Evidence for the treatment of patients with pulmonary nodules: When is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition)
Evidence for the treatment of patients with pulmonary nodules: When is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition)
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DOI：
10.1378/chest.07-1352
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发表时间：
2007-09-01
期刊：
影响因子：
9.6
通讯作者：
McCrory, Douglas C.
中科院分区：
文献类型：
--
作者：
Wahidi, Momen M.;Govert, Joseph A.;McCrory, Douglas C.
背景：孤立性肺结节（SPN）是一种常见的偶然发现，可能代表原发性肺癌或其他恶性或良性病变。 SPN的最佳治疗仍不清楚。方法：我们进行了系统的文献回顾，以解决以下问题：（1）SPN的患病率； (2) 具有不同特征（大小、形态和不透明类型）的结节的恶性肿瘤患病率； (3)生长速度、组织学和其他结节特征之间的关系； (4) SPN诊断试验的性能特点和并发症发生率。我们检索了 MEDLINE 和其他数据库，并使用了之前的系统评价和最近的初步研究。 结果：八项大型肺癌筛查试验表明，至少一个结节的患病率（8% 至 51%）和有结节患者的恶性肿瘤患病率（1.1% 至 12%）在不同研究中差异很大。恶性肿瘤的患病率因大小而异（< 5 毫米的结节为 0 至 1%，5 至 10 毫米的结节为 6 至 28%，> 20 毫米的结节为 64 至 82%）。对偶然或筛查发现结节的患者进行的六项研究的数据显示，边缘光滑的结节发生恶性肿瘤的风险约为 20% 至 30%；在具有不规则、分叶状或刺状边界的结节中，恶性率较高，但不同研究中的恶性率从 33% 到 100% 不等。纯粹毛玻璃样混浊的结节比实性结节（7% 至 9%）更可能是恶性的（59% 至 73%）。正电子发射断层扫描成像用于识别恶性 SPN 的敏感性始终很高（SO 至 100%），而特异性较低且在研究中差异较大（40 至 100%）。在影像学检查中，结节增强的动态 CT 产生了最有希望的敏感性（敏感性，98% 至 100%；特异性，54% 至 93%）。在 CT 引导下的针吸活检研究中，大约 20% 的时间出现非诊断结果，但当活检产生特定的良性或恶性结果时，敏感性和特异性都非常好。 结论：不同研究中 SPN 患者的 SPN 患病率和恶性肿瘤患病率差异很大。对这些可变患病率的解释不仅应考虑结节特征，还应考虑高危人群。现代影像学检查和 CT 引导下的针吸活检对于识别恶性 SPN 非常敏感，但影像学检查的特异性各不相同且通常较差。
Background: The solitary pulmonary nodule (SPN) is a frequent incidental finding that may represent primary lung cancer or other malignant or benign lesions. The optimal management of the SPN remains unclear.Methods: We conducted a systematic literature review to address the following questions: (1) the prevalence of SPN; (2) the prevalence of malignancy in nodules with varying characteristics (size, morphology, and type of opacity); (3) the relationships between growth rates, histology, and other nodule characteristics; and (4) the performance characteristics and complication rates of tests for SPN diagnosis. We searched MEDLINE and other databases and used previous systematic reviews and recent primary studies.Results: Eight large trials of lung cancer screening showed that both the prevalence of at least one nodule (8 to 51%) and the prevalence of malignancy in patients with nodules (1.1 to 12%) varied considerably across studies. The prevalence of malignancy varied by size (0 to 1% for nodules < 5 mm, 6 to 28% for nodules 5 to 10 mm, and 64 to 82% for nodules > 20 mm). Data from six studies of patients with incidental or screening-detected nodules showed that the risk for malignancy was approximately 20 to 30% in nodules with smooth edges; in nodules with irregular, lobulated, or spiculated borders, the rate of malignancy was higher but varied across studies from 33 to 100%. Nodules that were pure ground-glass opacities were more likely to be malignant (59 to 73%) than solid nodules (7 to 9%). The sensitivity of positron emission tomography imaging for identifying a malignant SPN was consistently high (SO to 100%), whereas specificity was lower and more variable across studies (40 to 100%). Dynamic CT with nodule enhancement yielded the most promising sensitivity (sensitivity, 98 to 100%; specificity, 54 to 93%) among imaging tests. In studies of CT-guided needle biopsy, nondiagnostic results were seen approximately 20% of the time, but sensitivity and specificity were excellent when biopsy yielded a specific benign or malignant result.Conclusions: The prevalence of an SPN and the prevalence of malignancy in patients with an SPN vary widely across studies. The interpretation of these variable prevalence rates should take into consideration not only the nodule characteristics but also the population at risk. Modern imaging tests and CT-guided needle biopsy are highly sensitive for identifying a malignant SPN, but the specificity of imaging tests is variable and often poor.