Ground-glass Nodules Research Articles

Reticulation Sign on Thin-Section CT: Utility for Predicting Invasiveness of Pure Ground-Glass Nodules.

BACKGROUND. Pure ground-glass nodules (pGGNs) may represent a diverse range of histologic entities of varying aggressiveness. OBJECTIVE. The purpose of this study was to evaluate the use of the reticulation sign on thin-section CT images for predicting the invasiveness of pGGNs. METHODS. This retrospective study included 795 patients (mean age, 53.4 ± 11.1 [SD] years; 254 men, 541 women) with a total of 876 pGGNs on thin-section CT that underwent resection between January 2015 and April 2022. Two fellowship-trained thoracic radiologists independently reviewed unenhanced CT images to assess the pGGNs for a range of features, including diameter, attenuation, location, shape, air bronchogram, bubble lucency, vascular change, lobulation, spiculation, margins, pleural indentation, and the reticulation sign (defined as multiple small linear opacities resembling a mesh or a net); differences were resolved by consensus. The relationship between the reticulation sign and lesion invasiveness on pathologic assessment was evaluated. RESULTS. On pathologic assessment, the 876 pGGNs included 163 nonneoplastic and 713 neoplastic pGGNs (323 atypical adenomatous hyperplasias [AAHs] or adenocarcinomas in situ [AISs], 250 minimally invasive adenocarcinomas [MIAs], and 140 invasive adenocarcinomas [IACs]). Interobserver agreement for the reticulation sign, expressed as kappa, was 0.870. The reticulation sign was detected in 0.0% of nonneoplastic lesions, 0.0% of AAHs/AISs, 6.8% of MIAs, and 54.3% of IACs. The reticulation sign had sensitivity of 24.0% and specificity of 100.0% for a diagnosis of MIA or IAC and sensitivity of 54.3% and specificity of 97.7% for a diagnosis of IAC. In multivariable regression analyses including all of the assessed CT features, the reticulation sign was a significant independent predictor of IAC (OR, 3.64; p = .001) but was not a significant independent predictor of MIA or IAC. CONCLUSION. The reticulation sign, when observed in a pGGN on thin-section CT, has high specificity (albeit low sensitivity) for invasiveness and is an independent predictor of IAC. CLINICAL IMPACT. Those pGGNs that show the reticulation sign should be strongly suspected to represent IAC; this suspicion may guide risk assessments and follow-up recommendations.

Pulmonary Recruitment Prior to Intraoperative Multiple Pulmonary Ground-Glass Nodule Localization Increases the Localization Accuracy-A Retrospective Study.

The standard treatment for early-stage lung cancer is complete tumor excision by limited resection of the lung. Preoperative localization is used before video-assisted thoracoscopic surgery (VATS) to improve the accuracy of pulmonary nodule excision. However, lung atelectasis and hypoxia resulting from controlling apnea during the localization procedure may affect the localization accuracy. Pre-procedural pulmonary recruitment may improve the respiratory mechanics and oxygenation during localization. In this study, we investigated the potential benefits of pre-localization pulmonary recruitment prior to pulmonary ground-glass nodule localization in a hybrid operating room. We hypothesized that pre-localization pulmonary recruitment would increase the localization accuracy, improve oxygenation, and prevent the need for re-inflation during the localization procedure. We retrospectively enrolled patients with multiple pulmonary nodule localizations before surgical intervention in our hybrid operating room. We compared the localization accuracy between patients who had undergone pre-procedure pulmonary recruitment and patients who had not. Saturation, re-inflation rate, apnea time, procedure-related pneumothorax, and procedure time were also recorded as secondary outcomes. The patients who had undergone pre-procedure recruitment had better saturation, shorter procedure time, and higher localization accuracy. The pre-procedure pulmonary recruitment maneuver was effective in increasing regional lung ventilation, leading to improved oxygenation and localization accuracy.

Suspicious lung lesions for malignancy: the lesion-to-spinal cord signal intensity ratio in T2WI and DWI–MRI versus PET/CT; a prospective pathologic correlated study with accuracy and ROC analyses

