Pulmonary Ground-glass Opacity Research Articles

Preliminary Results: Can Dual-Energy Computed Tomography Help Distinguish Cardiogenic Pulmonary Edema and Acute Interstitial Lung Disease?

We compared iodine concentration in pulmonary ground-glass opacity on iodine density images of contrast-enhanced chest dual-energy computed tomography (DECT) between patients with cardiogenic pulmonary edema (CPE) and acute interstitial lung disease (AILD). Five of 12 patients who underwent contrast-enhanced chest DECT to exclude pulmonary embolism were clinically diagnosed with CPE and 7, with AILD. We compared the mean CT value on monochromatic images at 65 keV and iodine concentration on iodine density images between the affected and normal areas. The mean iodine concentrations were comparable between the affected and normal areas (P = 0.3048) in patients with CPE and were significantly higher in the affected than in the normal areas in those with AILD (P < 0.0001). Measurement of iodine concentration in pulmonary ground-glass opacity of contrast-enhanced chest DECT has the potential to help distinguish CPE and AILD.

Multislice spiral computed tomography in the differential diagnosis of ground-glass opacity

This study aimed to evaluate the value of multislice spiral computed tomography (CT) in differential diagnosis of benign or malignant pulmonary ground-glass opacity (GGO). A total of 68 patients with pulmonary GGO who received surgical treatment in our hospital from January 2014 to January 2017 were retrospectively analyzed. Postoperative pathology showed that there were 22 cases of benign GGO and 47 cases of malignant GGO (adenocarcinoma). The diameter, maximum CT value, and mean CT value of benign and malignant GGOs were determined and compared. The clinical value of identifying benign or malignant GGOs with these indices was analyzed through receiver operating characteristic (ROC) curve. The mean GGO diameter, maximum CT value, and mean CT value in the benign group were significantly lower than those of in the malignant group, and the difference was statistically significant (P < 0.05). The diameter, maximum CT value, and mean CT value of GGO were applied to identify benign or malignant GGO: sensitivity was 60.87%, 69.57%, and 63.04%; and the specificity was 63.64%, 63.64%, and 81.82%; the cutoff values were 13.89 (mm), 26.18 (Hu), and 24.61 (Hu); and areas under the ROC curves were 0.66, 0.71, and 0.69, respectively. The possibility of malignancy has been significantly increased for GGOs with a large diameter, high mean CT value and maximum CT value. Surgical treatment should be performed for this type of GGOs.

Radiomic analysis of pulmonary ground-glass opacity nodules for distinction of preinvasive lesions, invasive pulmonary adenocarcinoma and minimally invasive adenocarcinoma based on quantitative texture analysis of CT.

ObjectiveTo identify the differences among preinvasive lesions, minimally invasive adenocarcinomas (MIAs) and invasive pulmonary adenocarcinomas (IPAs) based on radiomic feature analysis with computed tomography (CT).MethodsA total of 109 patients with ground-glass opacity lesions (GGOs) in the lungs determined by CT examinations were enrolled, all of whom had received a pathologic diagnosis. After the manual delineation and segmentation of the GGOs as regions of interest (ROIs), the patients were subdivided into three groups based on pathologic analyses: the preinvasive lesions (including atypical adenomatous hyperplasia and adenocarcinoma in situ) subgroup, the MIA subgroup and the IPA subgroup. Next, we obtained the texture features of the GGOs. The data analysis was aimed at finding both the differences between each pair of the groups and predictors to distinguish any two pathologic subtypes using logistic regression. Finally, a receiver operating characteristic (ROC) curve was applied to accurately evaluate the performances of the regression models. ResultsWe found that the voxel count feature (P<0.001) could be used as a predictor for distinguishing IPAs from preinvasive lesions. However, the surface area feature (P=0.040) and the extruded surface area feature (P=0.013) could be predictors of IPAs compared with MIAs. In addition, the correlation feature (P=0.046) could distinguish preinvasive lesions from MIAs better.ConclusionsPreinvasive lesions, MIAs and IPAs can be discriminated based on texture features within CT images, although the three diseases could all appear as GGOs on CT images. The diagnoses of these three diseases are very important for clinical surgery.

