A nomogram based on the quantitative and qualitative features of CT imaging for the prediction of the invasiveness of ground glass nodules in lung adenocarcinoma

PURPOSE

Based on the quantitative and qualitative features of CT imaging, a model for predicting the invasiveness of ground-glass nodules (GGNs) was constructed, which could provide a reference value for preoperative planning of GGN patients.

MATERIALS AND METHODS

Altogether, 702 patients with GGNs (including 748 GGNs) were included in this study. The GGNs operated between September 2020 and July 2022 were classified into the training group (n = 555), and those operated between August 2022 and November 2022 were classified into the validation group (n = 193). Clinical data and the quantitative and qualitative features of CT imaging were harvested from these patients. In the training group, the quantitative and qualitative characteristics in CT imaging of GGNs were analyzed by using performing univariate and multivariate logistic regression analyses, followed by constructing a nomogram prediction model. The differentiation, calibration, and clinical practicability in both the training and validation groups were assessed by the nomogram models.

RESULTS

In the training group, multivariate logistic regression analysis disclosed that the maximum diameter (OR = 4.707, 95%CI: 2.06-10.758), consolidation/tumor ratio (CTR) (OR = 1.027, 95%CI: 1.011-1.043), maximum CT value (OR = 1.025, 95%CI: 1.004-1.047), mean CT value (OR = 1.035, 95%CI: 1.008-1.063; P = 0.012), spiculation sign (OR = 2.055, 95%CI: 1.148-3.679), and vascular convergence sign (OR = 2.508, 95%CI: 1.345-4.676) were independent risk parameters for invasive adenocarcinoma. Based on these findings, we established a nomogram model for predicting the invasiveness of GGN, and the AUC was 0.910 (95%CI: 0.885-0.934) and 0.902 (95%CI: 0.859-0.944) in the training group and the validation group, respectively. The internal validation of the Bootstrap method showed an AUC value of 0.905, indicating a good differentiation of the model. Hosmer-Lemeshow goodness of fit test for the training and validation groups indicated that the model had a good fitting effect (P > 0.05). Furthermore, the calibration curve and decision analysis curve of the training and validation groups reflected that the model had a good calibration degree and clinical practicability.

CONCLUSION

Combined with the quantitative and qualitative features of CT imaging, a nomogram prediction model can be created to forecast the invasiveness of GGNs. This model has good prediction efficacy for the invasiveness of GGNs and can provide help for the clinical management and decision-making of GGNs.

Presurgical computed tomography-guided localization of lung ground glass nodules: comparing hook-wire and indocyanine green

BACKGROUND

Presurgical computed tomography (CT)-guided localization is frequently employed to reduce the thoracotomy conversion rate, while increasing the rate of successful sublobar resection of ground glass nodules (GGNs) via video-assisted thoracoscopic surgery (VATS). In this study, we compared the clinical efficacies of presurgical CT-guided hook-wire and indocyanine green (IG)-based localization of GGNs.

METHODS

Between January 2018 and December 2021, we recruited 86 patients who underwent CT-guided hook-wire or IG-based GGN localization before VATS resection in our hospital, and compared the clinical efficiency and safety of both techniques.

RESULTS

A total of 38 patients with 39 GGNs were included in the hook-wire group, whereas 48 patients with 50 GGNs were included in the IG group. There were no significant disparities in the baseline data between the two groups of patients. According to our investigation, the technical success rates of CT-based hook-wire- and IG-based localization procedures were 97.4% and 100%, respectively (P = 1.000). Moreover, the significantly longer localization duration (15.3 ± 6.3 min vs. 11.2 ± 5.3 min, P = 0.002) and higher visual analog scale (4.5 ± 0.6 vs. 3.0 ± 0.5, P = 0.001) were observed in the hook-wire patients, than in the IG patients. Occurrence of pneumothorax was significantly higher in hook-wire patients (27.3% vs. 6.3%, P = 0.048). Lung hemorrhage seemed higher in hook-wire patients (28.9% vs. 12.5%, P = 0.057) but did not reach statistical significance. Lastly, the technical success rates of VATS sublobar resection were 97.4% and 100% in hook-wire and IG patients, respectively (P = 1.000).

CONCLUSIONS

Both hook-wire- and IG-based localization methods can effectively identified GGNs before VATS resection. Furthermore, IG-based localization resulted in fewer complications, lower pain scores, and a shorter duration of localization.