BackgroundThe multi-detector computed tomography (MDCT) and tissue biopsy are the gold standards for the evaluation of lung malignancies. However, there is a wide range of pulmonary indeterminate lesions that could mimic lung cancer. Furthermore, the diagnosis of malignancy could be challenging if the lesion is small and early presenting by a part-solid or ground-glass nodule or if surrounded by parenchymal lung reaction with consolidation and atelectasis. The previous literature focused on the role of diffusion-weighted image–magnetic resonance imaging (DWI) and the apparent diffusion coefficient (ADC) mapping in the evaluation of lung malignancy. A novel quantitative T2 assessment is provided and tested in this study. Aim of the work: To evaluate the accuracy of specific non-invasive quantitative magnetic resonance imaging (MRI) parameters in the characterization of suspicious lung lesions and the discrimination between the malignant and benign nature. They included the lesion-to-spinal cord signal intensity ratio in T2-WI and DWI as well as the mean and minimum apparent diffusion coefficient (ADC) values. This is performed using a prospective pathologic correlated study with receiver-operating characteristics (ROC) analysis and comparison with positron emission tomography (PET-CT) accuracy results.ResultsThis study was prospectively performed during the period between June/2021 and June/2022. It was conducted on 43 suspicious lung lesions detected by MDCT. MRI and PET/CT examinations were performed for all patients, and the results were compared to the final diagnosis obtained after biopsy and pathological assessment, using the statistical tests of significance and P-value. Cutoff values were automatically calculated, and then, accuracy tests and ROC analyses were performed. Five expert radiologists and a single consulting pulmonologist participated in this study. The inter-rater reliability ranges between good and excellent with the intra-class correlation coefficient (ICC) ranging between 0.85 and 0.94. In T2-WI: The lesion-to-spinal cord signal intensity ratio was higher in the malignant group (1.35 ± 0.29) than in the benign group (0.88 ± 0.40), (P < 0.001). At the estimated cutoff value (> 1), the sensitivity was 96.43%, the specificity was 80.00%, and AUC = 0.86. In b500-DWI: The lesion-to-spinal cord signal intensity ratio was higher in the malignant group (0.70–1.35) than in the benign group (0.20–0.70) (P < 0.001). At the estimated cutoff value (> 0.7), the sensitivity was 71.43%, the specificity was 86.67%, and AUC = 0.86. The mean and minimum ADC values were lower in the malignant group (0.6–1.3 and 0.3–1.1 × 10–3 mm2/s) than the benign group (1–1.6 and 0.7–1.4 × 10–3 mm2/s), (P < 0.01 and < 0.001, respectively). At their estimated cutoff values (≤ 1.2 and ≤ 0.9 × 10–3 mm2/s, respectively), the sensitivity was (71.4 and 85.7%), specificity was (83.3 and 66.7%), respectively, and AUC = 0.77 for both. PET/CT had 96.4% sensitivity, 92.3% specificity, and AUC = 0.94.ConclusionsPET-CT remains the most specific and sensitive tool for the differentiation between benign and malignant lesions. The lesion-to-cord signal intensity ratios in T2WI and DWI-MRI and to a minor extent the mean and minimum ADC values are also considered good parameters for this differentiation based on their accurate statistical results, particularly if PET/CT was not available or feasible. The study added to the previous literature a novel quantitative T2WI assessment which proved a high sensitivity equal to PET/CT with a lower but a good specificity. The availability, expertise, time factor, and patients' tolerance remain challenging factors for MRI.

Application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection.

To explore the application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection. The clinical data of 90 patients who had small pulmonary nodules and received thoracoscopic sublobar resection during the period from September 2021 to October 2022 in the Department of Thoracic Surgery, Juxian People's Hospital, Shandong Province, were retrospectively analyzed. The diameters of 95 pulmonary nodules in the 90 patients in the whole group ranged from 0.40 to 1.24cm, and their distances from the visceral pleura ranged from 0.51 to 2.15cm. In these patients, percutaneous lung puncture was successfully performed under local anesthesia, through which coils were implanted in the nodules and medical adhesive was injected around the nodules, with a success rate of localization of 100%. Localization complications included 10 cases of asymptomatic pneumothorax, 9 cases of intrapulmonary hemorrhage, 5 cases of severe pain, and 1 case of pleural reaction, all of which required no special treatment. After preoperative localization, the success rate of resection of pulmonary nodules was 100%, and sufficient surgical margins were obtained. CT-guided localization using a coil in combination with medical adhesive is a safe, effective, and simple localization method that can meet the requirements of thoracic surgeons for intraoperative localization; for small pulmonary nodules, especially those small-sized and deep-located ground-glass nodules containing few solid mass, this method has important clinical application value, which is a preoperative localization technique worthy of wide application in clinical practice.

Early detection of lung cancer in a real-world cohort via tumor-associated immune autoantibody and imaging combination.

