A contemplative summary of the "seven-year itch" of ground-glass nodules in the lungs (finale)

This is the 3088th article of Da Yi Xiao Hu

The sky was slightly white, roosters crowing in the valley, and it was dawn. Wang Xiaoer looked at the emperor with apology and said: "You have worked hard tonight. I promise not to disturb you for a year. At the moment of my departure, I still can't help but want to make a summary. Please correct me."

The emperor looked at Wang Xiaoer unhappily: Well, let's see you off. You make your closing statement. I'm not sleepy at all now.

Wang Xiaoer drank the last cup of tea and said softly: After a night of long conversation, I have learned the following precautions, and I hope all patients will collect them!

one

Ground-glass nodules in the lungs are lesions that appear as blurry as ground glass on imaging, with visible blood vessels or bronchial shadows, round or quasi-round, and can be divided into benign and neoplastic. Benign (mostly infectious) nodules can dissipate, shrink, or disappear within a certain period of time (1-12 months, or even longer); neoplastic nodules are divided into atypical adenomatous hyperplasia, adenocarcinoma in situ, microinvasive adenocarcinoma, and invasive adenocarcinoma, and generally grow progressively. The probability of long-term and persistent ground-glass nodules being neoplastic is greatly increased. They are considered to be an inert subtype of lung adenocarcinoma, generally grow slowly, and are more common in East Asians, non-smokers, women, and young patients. The cause is still unknown and requires global efforts to clarify. Some ground-glass nodules can grow rapidly for unknown reasons, which may be related to certain genes such as TP53 mutations, gene copy number changes, and HLA heterozygosity loss, but little is known about the specific molecular microscopic events.

two

Various foreign guidelines (NCCN, ACCP, FLEISCHNER) focus on lung cancer screening, using regular CT follow-up as the main means to observe the size and density changes of tumor ground glass nodules to determine the development pattern and malignancy of the tumor. Follow-up observation is recommended for pure ground glass nodules less than 10 mm or even less than 20 mm in foreign countries. The reason is that most tumor pure ground glass nodules are adenocarcinoma in situ and micro-invasive adenocarcinoma, and the five-year survival rate after resection is almost 100%, but there is no in-depth discussion of the choice of treatment or follow-up. There are still doubts about various guidelines: Are the management standards credible? Is CT monitoring really the best choice? Does the surgical strategy have management advantages? It is encouraged to use Chinese data and issue Chinese guidelines. The consensus on the diagnosis and treatment of ground glass nodule adenocarcinoma issued by Shanghai Pulmonary Hospital has been published.

three

China has huge regional differences, practitioners are of varying quality, and cultural literacy varies greatly. Therefore, after patients decide to follow up with CT, they need to be careful not to be too nervous or too cautious; they should neither be overly anxious nor let things take their own course. It is best to have the examination in the same tertiary hospital and the same CT machine, and ask the same experienced doctor to read the films before and after, and carefully observe the changes in ground glass nodules to minimize errors. Do not simply believe the description on the report to avoid misdiagnosis. If there is a significant increase in size and density during the follow-up process, further consultation with thoracic surgery is recommended. The accumulation of radiation from follow-up CT is harmful to the human body. For every 2,500 lung cancer screening patients, 1 will die from cancer due to CT imaging radiation.

Four

Whether to choose surgery for ground-glass nodules in the lungs depends on the pathological stage of the nodule, taking the expert consensus of Shanghai Pulmonary Hospital as an example: surgical treatment is recommended for microinvasive adenocarcinoma and invasive adenocarcinoma; surgery can be performed if adenocarcinoma in situ meets the following three conditions: the nodule is larger than 8 mm, the patient is under great psychological pressure, and the patient is willing to undergo surgery; regular follow-up CT is recommended for atypical adenomatous hyperplasia.

five

It is crucial to determine the benign or malignant nature and pathological stage of ground-glass nodules based on their imaging characteristics. How patients can rationally, beneficially and moderately choose surgical options or regular CT follow-up depends on the following three points: First, fully understand the imaging characteristics of benign and malignant nodules, the laws and controversies of tumor metastasis; second, fully understand the meaning of scientific uncertainty, critically study various guidelines and literature, and learn to accept scientific uncertainty; finally, fully recognize the existing medical humanistic environment in China, think in other people's shoes, and achieve harmony between doctors and patients!