Comparison of the safety and effectiveness of the four-hook needle and hook wire for the preoperative positioning of localization ground glass nodules

BACKGROUND

With the implementation of lung cancer screening programs, an increasing number of pulmonary nodules have been detected.Video-assisted thoracoscopic surgery (VATS) could provide adequate tissue specimens for pathological analysis, and has few postoperative complications.However, locating the nodules intraoperatively by palpation can be difficult for thoracic surgeons. The preoperative pulmonary nodule localization technique is a very effective method.We compared the safety and effectiveness of two methods for the preoperative localization of pulmonary ground glass nodules.

METHODS

From October 2020 to April 2021, 133 patients who underwent CT-guided single pulmonary nodule localization were retrospectively reviewed. All patients underwent video-assisted thoracoscopic surgery (VATS) after successful localization. Statistical analysis was used to evaluate the localization accuracy, safety, information related to surgery and postoperative pathology information. The aim of this study was to evaluate the clinical effects of the two localization needles.

RESULTS

The mean maximal transverse nodule diameters in the four-hook needle and hook wire groups were 8.97 ± 3.85 mm and 9.00 ± 3.19 mm, respectively (P = 0.967). The localization times in the four-hook needle and hook wire groups were 20.58 ± 2.65 min and 21.43 ± 3.06 min, respectively (P = 0.09). The dislodgement rate was significantly higher in the hook wire group than in the four-hook needle group (7.46% vs. 0, P = 0.024). The mean patient pain scores based on the visual analog scale in the four-hook needle and hook wire groups were 2.87 ± 0.67 and 6.10 ± 2.39, respectively (P = 0.000). All ground glass nodules (GGNs) were successfully resected by VATS.

CONCLUSIONS

Preoperative pulmonary nodule localization with both a four-hook needle and hook wire is safe, convenient and effective.

Cone-Beam Computed Tomography-Guided Cryobiopsy Combined with Conventional Biopsy for Ground Glass Opacity-Predominant Pulmonary Nodules

INTRODUCTION

Cryobiopsy (CB) using a 1.1-mm cryoprobe under fluoroscopic guidance is feasible and safe for diagnosis of ground glass opacity (GGO) lesions. However, the efficacy of CB combined with cone-beam CT (CBCT) for GGO-predominant pulmonary nodules remains elusive.

METHODS

We retrospectively studied patients who underwent CB combined with conventional biopsy under CBCT guidance for GGO-predominant pulmonary nodules with a consolidation-to-tumour ratio <50.0%.

RESULTS

A total of 32 patients with GGO-predominant pulmonary nodules were enrolled: 17 pure GGOs and 15 mixed GGOs. The mean lesion diameter was 15.81 ± 5.52 mm and the overall diagnostic yield was 71.9%. Seven lesions were diagnosed by CB alone, which increased the diagnostic outcomes by 21.9%. Diagnostic yields for CB, forceps biopsy (FB), brushing, and guide sheath flushing were 65.6%, 46.9%, 15.6%, and 14.3%, respectively. Univariate analysis revealed that positive computed tomography (CT) bronchus sign (p = 0.035), positive CBCT sign (p < 0.01), and CB-first biopsy sequence (p = 0.036) were significant predictive factors for higher diagnostic yield. Specimens obtained by CB had larger mean sample size (p < 0.01), lower blood cell area (p < 0.01), and fewer crush artefacts (p < 0.01) than specimens from FB. No severe bleeding or other complications occurred.

CONCLUSION

CB using a 1.1-mm cryoprobe under CBCT guidance increased diagnostic yield for GGO-predominant pulmonary nodules based on conventional biopsy. Further, it provided larger and nearly intact samples compared with forceps.

Comparative immunological landscape between pre- and early-stage LUAD manifested as ground-glass nodules revealed by scRNA and scTCR integrated analysis

BACKGROUND

Mechanism underlying the malignant progression of precancer to early-stage lung adenocarcinoma (LUAD) as well as their indolence nature remains elusive.

METHODS

Single-cell RNA sequencing (scRNA) with simultaneous T cell receptor (TCR) sequencing on 5 normal lung tissues, 3 precancerous and 4 early-stage LUAD manifested as pulmonary ground-glass nodules (GGNs) were performed.

RESULTS

Through this integrated analysis, we have delineated five key modules that drive the malignant progression of early-stage LUAD in a disease stage-dependent manner. These modules are related to cell proliferation and metabolism, immune response, mitochondria, cilia, and cell adhesion. We also find that the tumor micro-environment (TME) of early-stage LUAD manifested as GGN are featured with regulatory T (Tregs) cells accumulation with three possible origins, and loss-functional state (decreased clonal expansion and cytotoxicity) of CD8 + T cells. Instead of exhaustion, the CD8 + T cells are featured with a shift to memory phenotype, which is significantly different from the late stage LUAD. Furthermore, we have identified monocyte-derived macrophages that undergo a lipid-phenotype transition and may contribute to the suppressive TME. Intense interaction between stromal cells, myeloid cells including lipid associated macrophages and LAMP3 + DCs, and lymphocytes were also characterized.