Efficient early detection methods for lung cancer can significantly decrease patient mortality. One promising approach is the use of tumor-associated autoantibodies (TAABs) as a diagnostic tool. In this study, the researchers aimed to evaluate the potential of seven TAABs in detecting lung cancer within a population undergoing routine health examinations. The results of this study could provide valuable insights into the utility of TAABs for lung cancer screening and diagnosis. In this study, the serum concentrations of specific antibodies were measured using enzyme-linked immunosorbent assay (ELISA) in a cohort of 15,430 subjects. The efficacy of both a 7-TAAB panel and LDCT for lung cancer detection were evaluated through receiver operating characteristic (ROC) analyses, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) being assessed and compared. These results could have significant implications for the development of improved screening methods for lung cancer. Over the 12-month observation period, 26 individuals were diagnosed with lung cancer. The 7-TAAB panel demonstrated promising sensitivity (61.5%) and a high degree of specificity (88.5%). The panel's area under the receiver operating characteristic (ROC) curve was 0.8062, which was superior to that of any individual TAAB. In stage I patients, the sensitivity of the panel was 50%. In our cohort, there was no gender or age bias observed. This 7-TAAB panel showed a sensitivity of approximately 60% in detecting lung cancer, regardless of histological subtype or lesion size. Notably, ground-glass nodules had a higher diagnostic rate than solid nodules (83.3% vs. 36.4%, P = 0.021). The ROC analyses further revealed that the combination of LDCT with the 7-TAAB assay exhibited a significantly superior diagnostic efficacy than LDCT alone. In the context of the study, it was demonstrated that the 7-TAAB panel showed improved detective efficacy of LDCT, thus serving as an effective aid for the detection of lung cancer in real-world scenarios.

Two-Centimeter Single-Port Incision Minimizing Intercostal Nerve Damage Applied in Video-Assisted Thoracoscopic Surgery Segmentectomy for Pulmonary Ground Glass Nodules.

Purposes: We introduced a novel modified 2-cm single-port incision made by blunt separation minimizing intercostal muscle and nerve damage applied in video-assisted thoracoscopic surgery (VATS) segmentectomy, and compared it with the traditional single-port incision or the novel incision plus a 3-mm tiny port, aiming to explore a more minimally invasive single-port technique for VATS segmentectomy. Materials and Methods: We retrospectively analyzed the clinical data of 174 pulmonary ground glass nodule patients who received single-port VATS segmentectomy (54 modified 2-cm single port, 67 modified single port plus tiny port, and 53 traditional single port, respectively) in our medical center from May 2020 to December 2022. Three kinds of approaches were compared retrospectively, concerning their safety, feasibility, and postoperative pain. Results: There were no serious complications and mortality in either group. The blood loss, tube duration, and hospitalization time were comparable among the three groups (P > .05). The 2-cm single-port and 2-cm single-port plus tiny-port group were obviously more advantageous in the visual analog scores of postoperative pain, the wound numbness, incision healing and appearance than that in the traditional group (P < .05), while they were comparable. Notably, the operation time of the 2-cm plus tiny-port group was shorter than that of the 2-cm group (P < .05) and similar to the traditional single-port group. Conclusions: The 2-cm modified single-port applied for VATS segmentectomy is feasible and safe, and has obviously advantages in postoperative pain, numbness, and appearance of incision. With addition of tiny port, the convenience of the operation can be significantly increased without increasing pain. Our finding could provide a promising new incision mode for VATS segmentectomy.

CT-based three-dimensional invasiveness analysis of adenocarcinoma presenting as pure ground-glass nodules.

We invest computed tomography (CT) image differences between non-invasive adenocarcinomas (NIAs) and invasive adenocarcinomas (IAs) presenting as pure ground glass nodules (GGNs). From 2013 to 2019, 48 pure GGNs were surgically resected in 45 patients. Of these, 40 were pathologically diagnosed as non-small cell lung cancers (NSCLCs). We assessed them using the Synapse Vincent (Fujifilm Co., Ltd., Tokyo, Japan) three-dimensional (3D) analysis system; we drew histograms of the CT densities. We calculated the maximum, minimum, means, and standard deviations of the densities. The proportions of GGNs of high CT density were compared between the two groups. The diagnostic performance was investigated via receiver operating curve (ROC) analysis. Of the 40 pure GGNs, 20 were NIAs (4 adenocarcinomas in situ and 16 minimally IAs) and 20 IAs. Significant correlations were evident between histological invasiveness and the maximum and mean CT densities and the standard deviation. Neither the nodule volume nor the minimum CT density significantly predicted invasiveness. A CT volume density proportion >-300 Hounsfield units optimally predicted the invasiveness of pure GGNs; the cutoff was 5.41% with a sensitivity of 85% and a specificity of 95%. CT density reflected the invasiveness of pure GGNs. A CT volume proportion density >-300 Hounsfield units may significantly predict histological invasiveness.

α-Cyanoacrylate Rapid Medical Adhesive (Medical EC Glue) Localization of Pulmonary Nodules Guided by Computed Tomography before Thoracoscopic Surgery.