Diagnostic value of endobronchial ultrasonography with a guide sheath for peripheral pulmonary ground glass opacity

Objective: To explore the diagnostic value of endobronchial ultrasonography with a guide sheath (EBUS-GS) for peripheral pulmonary ground glass opacity (GGO). Methods: The clinical data of 27 consecutive patients with 27 GGOs diagnosed by EBUS-GS between November 2014 to December 2015 in our Cancer Hospital were retrospectively analyzed. The average age of these 27 patients, including 9 males and 18 females, was 59±11 years. The median lesion size of the 27 GGOs was 2.9±1.2 cm, including 24 mixed GGOs and 3 pure GGOs. EBUS images of all 27 GGOs were evaluated, cytological, histological and combination diagnosis analyzed, and complications observed. Results: Under thin bronchoscope, 2 out of 27 cases showed bronchial stenosis, 1 showed bronchial stenosis with mucosal swelling, and the other 24 did not show abnormalities. Twenty-five out of 27 GGOs were found by EBUS, including 22 cases of mGGO and 3 of pGGO. In these ultrasonic images of 22 mGGOs, 18 showed mixed blizzard sign, 3 showed diffusely heterogeneous acoustic shadow and 1showed blizzard sign. Ultrasonic images of 3 pGGOs all appeared as blizzard sign. Twenty-six cytological specimens were obtained, and 16 were diagnosed clearly. All 27 histological specimens were collected, and 18 were diagnosed clearly. Nineteen of 27 cases were diagnosed by combination of cytological and histological specimens. One complication of EBUS-GS with mild bleeding was observed, and hemorrhage was terminated by conservative treatment. Conclusions: EBUS-GS is valuable for GGO diagnosis with less complications and higher safety. GGO ultrasonic image manifested as mixed blizzard sign, blizzard sign or diffusely heterogeneous acoustic shadow.

P2.05-015 Wedge Resection Is Enough for Curing GGO Patients with Minimally Invasive Adenocarcinoma (MIA) of the Lung?

More and more pulmonary ground-glass opacity (GGO) were detected and surgically resected, but the resection extent remains unconcluded, especially for those micro- small lung cancer (≤1cm) (mi-SLC), some are adenocarcinoma in situ (AIS), some minimally invasive adenocarcinoma (MIA), both belonging to early stage lung cancer. Wedge resection may be enough for curing lung MIA.

Solitary pulmonary ground-glass opacity: is it time for new surgical guidelines?

As screening for lung cancer becomes more common around the world, so too does detection of pulmonary ground-glass opacities (GGOs). Although a number of guidelines have been published that cover the management of GGOs, they typically feature some common themes. These include basing management and surveillance on a limited number of computed tomography imaging criteria only, inadequate consideration of the pros and cons of non-surgical biopsy versus surgery, inadequate consideration of modern advances in surgery for GGOs and inadequate consideration of potential variations in pathology in different parts of the world. As GGOs become increasingly common in thoracic surgical practice, it may be appropriate to draft new guidelines for the clinical management GGOs that take a more distinctly surgical and international perspective.

Cosmetic Talc–Related Pulmonary Granulomatosis

Inhalation of cosmetic talc can lead to pulmonary foreign-body granulomatosis, though fewer than 10 cases of inhaled cosmetic talc–related pulmonary granulomatosis have been reported in adults. We report the case of a 64-year-old man with diffuse, bilateral pulmonary nodules and ground glass opacities associated with chronic inhalation of cosmetic talc. Transbronchial biopsy showed peribronchiolar foreign-body granulomas. After cessation of talc exposure, the patient demonstrated clinical and radiographic improvement without the use of corticosteroids. This case demonstrates that a conservative approach with cessation of exposure alone, without the use of corticosteroids, can be an effective therapy in cosmetic talc–related pulmonary granulomatosis.

Pulmonary ground-glass opacity: computed tomography features, histopathology and molecular pathology.

The incidence of pulmonary ground-glass opacity (GGO) lesions is increasing as a result of the widespread use of multislice spiral computed tomography (CT) and the low-dose CT screening for lung cancer detection. Besides benign lesions, GGOs can be a specific type of lung adenocarcinomas or their preinvasive lesions. Evaluation of pulmonary GGO and investigation of the correlation between CT imaging features and lung adenocarcinoma subtypes or driver genes can be helpful in confirming the diagnosis and in guiding the clinical management. Our review focuses on the pathologic characteristics of GGO detected at CT, involving histopathology and molecular pathology.

Usefulness of Intraoperative Cone Beam CT Images on Video-assisted Thoracic Surgery.