CONCLUSIONS

Our work provides new insight into the molecular and cellular mechanism underlying malignant progression of LUAD manifested as GGN, and pave way for novel immunotherapies for GGN. Video Abstract.

Clinical significance of spread of lipiodol marking for pulmonary nodules and its influence on surgery

OBJECTIVE

Computed tomography (CT)-guided lipiodol marking is one of the targeting methods for resecting small pulmonary nodules or ground-glass nodules in video-assisted thoracic surgery (VATS). However, lipiodol spreading during marking has not been assessed, practically. In this study, we examined the clinical significance and the influence of lipiodol spreading on surgery.

METHODS

From April 2010 to March 2021, 176 pulmonary nodules in 167 patients were marked with lipiodol under CT guided before VATS. The marking images after lipiodol injection were classified into "Spread" and "non-Spread." Lung resection was sequentially performed on the same day.

RESULTS

All target nodules were successfully resected in VATS. In the classification of marking images, Spread was 32 (18%), non-Spread was 144 (82%). There was a significant difference in duration of surgery (mean; 138.7 min vs. 118.3 min, p = 0.0496) and amount of bleeding (mean; 32.7 g vs. 11.2 g, p = 0.0173). Provided that limited to the data of wedge resections without intrathoracic pleural adhesion (n = 117), there was no significant difference in duration of surgery (mean; 104.8 min vs. 99.6 min, p = 0.48), amount of bleeding (mean; 4.9 g vs. 5.3 g, p = 0.58). In the multivariate logistic regression analysis, the risk factor of lipiodol spreading was intrathoracic pleural adhesion (odds ratio: 3.16, 95% confidence interval: 1.12-8.97, p = 0.03). There was no relationship between marking image and complication rate.

CONCLUSIONS

Lipiodol spreading did not directly influence surgery and complication. However, it was a sign of intrathoracic pleural adhesion, which could lead to increased duration of surgery and amount of bleeding.

The risk factors for the failure of hook wire localization of ground glass nodules prior to thoracoscopic surgery

Objectives

To retrospectively analyse the potential influencing factors of CT-guided hook wire localization failure prior to thoracoscopic resection surgery of ground glass nodules (GGNs), and determine the main risk elements for localization failure.

Methods

In all, 372 patients were included in this study, with 21 patients showing localization failure. The related parameters of patients, GGNs, and localization were analysed through univariate and multiple logistic regression analysis to determine the risk factors of localization failure.

Results

Univariate logistic regression analysis indicated that trans-fissure (odds ratio [OR] 4.896, 95% confidence interval [CI] 1.489–13.939); trans-emphysema (OR 3.538, 95% CI 1.343–8.827); localization time (OR 0.956, 95% CI 0.898–1.019); multi-nodule localization (OR 2.597, 95% CI 1.050–6.361); and pneumothorax (OR 10.326, 95% CI 3.414–44.684) were risk factors for localization failure, and the p-values of these factors were < 0.05. However, according to the results of multivariate analysis, pneumothorax (OR 5.998, 95% CI 1.680–28.342) was an exclusive risk factor for the failure of preoperative localization of GGNs.

Conclusion

CT-guided hook wire localization of GGNs prior to thoracoscopic surgery is often known to fail; however, the incidence is low. Pneumothorax is an independent risk factor for failure in the localization process.

[Progress in screening and follow-up studies of pulmonary ground glass nodules]

With the wide application of high-resolution chest CT in health check-up, the ground glass nodule(GGN) has been increasingly detected. GGNs have a complex etiology and image features, which can develop fast or very slowly. Therefore, whether to follow up or to resect it is usually very difficult to be determined. Overdiagnosis or overtreatment frequently happens. According to the development of GGNs, the process can be clinically divided into four stages: biological onset stage (pre-detection stage), observational stage, clinical treatment stage and postoperative follow-up stage. This review summarizes the progress on the natural development process, imaging monitoring and differentiation, the optimal time of surgical treatment for GGNs based on the decision of multidisciplinary team. This revie wmay be helpful for clinicians to understand the rule of GGN development in the follow-up, and find an optimal time to give surgical intervention for improving the prognosis of and life quality of the GGN patients.

Predicting the Ki-67 proliferation index in pulmonary adenocarcinoma patients presenting with subsolid nodules: construction of a nomogram based on CT images

BACKGROUND

The Ki-67 proliferation index (PI) reflects the proliferation of cells. However, the conventional methods for the acquisition of the Ki-67 PI, such as surgery and biopsy, are generally invasive. This study investigated a potential noninvasive method of predicting the Ki-67 PI in patients with lung adenocarcinoma presenting with subsolid nodules.