The study aims to conduct lung cancer screening by low-dose CT to identify the nature of the pulmonary nodule. The purpose of this study was to evaluate the role of preoperative medical EC glue localization of pulmonary nodules of uncertain nature by minimally invasive surgical resection. From December 2017 to December 2019, 18 patients (12 women, 6 men; median age: 54 years)with pulmonary nodules were located using medical EC glue under the guidance of preoperative CT and then resected under video thoracoscopy at Air Force Medical Center of PLA. The clinical characteristics were retrospectively collected to evaluate the effectiveness, safety and feasibility of the operation. The mean value of the maximum diameter of pulmonary nodules on CT images before the operation was 10.8 mm. The average depth was 10.3 mm (1.0-39.5 mm). Among 18 nodules, 8 were pure ground glass nodules, 3 were solid nodules, and 7 were partial solid nodules. The diagnosis rate of medical glue localization under the guidance of CT after the operation was 100%. Postoperative pathological diagnosis showed that there were 10 cases of primary lung adenocarcinoma, 1 case of invasive lung adenocarcinoma, 3 cases of adenocarcinoma in situ, 1 case of metastatic adenocarcinoma, and 3 cases of benign nodules. No obvious serious complications were found after localization. This study suggests that CT-guided percutaneous medical EC glue localization is a reliable, safe, feasible and practical method for undiagnosed pulmonary nodules and can significantly improve the rate of resection of small pulmonary nodules. Furthermore, it was considered to be more reasonable to remove pulmonary nodules and maximize the preservation of lung function.

MRI Compared with Low-Dose CT for Incidental Lung Nodule Detection in COPD: A Multicenter Trial.

To investigate morphofunctional chest MRI for the detection and management of incidental pulmonary nodules in participants with chronic obstructive pulmonary disease (COPD). In this prospective study, 567 participants (mean age, 66 years ± 9 [SD]; 340 men) underwent same-day contrast-enhanced MRI and nonenhanced low-dose CT (LDCT) in a nationwide multicenter trial (clinicaltrials.gov: NCT01245933). Nodule dimensions, morphologic features, and Lung Imaging Reporting and Data System (Lung-RADS) category were assessed at MRI by two blinded radiologists, and consensual LDCT results served as the reference standard. Comparisons were performed using the Student t test, and agreements were assessed using the Cohen weighted κ. A total of 525 nodules larger than 3 mm in diameter were detected at LDCT in 178 participants, with a mean diameter of 7.2 mm ± 6.1 (range, 3.1-63.1 mm). Nodules were not detected in the remaining 389 participants. Sensitivity and positive predictive values with MRI for readers 1 and 2, respectively, were 63.0% and 84.8% and 60.2% and 83.9% for solid nodules (n = 495), 17.6% and 75.0% and 17.6% and 60.0% for part-solid nodules (n = 17), and 7.7% and 100% and 7.7% and 50.0% for ground-glass nodules (n = 13). For nodules 6 mm or greater in diameter, sensitivity and positive predictive values were 73.3% and 92.2% for reader 1 and 71.4% and 93.2% for reader 2, respectively. Readers underestimated the long-axis diameter at MRI by 0.5 mm ± 1.7 (reader 1) and 0.5 mm ± 1.5 (reader 2) compared with LDCT (P < .001). For Lung-RADS categorization per nodule using MRI, there was substantial to perfect interreader agreement (κ = 0.75-1.00) and intermethod agreement compared with LDCT (κ = 0.70-1.00 and 0.69-1.00). In a multicenter setting, morphofunctional MRI showed moderate sensitivity for detection of incidental pulmonary nodules in participants with COPD but high agreement with LDCT for Lung-RADS classification of nodules.Clinical trial registration no. NCT01245933 and NCT02629432Keywords: MRI, CT, Thorax, Lung, Chronic Obstructive Pulmonary Disease, Screening© RSNA, 2023 Supplemental material is available for this article.

Long-term follow-up of persistent pulmonary subsolid nodules: Natural course of pure, heterogeneous, and real part-solid ground-glass nodules.