For the resection of pulmonary ground glass opacity (GGO) or non-palpable nodule on video-assisted thoracic surgery (VATS), preoperative computed tomography (CT)-guided VATS marker pricking is usually performed. Recently, air embolisms after VATS marker pricking have been reported to be serious problems. The purpose of this study was to evaluate the usefulness of intraoperative cone beam CT images on VATS to avoid preoperative VATS marker pricking. The CT number of the both GGO and nodule indicate the range from -200 to -800 HU in general. We evaluated the detection ability of the lesion in seven elements and the simulated lungs. The result indicated that there was a linear equation of "y=1.0599×-2.1492" and the degree of correlation was "R2=0.9826" for the relationship between CT number and W number [voxel number in cone beam computed tomography (CBCT)]. Evaluation of low contrast resolution has been performed. The contrast noise ratios were 2.86 on CBCT and 1.50 on multi detector-row computed tomography (MDCT), while the relative contrast ratios were same both on CBCT and MDCT (0.19) as the lowest CT number (-700 HU). In clinical situation, four types of pulmonary lesions (pure GGO, mixed GGO, solid nodule, and cyst) were detected on MDCT, and intraoperative CBCT could identify all lesions as same configuration as on MDCT. The contrast noise ratio (CNR) and relative contrast ratio (RCR) could not admit the significant difference. In conclusion, the intraoperative CBCT can be used as a non-invasive image navigator for VATS, and the preoperative CT-guided VATS marker pricking can be avoided.

Progressions on Diagnosis and Treatment of Ground-glass Opacity

近年来，肺部磨玻璃影（ground-glass opacity, GGO）逐渐得到了肿瘤科和胸外科医生的普遍关注。GGO是指肺部CT表现为密度轻微增加，增加程度小于实性改变，呈模糊的云雾状，并可见其内血管和支气管纹理。GGO多数情况下呈惰性，但也可进一步发展为肺腺癌，这使其治疗方案的选择颇为棘手；近年来GGO发现率的日益增加也使其关注度得到大大提升。许多报道都从组织学、放射诊断学、治疗学等多个方面对GGO的诊治进行了探讨。本文综述了近10年来学界对GGO的诊断和处理的进展，希望临床医生能更好地认识这个问题，在临床工作中收集并总结更多循证学证据，以指导未来的临床诊治方案的选择。

術中同定困難な肺末梢小型ground-glass opacities (GGO)に対するEBUS-GSおよび気管支ナビゲーションシステムを用いたマーキング法

術中同定困難な肺末梢小型ground-glass opacities (GGO)に対するEBUS-GSおよび気管支ナビゲーションシステムを用いたマーキング法

Uniportal video-assisted thoracic surgery resection of small ground-glass opacities (GGOs) localized with CT-guided placement of microcoils and palpation.

Although uniportal video-assisted thoracic surgery (VATS) is becoming more popular, it's still very challenging to conduct a wedge resection of small pulmonary ground-glass opacities (GGOs), especially deeply situated subpleural GGOs, via uniportal VATS. We successfully performed thirteen uniportal VATS wedge resections through an approach that combines radiologically guided microcoil localization with palpation, and we encountered no complications related to the new approach. Based on our experience, a combination of CT-guided microcoil localization with palpation in uniportal VATS for deeply situated subpleural GGOs is a safe and effective procedure for accurate diag¬nosis and resection of indeterminate GGOs.

Surgery for Pulmonary Multiple Ground Glass Opacities

肺部磨玻璃影（ground glass opacity, GGO）的发病率近年来日益增高，很多患者发现有多发GGO，但多发GGO的诊疗还存在争议。肺部GGO是一种影像学表现，包含了多种病理类型，其中有一部分GGO是早期肺癌。GGO是一种惰性结节，只有少数GGO会发生变化，且随访不会影响外科治疗的效果。多发GGO的手术时机主要由主病灶决定，主病灶中实性成分大于5 mm时建议外科干预。手术方式可以选择肺叶切除或亚肺叶切除，除主病灶以外，其他GGO不必全部切除。具有高危因素的多发GGO需要纵隔淋巴结清扫或采样。

Advances in Surgical Treatment of Early Stage Non-small Cell Lung Cancer

肺癌是恶性肿瘤患者首位的死亡原因，随着计算机断层扫描（computed tomography, CT）等影像筛查的普及，肺癌的疾病谱正在发生变化，以往以中央型局部晚期肺鳞癌为主，而目前肺癌疾病谱主要为以孤立性肺结节、磨玻璃结节、亚厘米结节等为影像学表现的早期肺腺癌。早期肺癌是目前临床研究的热点，本文将就早期肺癌外科治疗的多个方面进展进行述评。

Thoracoscopic anatomic pulmonary segmentectomy: a 3-dimensional guided imaging system for lung operations.