METHODS

This retrospective study enrolled 153 patients who presented with pulmonary adenocarcinoma appearing as subsolid nodules (SSNs) on computed tomography (CT) images between January 2015 and December 2018. Presence of LUAD with SSNs was confirmed by histopathology. Of these participants, 107 patients were from institution 1 and were divided into a training cohort and an internal validation cohort in a 7:3 ratio. The other 46 patients were from institution 2 and were enrolled as an external validation cohort. All patients underwent conventional CT scans with thin-slice (≤1.25 mm) reconstruction, and 1,316 quantitative radiomic features were extracted from the CT images for each nodule. The minimum redundancy maximum relevance and the least absolute shrinkage and selection operator were used for feature selection, and the radiomics signature was constructed based on these selected features. Clinical features were examined using univariate logistic regression analysis. The nomogram was developed based on the radiomics signature and the independent clinical risk factors. The Delong test and t test were employed for statistical analysis. The performance of different models was assessed by the receiver operating characteristic (ROC) curve.

RESULTS

The diameter of the nodules [odds ratio (OR) =1.17; P=0.003] was identified as an independent predictive parameter. Both the radiomics signature and the nomogram suggested a good predictive probability for Ki-67 expression. For the radiomics signature, the area under the ROC curve (AUC) for the training cohort, the internal validation cohort, and the external validation cohort was 0.86 [95% confidence interval (CI): 0.77 to 0.95], 0.81 (95% CI: 0.64 to 0.98), and 0.77 (95% CI: 0.62 to 0.91), respectively. For the nomogram, the AUC for the training cohort, the internal validation cohort, and the external validation cohort was 0.86 (95% CI: 0.77 to 0.95), 0.80 (95% CI: 0.64 to 0.97), and 0.79 (95% CI: 0.65 to 0.94), respectively. There were no statistical differences in the AUCs between the radiomics signature and the radiomic nomogram in the training cohort or the validation cohorts (all P>0.05).

CONCLUSIONS

The nomogram provides a novel strategy for determining the Ki-67 PI in predicting the proliferation of subsolid nodules, which may be beneficial for the management of patients with SSNs.

Percutaneous Electromagnetic Transthoracic Nodule Localization for Ground Glass Nodules

Background

A recent increase in the incidental detection of ground glass nodules (GGNs) has created a need for improved diagnostic accuracy in screening for malignancies. However, surgical diagnosis remains challenging, especially via video-assisted thoracoscopic surgery (VATS). Herein, we present the efficacy of a novel electrical navigation system for perioperative percutaneous transthoracic nodule localization.

Methods

Eighteen patients with GGNs who underwent electromagnetic navigated percutaneous transthoracic needle localization (ETTNL), followed by 1-stage diagnostic wedge resections via VATS between January and December 2020, were included in the analysis. Data on patient characteristics, nodules, procedures, and pathological diagnoses were collected and retrospectively reviewed.

Results

Of the 18 nodules, 17 were successfully localized. Nine nodules were pure GGNs, and the remaining 9 were part-solid GGNs. The median nodule size was 9.0 mm (range, 4.0-20.0 mm); and the median depth from the visceral pleura was 5.2 mm (range, 0.0-14.4 mm). The median procedure time was 10 minutes (range, 7-20 minutes). The final pathologic results showed benign lesions in 3 cases and malignant lesions in 15 cases.

Conclusion

Perioperative ETTNL appears to be an effective method for the localization of GGNs, providing guidance for a 1-stage VATS procedure.

HRCT features between lepidic-predominant type and other pathological subtypes in early-stage invasive pulmonary adenocarcinoma appearing as a ground-glass nodule

Background

Different pathological subtypes of invasive pulmonary adenocarcinoma (IPA) have different surgical methods and heterogeneous prognosis. It is essential to clarify IPA subtypes before operation and high-resolution computed tomography (HRCT) plays a very important role in this regard. We aimed to investigate the HRCT features of lepidic-predominant type and other pathological subtypes of early-stage (T1N0M0) IPA appearing as a ground-glass nodule (GGN).

Methods

We performed a retrospective analysis on clinical data and HRCT features of 630 lesions in 589 patients with pathologically confirmed IPA (invasive foci > 5 mm) appearing as pure GGN (pGGN) and mixed GGN (mGGN) with consolidation-to-tumor ratio (CTR) ≤0.5 from January to December 2019. All GGNs were classified as lepidic-predominant adenocarcinoma (LPA) and nonlepidic-predominant adenocarcinoma (n-LPA) groups. Univariate analysis was performed to analyze the differences of clinical data and HRCT features between the LPA and n-LPA groups. Multivariate analysis was conducted to determine the variables to distinguish the LPA from n-LPA group independently. The diagnostic performance of different parameters was compared using receiver operating characteristic curves.