Previous studies have suggested the applicability of three classifications of subsolid nodules (SSNs). However, few studies have unraveled the natural history of the three types of SSNs. A retrospective study from two medical centers between November 2007 and November 2017 was conducted to explore the long-term follow-up results of three different types of SSNs, which were divided into pure ground-glass nodules (pGGNs), heterogeneous ground-glass nodules (hGGNs), and real part-solid nodules (rPSNs). A total of 306 consecutive patients, including 361 SSNs with long-term follow-up, were reviewed. The median growth times of pGGNs, hGGNs, and rPSNs were 7.7, 6.0, and 2.0 years, respectively. For pGGNs, the median period of development into rPSNs was 4.6 years, while that of hGGNs was 1.8 years, and the time from pGGNs to hGGNs was 3.1 years (p < 0.05). In SSNs with an initial lung window consolidation tumor ratio (LW-CTR) >0.5 and mediastinum window (MW)-CTR >0.2, all cases with growth were identified within 5 years. Meanwhile, in SSNs whose LW-CTR and MW-CTR were 0, it took over 5 years to detect nodular growth. Pathologically, 90.6% of initial SSNs with LW-CTR >0 were invasive carcinomas (invasive adenocarcinoma and micro-invasive adenocarcinoma). Among patients with rPSNs in the initial state, 100.0% of the final pathological results were invasive carcinoma. Cox regression showed that age (p=0.038), initial maximal diameter (p < 0.001), and LW-CTR (p=0.002) were independent risk factors for SSN growth. pGGNs, hGGNs, and rPSNs have significantly different natural histories. Age, initial nodule diameter, and LW-CTR are important risk factors for SSN growth.

“Will I change nodule management recommendations if I change my CAD system?”—impact of volumetric deviation between different CAD systems on lesion management

ObjectivesTo evaluate and compare the measurement accuracy of two different computer-aided diagnosis (CAD) systems regarding artificial pulmonary nodules and assess the clinical impact of volumetric inaccuracies in a phantom study.MethodsIn this phantom study, 59 different phantom arrangements with 326 artificial nodules (178 solid, 148 ground-glass) were scanned at 80 kV, 100 kV, and 120 kV. Four different nodule diameters were used: 5 mm, 8 mm, 10 mm, and 12 mm. Scans were analyzed by a deep-learning (DL)–based CAD and a standard CAD system. Relative volumetric errors (RVE) of each system vs. ground truth and the relative volume difference (RVD) DL–based vs. standard CAD were calculated. The Bland–Altman method was used to define the limits of agreement (LOA). The hypothetical impact on LungRADS classification was assessed for both systems.ResultsThere was no difference between the three voltage groups regarding nodule volumetry. Regarding the solid nodules, the RVE of the 5-mm-, 8-mm-, 10-mm-, and 12-mm-size groups for the DL CAD/standard CAD were 12.2/2.8%, 1.3/ − 2.8%, − 3.6/1.5%, and − 12.2/ − 0.3%, respectively. The corresponding values for the ground-glass nodules (GGN) were 25.6%/81.0%, 9.0%/28.0%, 7.6/20.6%, and 6.8/21.2%. The mean RVD for solid nodules/GGN was 1.3/ − 15.2%. Regarding the LungRADS classification, 88.5% and 79.8% of all solid nodules were correctly assigned by the DL CAD and the standard CAD, respectively. 14.9% of the nodules were assigned differently between the systems.ConclusionsPatient management may be affected by the volumetric inaccuracy of the CAD systems and hence demands supervision and/or manual correction by a radiologist.Key Points• The DL-based CAD system was more accurate in the volumetry of GGN and less accurate regarding solid nodules than the standard CAD system.• Nodule size and attenuation have an effect on the measurement accuracy of both systems; tube voltage has no effect on measurement accuracy.• Measurement inaccuracies of CAD systems can have an impact on patient management, which demands supervision by radiologists.

CT imaging indications correlate with the degree of lung adenocarcinoma infiltration.

Ground glass nodules (GGN) of the lung may be a precursor of lung cancer and have received increasing attention in recent years with the popularity of low-dose high-resolution computed tomography (CT). Many studies have discussed imaging features that suggest the benignity or malignancy of GGN, but the extent of its postoperative pathological infiltration is poorly understood. In this study, we identified CT imaging features that indicate the extent of GGN pathological infiltration. A retrospective analysis of 189 patients with pulmonary GGN from January 2020 to December 2021 at Shanxi Cancer Hospital was performed. Patients were classified according to their pathological type into non-invasive adenocarcinoma [atypical adenomatous hyperplasia (AAH) and adenocarcinoma in situ (AIS) in a total of 34 cases], micro-invasive adenocarcinoma (MIA) in 80 cases, and invasive adenocarcinoma (IAC) in a total of 75 cases. The general demographic data, nodule size, nodule area, solid component, CT indications and pathological findings of the three groups of patients were analyzed to predict the correlation between GGN and the degree of lung adenocarcinoma infiltration. No statistically significant differences were found among the three groups in general information, vascular signs, and vacuolar signs (P > 0.05). Statistically significant differences among the three groups were found in nodule size, nodule area, lobar signs, pleural traction, burr signs, bronchial signs, and solid components (P < 0.05). Logistic regression equation tests based on the statistically significant indicators showed that nodal area, lobar sign, pleural pull, burr sign, bronchial sign, and solid component were independent predictors of lung adenocarcinoma infiltration. The subject operating characteristic (ROC) curve analysis showed that nodal area is valuable in predicting GGN infiltration. CT-based imaging indications are useful predictors of infiltrative adenocarcinoma manifested as pulmonary ground glass nodules.