To evaluate the Lung Operation Three-dimensional Imaging System software by Xiamen TRONG Technology Co. Ltd in detecting the precise position of solitary pulmonary nodules or ground-glass opacity nodules before surgery. Chest, arterial phase, portal venous phase, enhanced and delayed-phase images of 10 cases with 12 nodules were obtained with a Toshiba Aquilion One 320 computed tomography (CT) scanner. According to the image data of the nodules, 0.5 mm thick images of 320-row multislice CT scanners were reconstructed as 3D images, and the boundary of each segment was automatically partitioned and pigmented in accordance with the pulmonary artery system. To locate the nodules, the 3D images and coloured segments were merged. The clearly labelled lung structure was utilized in a preoperative virtual segmentectomy and the subsequently planned thoracoscopic surgery. In all 10 cases, the reconstruction of the pulmonary artery could image branches as far as Grade 5. The anatomically adjacent relationship of the nodules among the arteries, veins and bronchi in the target pulmonary segments could be displayed in any view. The thoracoscopic anatomic pulmonary segmentectomy was performed successfully. All 12 nodules, which had deeply settled in the parenchyma, were resected using the virtual planning software and diagnosed pathologically. The software can be used preoperatively as a tracing method to identify the location of nodules in most general thoracic surgeries, subsequently providing guidance during the surgery.

Modified inflammation-based score as an independent malignant predictor in patients with pulmonary focal ground-glass opacity: a propensity score matching analysis

Pulmonary focal Ground-glass Opacities (fGGOs) would frequently be identified after widely implementation of low-dose computed tomography (LDCT) screening. Because of the high false-positive rate of LDCT, antibiotics should be regarded as advocates in clinical management for detected fGGOs. Retrospectively review consecutive patients with fGGOs between August 2006 and August 2012. Then, relative Glasgow prognostic score (GPS) were constructed in three different systems, traditional GPS system (tGPS), modified GPS system 1 (m1GPS), and modified GPS system 2 (m2GPS). Moreover, propensity score matching (PSM) was employed in balancing baseline covariates. After PSM, patients were matched and included in benign and malignant groups as 1:1 ratio. All reported parameters were balanced in both groups and no statistical differences could be detected. Finally, m1GPS exhibited remarkable different distribution between benign and malignant fGGOs. In detail, m1GPS 1 was more frequently observed in benign fGGOs nodules, while m1GPS 2 in malignant fGGOs nodules. Modified inflammation-based score was identified as an independent predictor of malignancies in patients with pulmonary fGGOs. Patients with m1GPS 1 were more likely to be benign fGGOs, while victims with m1GPS 2 more likely to be malignant.

Computed tomography guided microcoil localization for pulmonary small nodules and ground-glass opacity prior to thoracoscopic resection.

To evaluate the feasibility, safety and efficacy of computed tomography (CT)-guided microcoil localization for small pulmonary lesions prior to thoracoscopic resection. We retrospectively reviewed the medical data of patients with pulmonary solid nodules and ground-glass opacity (GGO) who underwent CT-guided microcoil localization prior to thoracoscopic surgery. The microcoil was deployed with the proximal end of the microcoil coiling beyond the parietal pleura while the distal part anchoring in the lung parenchyma. After marking with microcoil, the pulmonary lesions were removed by thoracoscopic surgery. CT-guided microcoil placements were successful in all 98 lesions, including 14 solid nodules, 11 part-solid GGO, and 73 pure GGO. The mean distance from the lesions to the pleura surface was 11.1±6.6 mm. Eighty-four microcoils (85.7%) were successfully placed with the tails coiled beyond the parietal pleura. Seventeen patients (17.3%) had mild complications after the procedure of localization. Thirteen patients with asymptomatic pneumothorax, only one patient required further thoracentesis, four patients with pulmonary hematoma. Removal of the pulmonary lesions was successful in all patients. Sixty-six lesions (67.3%) were localized through the proximal end of the microcoil beyond the visceral pleura by visual inspection, 29 lesions were localized by palpation of the microcoil or the nodule, and 3 lesions had dislocation of the microcoil, resulting in a success rate of 96.9% for intraoperative localization. CT-guided microcoil localization prior to thoracoscopic resection is a feasible, safe, and effective method for localization of pulmonary small nodules and GGO.