Results

In total, 367 GGNs in the LPA group and 263 GGNs in the n-LPA group were identified. In the univariate analysis, the CTR, mean CT values, and mean diameters as well as mixed GGN, deep lobulation, spiculation, vascular change, bronchial change, and tumor–lung interface were smaller in the LPA group than in the n-LPA group (P <  0.05). Logistic regression model was reconstructed including the mean CT value, CTR, deep lobulation, spiculation, vascular change, and bronchial change (P <  0.05). Area under the curve of the logistic regression model for differentiating LPA and n-LPA was 0.840 (76.4% sensitivity, 78.7% specificity), which was significantly higher than that of the mean CT value or CTR.

Conclusions

Deep lobulation, spiculation, vascular change, and bronchial change, CT value > − 472.5 HU and CTR > 27.4% may indicate nonlepidic predominant invasive pulmonary adenocarcinoma in GGNs.

Adenocarcinoma spectrum lesions of the lung: Detection, pathology and treatment strategies

Adenocarcinoma has become the most prevalent lung cancer sub-type and its frequency is increasing. The earliest stages in the development of lung adenocarcinomas are visible using modern computed tomography (CT) as ground glass nodules. These pre-invasive nodules can progress over time to become invasive lung adenocarcinomas. Lesions in this developmental pathway are termed 'adenocarcinoma spectrum' lesions. With the introduction of lung cancer screening programs there has been an increase in the detection of these lesions raising questions about natural history, surveillance and treatment. Here we review how the radiological appearance of an adenocarcinoma spectrum lesion relates to its underlying pathology and explore the natural history and factors driving lesion progression. We examine the molecular changes that occur at each stage of adenocarcinoma spectrum lesion development, including the effects of the driver mutations, EGFR and KRAS, that are key to invasive adenocarcinoma pathology. A better understanding of the development of pre-invasive disease will create treatment targets. Our understanding of how tumours interact with the immune system has led to the development of new therapeutic strategies. We review the role of the immune system in the development of adenocarcinoma spectrum lesions. With a clear preinvasive phase there is an opportunity to treat early adenocarcinoma spectrum lesions before an invasive lung cancer develops. We review current management including surveillance, surgical resection and oncological therapy as well as exploring potential future treatment avenues.

A case of lymphocytic interstitial pneumonia presenting with a ground glass nodule as an initial finding

A 65-year-old woman had a ground glass nodule, which was suspicious for lung cancer, in her right lung S⁶ by chest computed tomography. For diagnosis, video-assisted thoracoscopic surgery was performed, and the specimen showed a pathological pattern of lymphocytic interstitial pneumonia (LIP). Four years after surgery, new localized ground glass shadows gradually increased on the base of the lung. However, because she had no respiratory symptoms and had normal respiratory function, she was observed with no medication. Subsequently, no other underlying diseases associated with LIP developed. The ground glass nodule was the initial lesion of LIP.

Approach to the Subsolid Nodule

Most focal persistent ground glass nodules (GGNs) do not progress over 10 years. Research suggests that GGNs that do not progress, those that do, and solid lung cancers are fundamentally different diseases, although histologically they seem similar. Surveillance of GGNs to identify those that gradually progress is safe and does not risk losing a window. GGNs with 5 mm solid component or less than 10 mm consolidation (mediastinal and lung windows, respectively, on thin slice CT) are highly curable with resection. The optimal type of resection is unclear; sublobar resection is reasonable but an adequate margin is critically important.

A case of a rare non-invasive lung adenocarcinoma

BACKGROUND

According to the WHO classification, adenocarcinoma in situ (AIS) is a localised small (≤3 cm) adenocarcinoma whose growth is restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, lymphovascular, or pleural invasion. There is no evidence to define AIS as having a tumour size of ≤3 cm. It is extremely rare for adenocarcinomas with pure lepidic growth lacking invasion to be >3.0 cm. The biological characteristics of these large AISs should be revealed.

PRESENTATION OF CASE

The patient was an 82-year-old asymptomatic woman. Chest computed tomography showed a 6-cm-diameter pure ground-glass opacity in the left lower lung. The patient underwent lobectomy. On histologic examination, the tumour was restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, vascular, alveolar space, and pleural invasion. Papillary patterns were absent. Initially, the histopathological diagnosis was AIS, but the total tumour diameter exceeded 3 cm. The final pathological diagnosis was lepidic adenocarcinoma lacking an invasive component and harbouring an EGFR exon 20 insertion V774_C775insHV mutation using next-generation sequencing (NGS).