Computer-Aided Detection of Subsolid Nodules on Chest Computed Tomography: Assessment of Visualization on Vessel-Suppressed Images.

This study aimed to clarify the performance of automatic detection of subsolid nodules by commercially available software on computed tomography (CT) images of various slice thicknesses and compare it with visualization on the accompanying vessel-suppression CT (VS-CT) images. A total of 95 subsolid nodules from 84 CT examinations of 84 patients were included. The reconstructed CT image series of each case with 3-, 2-, and 1-mm slice thicknesses were loaded into a commercially available software application (ClearRead CT) for automatic detection of subsolid nodules and generation of VS-CT images. Automatic nodule detection sensitivity was assessed for 95 nodules on each series of images acquired at 3 slice thicknesses. Four radiologists subjectively evaluated visual assessment of the nodules on VS-CT. ClearRead CT automatically detected 69.5% (66/95 nodules), 68.4% (65/95 nodules), and 70.5% (67/95 nodules) of all subsolid nodules in 3-, 2-, and 1-mm slices, respectively. The detection rate was higher for part-solid nodules than for pure ground-glass nodules at all slice thicknesses. In the visualization assessment on VS-CT, 3 nodules at each slice thickness (3.2%) were judged as invisible, while 26 of 29 (89.7%), 27 of 30 (90.0%), and 25 of 28 (89.3%) nodules, which were missed by computer-aided detection, were judged as visible in 3-, 2-, and 1-mm slices, respectively. The automatic detection rate of subsolid nodules by ClearRead CT was approximately 70% at all slice thicknesses. More than 95% of subsolid nodules were visualized on VS-CT, including nodules undetected by the automated software. Computed tomography acquisition at slices thinner than 3 mm did not confer any benefits.

A combined non-enhanced CT radiomics and clinical variable machine learning model for differentiating benign and malignant sub-centimeter pulmonary solid nodules.

Radiomics has been used to predict pulmonary nodule (PN) malignancy. However, most of the studies focused on pulmonary ground-glass nodules. The use of computed tomography (CT) radiomics in pulmonary solid nodules, particularly sub-centimeter solid nodules, is rare. This study aims to develop a radiomics model based on non-enhanced CT images that can distinguish between benign and malignant sub-centimeter pulmonary solid nodules (SPSNs, <1cm). The clinical and CT data of 180 SPSNs confirmed by pathology were analyzed retrospectively. All SPSNs were divided into two groups: training set (n=144) and testing set (n=36). From non-enhanced chest CT images, over 1000 radiomics features were extracted. Radiomics feature selection was performed using the analysis of variance and principal component analysis. The selected radiomics features were fed into a support vector machine (SVM) to develop a radiomics model. The clinical and CT characteristics were used to develop a clinical model. Associating non-enhanced CT radiomics features with clinical factors were used to develop a combined model using SVM. The performance was evaluated using the area under the receiver-operating characteristic curve (AUC). The radiomics model performed well in distinguishing between benign and malignant SPSNs, with an AUC of 0.913 (95% confidence interval [CI], 0.862-0.954) in the training set and an AUC of 0.877 (95% CI, 0.817-0.924) in the testing set. The combined model outperformed the clinical and radiomics models with an AUC of 0.940 (95% CI, 0.906-0.969) in the training set and an AUC of 0.903 (95% CI, 0.857-0.944) in the testing set. Radiomics features based on non-enhanced CT images can be used to differentiate SPSNs. The combined model, which included radiomics and clinical factors, had the best discrimination power between benign and malignant SPSNs.

Correlations Between Inflammatory Cell Infiltration and Relative Density and the Boundary Manifestation of Pulmonary Non-Neoplastic Ground Glass Nodules.