six

If the patient decides to undergo surgery, the surgical methods include lobectomy and sublobar resection (wedge resection, segmental resection) by single-port thoracoscopic minimally invasive surgery. At present, the thoracic surgery industry can use sublobar resection for adenocarcinoma in situ and micro-invasive adenocarcinoma, and lymph nodes may not be cleared; in certain specific cases of invasive adenocarcinoma (mainly adherent growth, pure ground glass nodules, less than 50% solid components, low invasiveness), it may be considered whether to not perform lobectomy, and systematic lymph node sampling may be performed; invasive adenocarcinoma (solid components more than 50%, rapid growth rate, obvious malignant imaging features) is recommended to perform lobectomy and systematic lymph node dissection.

seven

If the patient is elderly, has multiple underlying diseases, and is unwilling to undergo surgery, alternative options for neoplastic ground-glass nodules can be considered: stereotactic radiotherapy and radiofrequency ablation. In terms of local control, stereotactic radiotherapy seems to be superior to radiofrequency ablation. In the comparison of the selection of specific treatment methods, more clinical research data support is still awaited. Although both are listed as alternatives for patients who are unable to undergo surgery, they are not necessarily alternatives for patients who can undergo surgery. In-depth discussion and observation are still needed in terms of the long-term effects, side effects, and complications of the treatment options. At present, surgery is still the gold standard for neoplastic ground-glass nodules, and its alternatives are trying to prove that they have short-term effects that are not inferior to surgery.

eight

Patients who have difficulty deciding between surgery and follow-up, or who have long-standing ground-glass nodules in the lungs: If the patient is young and the nodules are located at the edge of the lungs, surgical resection may be preferred to avoid pathological escalation; if the patient is old and the nodules are located in the center of the lungs, non-surgical alternative treatment options or follow-up may be preferred. Postoperative follow-up can include CT scans every six months for 2 years, and then once a year; for follow-up of adenocarcinoma in situ and microinvasive adenocarcinoma, there may be no need to monitor for recurrence within 3-5 years after surgery, and appropriate low-intensity monitoring and re-examination of CT scans may be performed.

Nine

Whether multiple ground-glass nodules are multiple primary lesions or metastatic lesions requires further pathological histological subtypes, driver mutations, and diagnostic strategies for genomic maps, and surgical resection requires further comprehensive consideration. Intra-airway spread metastasis refers to cancer cells detaching from the basement membrane, spreading through the airways, and then reattaching and growing along the alveolar septa away from the primary lesions. The specific mechanism of the intra-airway spread metastasis process is unknown, and it is common in patients with primary lung adenocarcinoma, especially those with invasive mucinous, papillary, and micropapillary types. The surgical strategy for multiple ground-glass nodules needs to be comprehensively evaluated based on the size, location, CT imaging characteristics, cardiopulmonary function, and performance status of the tumor. Pulmonary parenchymal function should be preserved as much as possible and unnecessary lymph node dissection should be avoided. Metastatic multiple ground-glass nodules have a poor prognosis, and the survival period is lower than that of patients with multiple primary lesions.

The emperor couldn't help but clapped his hands after hearing this:

Xiaoer, your ability to summarize is indeed extraordinary. You not only summarized what I said, but also summarized the experience of our previous conversations. I sincerely hope that you will treat medicine with a scientific attitude and look at the joint decision-making between doctors and patients from the perspective of patients. We doctors and patients can work together, speak freely, and make progress together!

Wang Xiaoer hurriedly said:

Thank you, I have disturbed you for a whole night and delayed your sleep. I sincerely apologize to you this time. I will leave first, you take time to rest! See you in a year!

Looking at the back of the waiter going away and the morning light of the rising sun, the emperor could not help but lose all sleepiness. To embrace the nature of the valley and breathe the morning sun, the emperor stood up and walked out the door. It was a green world... The "seven-year itch" of ground glass nodules was wiped out, but the thoughtful summary of the "transfer path" was still echoing in the world, affecting many grinding friends!

Author: Department of Thoracic Surgery, Shanghai Pulmonary Hospital

Zhao XiaogangDeputy Chief Physician