CONCLUSION

We report a rare case of lepidic adenocarcinoma with a total tumour diameter of 6 cm and without an invasive component. Although EGFR mutations are oncogenic driver mutations, AISs have fewer EGFR mutations than invasive adenocarcinomas do. An adenocarcinoma that progresses to AIS, not stepwise progression, might have uncommon mutations and might be another type of adenocarcinoma. NGS could be useful for detecting uncommon genes that reveal the biological characteristics of AIS, and may contribute to the validation of next TNM classification.

Subsolid pulmonary nodules: Controversy and perspective

Ground glass and part-solid nodules, collectively referred to as subsolid nodules, present a challenge in management, with a high risk of malignancy but, when malignant, demonstrating indolent behavior. Emerging data suggest longer follow-up intervals and shorter duration of follow-up is likely appropriate in these nodules. Additionally, definitive therapy is shifting to less aggressive approaches such as sub-lobar resection. Patients may benefit from individualized approaches, incorporating both patient and imaging features to determine whether treatment is necessary.

Three-dimensional printing technology for localised thoracoscopic segmental resection for lung cancer: a quasi-randomised clinical trial

Background

Three-dimensional (3D) computed tomography (CT) reconstruction technology has gained attention owing to its potential in locating ground glass nodules in the lung. The 3D printing technology additionally allows the visualisation of the surrounding anatomical structure and variations. However, the clinical utility of these techniques is unknown. This study aimed to establish a lung tumour and an anatomical lung model using 3D printing and 3D chest CT reconstruction and to evaluate the clinical potential of 3D printing technology in uniportal video-assisted thoracoscopic segmentectomy.

Methods

Eighty-nine patients with ground glass nodules who underwent uniportal video-assisted thoracoscopic segmentectomy were classified into the following groups: group A, lung models for pre-positioning and simulated surgery that were performed with 3D chest CT reconstruction and 3D printing, and group B, patients who underwent chest CT scans with image enhancement for 3D reconstruction. The differences in the surgery approach transfer rate, surgical method conversion rate, operative time, intraoperative blood loss, and postoperative complication rate were compared between the two groups.

Results

Between groups A and B, there were significant differences in the approach transfer rate (0% vs.10.5%, p = 0.030), operative time (2.07 ± 0.24 h vs. 2.55 ± 0.41 h, p < 0.001), intraoperative blood loss volume (43.25 ± 13.63 mL vs. 96.68 ± 32.82 mL, p < 0.001) and the rate of surgical method conversion to lobectomy (0% vs. 10.5%, p < 0.030). In contrast, there was an insignificant difference in the postoperative complication rate between groups A and B (3.9% vs. 13.2%, p = 0.132).

Conclusions

3D printing technology facilitates a more accurate location of nodules by surgeons, as it is based on two-dimensional and 3D image-based findings, and therefore, it can improve surgical accuracy and safety. This technique is worth applying in clinical practice.

Risk factors for lymph node metastasis and surgical methods in patients with early-stage peripheral lung adenocarcinoma presenting as ground glass opacity

Background

It is difficult to predict lymph node metastasis in patients with early lung cancer. Pure ground glass opacity (GGO) on computed tomography indicates an early-stage adenocarcinoma that can be removed by limited resection or lobectomy without the need for mediastinal lymph node dissection or sampling, and lung adenocarcinoma with GGO therefore has a good prognosis. We examined the incidence and risk factors of lymph node metastasis in patients with clinical stage IA lung adenocarcinoma.

Methods

We retrospectively analyzed clinical data for 327 patients with stage IA peripheral lung cancer treated in our hospital from March 2014 to December 2018. The patients were divided into four groups according to computed tomography signs. Lobectomy and systematic lymph node dissection were performed in all patients. Correlations between lymph node metastasis and clinical pathological factors were analyzed by logistic regression.

Results

Among the 327 patients, 26 (7.95%) had lymph node metastasis. No patients with pure GGO or GGO-dominant types had lymph node metastasis. Logistic regression identified tumor diameter, solid content, plasma carcinoembryonic antigen (CEA) level, pathological type, lymphovascular invasion, and pleural invasion as factors related to the presence of lymph node metastasis.

Conclusions

Tumor diameter, solid component ratio, plasma CEA level, pathological type, vascular tumor thrombus, and pleural invasion are possible independent risk factors for lymph node metastasis in patients with stage IA lung adenocarcinoma. In contrast, lymph node metastasis is rare in patients with pure GGO or GGO-dominant lung adenocarcinoma.