To investigate the influence factors for the various boundary manifestations of pulmonary non-neoplastic ground glass nodules (GGNs) on computed tomography (CT). From January 2015 to March 2022, a total of 280 patients with 318 non-neoplastic GGNs were enrolled. The correlations between degree of inflammatory cell infiltration and relative density (ΔCT) and the boundary manifestations of lesions were evaluated, respectively. Nongranulomatous nodules (283, 89.0%) with fibrous tissue proliferation and/or inflammatory cells as the predominant pathological findings were the most common non-neoplastic GGNs, followed by granulomatous nodules (28, 8.8%). Among nongranulomatous GGNs, cases with more and less/no inflammatory cells were 15 (10.9%) and 122 (89.1%) in 137 well-defined ones with smooth margin, 16 (24.6%) and 49 (75.4%) in 65 well-defined ones with coarse margin, 43 (91.5%) and 4 (8.5%) in 47 ill-defined ones with higher ΔCT (>151HU), and 4 (11.8%) and 30 (88.2%) in 34 ill-defined ones with lower ΔCT (< 151HU). The proportion of cases with more inflammatory cells in well-defined nodules was similar to that in ill-defined ones with lower ΔCT (P = 0.587) but significantly lower than that in ill-defined ones with higher ΔCT (P < 0.001). Among the granulomatous nodules, ill-defined cases with higher ΔCT (16, 57.1%) were the most common, and they (7/8, 87.5%) frequently had changes during short-term follow-up. Nongranulomatous nodules are the most common non-neoplastic GGNs, their diverse boundary manifestations closely correlate with degree of inflammatory cell infiltration and density difference.

A narrative review of the clinical approach to subsolid pulmonary nodules.

The widespread use of chest computed tomography (CT) for lung cancer screening has led to increased detection of subsolid pulmonary nodules. The management of subsolid nodules (SSNs) is challenging since they are likely to grow slowly and a long-term follow-up is needed. In this review, we discuss the characteristics, natural history, genetic features, surveillance, and management of SSNs. PubMed and Google Scholar were searched to identify relevant articles published in English between January 1998 and December 2022 using the following keywords: "subsolid nodule", "ground-glass nodule (GGN)", and "part-solid nodule (PSN)". The differential diagnosis of SSNs includes transient inflammatory lesions, focal fibrosis, and premalignant or malignant lesions. Long-term CT surveillance follow-up is needed to manage SSNs that persist for >3 months. Although most SSNs have an indolent clinical course, PSNs may have a more aggressive clinical course than pure GGNs. The proportion of growth and the time to grow is higher and shorter in PSN than pure GGN. In lung adenocarcinoma manifesting as SSNs, EGFR mutations were the major driver mutations. Guidelines are available for the management of incidentally detected and screening-detected SSNs. The size, solidity, location, and number of SSNs are important factors in determining the need for surveillance and surgical resection, as well as the interval of follow-up. Positron emission tomography/CT and brain magnetic resonance imaging (MRI) are not recommended for the diagnosis of SSNs, especially for pure GGNs. Periodic CT surveillance and lung-sparing surgery are the main strategies for the management of persistent SSNs. Nonsurgical treatment options for persistent SSNs include stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA). For multifocal SSNs, the timing of repeated CT scans and the need for surgical treatment are decided based on the most dominant SSN(s). The SSN is a heterogeneous disease and a personalized medicine approach is required in the future. Future studies of SSNs should focus on their natural history, optimal follow-up duration, genetic features, and surgical and nonsurgical treatments to improve the corresponding clinical management. All these efforts will lead to the personalized medicine approach for the SSNs.

Uniportal video-assisted thoracoscopic combined subsegmentectomy: a case report of left S3b + S4b

: Anatomical complex segmentectomy has become increasingly important in oncological lung resection, particularly for small ground-glass nodules of primary lung cancers. Resection of a lung nodule located between the left upper division and the lingual segment is technically challenging. Delicate surgical planning is crucial to ensure adequate surgical margin while preserving maximum pulmonary function. A combined subsegmentectomy can be a feasible choice but is challenging to perform under uniportal approach due to limited working space and insufficient exposure of target segmental bronchi and pulmonary arteries. The purpose of this article is to introduce the technique we use to overcome these challenges. Herein, we report a case with two ground-glass nodules in the left upper lobe, one 0.6-cm adjacent to the V3b and one 0.4-cm beneath the S4b surface. Instead of extended upper division trisegmentectomy or extended lingulectomy, a uniportal video-assisted thoracoscopic S3b + S4b combined subsegmentectomy was planned and performed. Three-dimensional computed tomography reconstruction was performed preoperatively to reveal the branching pattern of the associated sub-segmental bronchi and pulmonary vessels. Inflation-deflation method was applied to identify intersegmental planes, and both lesions were removed successfully. We describe our “open the side door” technique for performing subsegmentectomy in this patient. This technique is helpful when performing a complex subsegmentectomy.

Clinical characteristics and risk factors of in-hospital mortality in patients coinfected with Pneumocystis jirovecii and Aspergillus.

