and percutaneous lung puncture biopsy has been performed in our department for many years, so the technique is skilled and the chance of complications is small.
12.My father had a chest HRCT, and the report said that the left lung lingual segment mass shadow, size about 4.8cm, I took the film to the oncology hospital for the doctor to see, it is recommended to perform ultrasonic bronchoscopy, can you explain to me what is ultrasonic bronchoscopy?
Conventional bronchoscopy can only see the lesions located in the trachea and bronchus, but it is often unable to help the lesions outside the trachea. In the past, doctors could only perform “blind” puncture based on their experience. Ultrasound bronchoscopy (EBUS) is a device with an ultrasound probe installed in the anterior segment of the bronchoscope, which can clearly display the structure of the tracheal wall and the relationship between the blood vessels, lymph nodes, and occupying lesions in the mediastinum outside the airway, enabling real-time ultrasound-guided transbronchial needle aspiration biopsy (EBUS-TBNA). Compared with percutaneous lung puncture, which limits the location of large blood vessels and important organs, and mediastinal examination, which requires open chest and general anesthesia and is limited by the patient’s physical condition and functional status, ultrasound-guided transbronchial needle aspiration biopsy can solve the diagnostic problems of intra-pulmonary and mediastinal lesions outside the tracheobronchial cavity, which are difficult to be completed by traditional techniques. It is an efficient, safe and accurate diagnostic method.