Comparative postoperative outcomes of GGN-dominant vs single lesion lung adenocarcinomas

Background

Multiple synchronous ground glass nodules (GGNs) are known to be malignant, however, they tend to progress slowly. Multiple synchronous lesions in the same patient which show different characteristics must be treated individually.

Methods

This was a retrospective review of 34 lung adenocarcinoma patients with multiple synchronous GGNs in an Asian population. One hundred twenty-seven single lung adenocarcinoma patients were included for comparison purposes. The follow-up period was 5 years for all patients.

Results

The 5-year overall survival (OS) patients with multiple lesions did not differ from that of the patients with single lesions to a statistically significant extent (Single: 81.8% vs. Multiple: 88.2%, P = 0.3602). Dominant tumors (DTs) with a ground glass component and consolidation were divided into three categories based on the consolidation-to-tumor ratio on radiological imaging. No significant differences were observed among the three DT categories. Twenty-four patients had unresected GGNs, while a progression of the unresected GGN occurred in 10 of these cases. The OS and disease-free survival (DFS) curves of patients with and without GGN progression did not differ to a statistically significant extent (OS: 80% vs. 92.9%, P = 0.3870; DFS: 80% vs. 100%, P = 0.0977).

Conclusions

The outcomes were best predicted by the stage of the DT. After surgery patients require a careful follow-up because unresected GGNs may show progression. At the same time, the increase in residual lesions and the appearance of new GGNs were not related to OS. The management of such patients should be determined according to the DT with the worst prognosis.

Marking method for peripheral non-palpable pulmonary nodules using a mobile computed tomography scanner with a navigation system

Intraoperative localization is essential for video-assisted thoracoscopic surgery of non-palpable pulmonary nodules. Although a computed tomography (CT) guided hook-wire localization is widely used, it might be accompanied by a rare but fatal complication such as an air embolism. We applied a mobile CT scanner with a navigation system to resolve this problem. The three-dimensional images obtained by the mobile CT scanner were transferred to the navigation system, which allowed for virtual fluoroscopy to scan the nearest skin site from the target lesion using a navigation probe. The lung surface was stamped by a dyed gauze ball anchored just beneath the skin marking and a needle was placed at this point as a landmark. With this method, we could verify the positional relationship between the needle and target lesion by the additional CT scan without any procedure-related morbidity.

Can texture features improve the differentiation of infiltrative lung adenocarcinoma appearing as ground glass nodules in contrast-enhanced CT?

OBJECTIVES

To investigate the validity and efficacy of comparing texture features from contrast-enhanced images with non-enhanced images in identifying infiltrative lung adenocarcinoma represented as ground glass nodules (GGN).

MATERIALS AND METHODS

A retrospective cohort study was conducted with patients presenting with lung adenocarcinoma and treated at a single centre between January 2015 to December 2017. All patients underwent standard and contrast-enhanced thoracic CT scans with 0.5 mm collimation and 1 mm slice reconstruction thickness before surgery. A total of 34 lung adenocarcinoma patients (representing 34 lesions) were analysed; including 21 instances of invasive adenocarcinoma (IAC) lesions, 4 instances of adenocarcinoma in situ (AIS) lesions, and 9 minimally invasive adenocarcinoma (MIA) lesions. After radiologists manually segmented the lesions, texture features were quantitatively extracted using Artificial Intelligence Kit (AK) software. Then, multivariate logistic regression analysis based on standard and contrast-enhanced CT texture features was employed to analyse the invasiveness of lung adenocarcinoma lesions appearing as GGNs. A receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of those models.

RESULTS

A total of 21 quantitative texture features were extracted using the AK software. After dimensionality reduction, 5 and 3 features extracted from thin-section unenhanced and contrast-enhanced CT, respectively, were used to establish the model. The area under the ROC curve (AUC) values for unenhanced CT and enhanced CT features were 0.890 and 0.868, respectively. There was no significant difference (P = 0.190) in the AUC between models based on non-enhanced and contrast-enhanced CT texture features.

CONCLUSION

Compared with unenhanced CT, texture features extracted from contrast-enhanced CT provided no benefit in improving the differential diagnosis of infiltrative lung adenocarcinoma from non-infiltrative malignancies appearing as GGNs.