To analyze clinical characteristics and risk factors for in-hospital mortality in patients coinfected with P. jirovecii and Aspergillus. This study included 53 patients with coinfection of P. jirovecii pneumonia (PJP) and invasive pulmonary aspergillosis (IPA) in our center from January 2011 to December 2021. All cases were divided into survivor (n=27) and non-survivor groups (n=26). Medical records, laboratory and radiology data were collected. Risk factors for in-hospital mortality were identified by multivariable analyses. HIV-positive patients accounted for 3.8%. Fever (77.4%), dyspnea (69.8%) and wet cough (24.5%) were common symptoms. Ground-glass opacity (83.0%), consolidation (71.7%), septal thickening (66.0%), and nodules (54.7%) were the most common radiological signs. CD4+ T cell count and serum albumin (ALB) level were significantly lower in non-survival group than in the survival group. Conversely, serum lactate dehydrogenase (LDH) and procalcitonin (PCT) levels were higher in non-survival group than in survival group. Lactic acidosis [odds ratio (OR): 33.999,95% confidential interval (CI): 3.112-371.409; p=0.004], low CD4+ T cell count (<114 cell/µL) [OR: 19.343, 95% CI: 1.533-259.380; p=0.022] and high level of LDH (> 519 U/L) [OR: 11.422, 95% CI: 1.271-102.669; p=0.030] were independent risk factors for mortality. PJP coinfected with IPA incurs high mortality with nonspecific clinical characteristics and is more likely to involve HIV-negative patients. Lactic acidosis, low CD4+ T cell count and high LDH level are independent risk factors for mortality, close monitoring of these parameters is necessary to help distinguish high-risk patients and make appropriate clinical decisions.

Ground glass nodules with scattered or eccentric island-shaped consolidations may have poor outcomes.

To explore the effect of scattered or eccentric shaped types of ground glass opacity (GGO) on outcomes of patients with solid-dominant peripheral lung adenocarcinoma. We evaluated patients with solid-dominant peripheral lung adenocarcinoma, who underwent radical surgery at Zhongshan Hospital, Fudan University, between January 2013 and December 2015. Morphologically heterogeneous solid-dominant lung adenocarcinoma in imaging findings was based on the last preoperative computed tomography(CT) scans. Endpoints were recurrence-free survival (RFS) and overall survival (OS). Kaplan-Meier analysis and the log-rank test were used to estimate survival differences. Impact factors were assessed by univariable logistic regression analysis. We retrospectively collected data from 200 patients, including 170 patients with central island-shaped CT imaging, 18 patients with scattered shaped CT imaging, and 12 patients with eccentric shaped CT imaging. Eleven patients experienced recurrence or metastases. Kaplan-Meier survival curves showed significant survival differences between the central island-shaped type and scattered shaped or eccentric shaped type for OS (c-stage IA: 5-year OS: 100% vs. 92.1%; HR = 0.019, p = 0.0025; p-stage IA: 100% vs. 95.2%; HR = 0.146, p = 0.1139) and RFS (c-stage IA: 5-year RFS: 100% vs. 59.7%; HR = 0.001, p < 0.0001; p-stage IA: 100% vs. 64.5%; HR < 0.001, p < 0.0001). Univariable logistic regression analysis showed that scattered and eccentric shaped types were related to poor outcomes (p < 0.012, odds ratio = 18.8). Relative spatial position of GGO and solid components may affect patient outcomes. Patients with scattered or eccentric shaped GGO may have a poor prognosis.

Prediction of Lymph Node Metastasis of Mixed Ground-glass Nodules Based on Clinical Imaging Information

Previous studies have shown that lymph node metastasis only occurs in some mixed ground-glass nodules (mGGNs) which the pathological results were invasive adenocarcinoma (IAC). However, the presence of lymph node metastasis leads to the upgrading of tumor-node-metastasis (TNM) stage and worse prognosis of the patients, so it is important to perform the necessary evaluation before surgery to guide the operation method of lymph node. The aim of this study was to find suitable clinical and radiological indicators to distinguish whether mGGNs with pathology as IAC is accompanied by lymph node metastasis, and to construct a prediction model for lymph node metastasis. From January 2014 to October 2019, the patients with resected IAC appearing as mGGNs in computed tomography (CT) scan were reviewed. All the lesions were divided into two groups (with lymph node metastasis or not) according to their lymph node status. Lasso regression model analysis by applying R software was used to evaluate the relationship between clinical and radiological parameters and lymph node metastasis of mGGNs. A total of 883 mGGNs patients were enroled in this study, among which, 12 (1.36%) showed lymph node metastasis. Lasso regression model analysis of clinical imaging information in mGGNs with lymph node metastasis showed that previous history of malignancy, mean density, mean density of solid components, burr sign and percentage of solid components were informative. Prediction model for lymph node metastasis in mGGNs was developed based on the results of Lasso regression model with area under curve=0.899. Clinical information combined with CT imaging information can predict lymph node metastasis in mGGNs.