Migration of a hookwire used as a video-assisted thoracoscopic surgery marker into the splenic artery

We present a case in which a hookwire that was used as a video-assisted thoracoscopic (VATS) surgery marker migrated into the splenic artery. The patient was a 70-year-old man with an 18-mm ground glass nodule (GGN) in the right S2. As the GGN was not located in the peripheral part of the lung, a percutaneous hookwire was placed as a marker under CT-guided just before the surgery. We performed VATS right S2 segmentectomy to remove the GGN and the marker; however, we could not locate the marker in the specimen. Histopathological examination revealed adenocarcinoma, TisN0M0, stage 0. CT findings after surgery showed that the marker had migrated into the splenic artery. We followed up the patient, and CT examination conducted 1, 3 and 6 months after the surgery showed no further migration and no damage of the splenic artery. We report the complication of percutaneous hookwire migration into a blood vessel.

Contrast analysis of the relationship between the HRCT sign and new pathologic classification in small ground glass nodule-like lung adenocarcinoma

PURPOSE

To perform contrast analysis of the relationship between high-resolution computed tomography (HRCT) signs and new pathologic classification of small GGNs-like lung adenocarcinoma.

MATERIALS AND METHODS

The HRCT data from 145 pathologically confirmed cases of small GGNs of lung adenocarcinoma were analysed retrospectively. The 145 cases of GGNs were divided into pre-invasive (PI) group (n = 46), micro-invasive adenocarcinoma (MIA) group (n = 48), and invasive adenocarcinoma (IAC) group (n = 51). HRCT imaging sign of GGNs in each group was assessed and compared.

RESULTS

Significant differences in GGN size were found among the three groups (P < 0.05). The presence of a tumour-lung interface in the MIA and IAC groups was significantly higher than that in the PI group (P < 0.05), but no significant difference was found between the MIA and IAC groups. The presence of a pleural indentation sign in the IAC group was significantly higher than that in the other two groups (P < 0.05), but no significant difference was noted between the latter two groups. Significant differences were found in the lobulated and spicule signs among the three groups (P < 0.05). The presence of a microvascular sign in the MIA and IAC groups was significantly higher than that in the PI group (P < 0.05). No significant difference was found in the GGN density, vacuole sign, air bronchus sign and notch sign among the three groups.

CONCLUSIONS

The HRCT signs of GGNs could be used to differentiate among pre-invasive lesions, micro-invasive lesions and invasive lung adenocarcinoma.

Squamous cell carcinoma of the lung showing a ground glass nodule on high-resolution computed tomography associated with pneumoconiosis: a case report

Background

Adenocarcinoma with lepidic growth pattern presents as a ground glass nodule (GGN) on high resolution computed tomography (CT), whereas peripheral pulmonary squamous cell carcinoma (SCC) usually presents as a solid nodule. We herein report a rare case of pulmonary SCC extending along the alveolar lumen representing as a GGN on a CT scan in a patient with pneumoconiosis.

Case presentation

A 77-year-old man with pneumoconiosis was found to have a gradually enlarging GGN in the right lower lobe of the lung on CT. An adenocarcinoma of the lung was suspected. The GGN was successfully resected by thoracoscopic segmentectomy. Pathological examination of the resected specimen was pathologically diagnosed as a stage IA SCC extending along the alveolar lumen. The patient had no evidence of recurrence 19 months after surgery.

Conclusions

SCC should be included in the differential diagnosis of peripherally located GGNs, especially in patients at high risk of SCC of the lung such as those with pneumoconiosis.

Mixed squamous cell and glandular papilloma of the lung resembling early adenocarcinoma: A case report

Introduction

An extremely rare case of mixed squamous cell and glandular papilloma of the lung is reported. The correlation between the radiological and the pathological features as well as the clinical pitfall in making a diagnosis is discussed.

Presentation of case

An asymptomatic 68-year-old female with a cigarette smoking habit presented with a small nodule in her peripheral lung. A wedge resection was performed though it failed on-site diagnosis which was instead obtained following pathological scrutiny. The postsurgical course was excellent with no recurrence of disease.

Discussion

A small ground glass nodule gradually enlarged and transformed to a partially solid nodule a year and a half later. This transformation falsely made us suspect an early adenocarcinoma development. Eventually, the extremely rare subtype of pulmonary papilloma, with biphasic glandular and squamous cells, had been demonstrated to obstruct the peripheral bronchiole; and the adjoining alveoli had filled with a large volume of mucus. These pathological features seemed to have constituted the inner solid portion and the marginal ground glass portion respectively in the CT images, mimicking invasive lepidic adenocarcinoma.

Conclusion

Both pre- and intra-operative diagnoses are difficult mainly because of the rareness of the disease, however, mixed squamous cell and glandular papilloma may be considered in case the presence of primary adenocarcinoma is not validated.

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Mixed squamous cell and glandular subtype is extremely rare pulmonary papilloma.

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Initial presentation of this benign tumor had resembled early adenocarcinoma.

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This disease should be taken into account in making a differential diagnosis.