Quantitative CT analysis of pulmonary ground-glass opacity nodules for distinguishing invasive adenocarcinoma from non-invasive or minimally invasive adenocarcinoma: the added value of using iodine mapping.

To determine whether quantitative analysis of iodine-enhanced images generated from dual-energy CT (DECT) have added value in distinguishing invasive adenocarcinoma from non-invasive or minimally invasive adenocarcinoma (MIA) showing ground-glass nodule (GGN). Thirty-four patients with 39 GGNs were enrolled in this prospective study and underwent DECT followed by complete tumour resection. Various quantitative imaging parameters were assessed, including virtual non-contrast (VNC) imaging and iodine-enhanced imaging. Of all 39 GGNs, four were adenocarcinoma in situ (AIS) (10 %), nine were MIA (23 %), and 26 were invasive adenocarcinoma (67 %). When assessing only VNC imaging, multivariate analysis revealed that mass, uniformity, and size-zone variability were independent predictors of invasive adenocarcinoma (odds ratio [OR] = 19.92, P = 0.02; OR = 0.70, P = 0.01; OR = 16.16, P = 0.04, respectively). After assessing iodine-enhanced imaging with VNC imaging, both mass on the VNC imaging and uniformity on the iodine-enhanced imaging were independent predictors of invasive adenocarcinoma (OR = 5.51, P = 0.04 and OR = 0.67, P < 0.01). The power of diagnosing invasive adenocarcinoma was improved after adding the iodine-enhanced imaging parameters versus VNC imaging alone, from 0.888 to 0.959, respectively (P = 0.029). Quantitative analysis using iodine-enhanced imaging metrics versus VNC imaging metrics alone generated from DECT have added value in distinguishing invasive adenocarcinoma from AIS or MIA. Quantitative analysis using DECT was used to distinguish invasive adenocarcinoma. Tumour mass and uniformity were independent predictors of invasive adenocarcinoma. Diagnostic performance was improved after adding iodine parameters to VNC parameters.

Application of preoperative CT-guided Hook-wire localization of pulmonary nodules in thoracoscopic lobectomy of lung

Objective To evaluate the application of preoperative CT-guided Hook-wire localization of pulmonary nodules in thoracoscopic lobectomy of lung. Method Twenty eight patients with 31 pulmonary nodules of ground-glass opacity (GGO) detected by CT scan were admitted in our hospital from December 2008 to December 2013, including 17 males and 11 females with an average age of 55. The lesions were located by CT-guided Hook-wire technique, and lobectomy plus lymphadenectomy or pulmonary wedge resection were performed according to the results of fast frozen pathology. The characteristics of pulmonary nodules and general condition of the patients were analyzed. Results Among 31 nodules, 19 were malignant and 12 benign with an average size of (1.8±0.6) cm and thickness of (1.2±0.4) cm. The vertical distance from pleural to nodules was (1.5±0.7) cm and the insert depth of needle was (2.5±0.9) cm. The time for CT-guided Hook-wire localization was (16.5±5.2) min. The operation time for pulmonary wedge resection and pulmonary lobectomy was (18.5±5.5) min and (54.7±12.5) min, respectively. Intraoperative frozen section showed malignant tumors in 18 patients (19 GGO nodules), lobectomy plus lymphadenectomy were performed in 16 cases; 2 patients did not undergo pulmonary lobectomy because of poor physical condition or 2 GGO nodules in different lobes. There were no operation complications in this series. Postoperative pathologic findings of 31 nodules showed 9 cases of adenocarcinoma, 10 bronchioloalveolar carcinoma, 5 atypical adenomatous hyperplasia, 2 epithelioid hemangioendothelioma, 2 chronic inflammation, 1 hamartoma, 1 inflammatory pseudotumor and 1 sarcoidosis. The average postoperative hospital stay was (6.6±1.9) days. Conclusions Endoscopic resection of pulmonary GGO nodules with CT-guided Hook-wire localization technique is feasible and safe, with less complications and less time consuming. Key words: Surgery, computer-assisted; Tomography, X-ray computed; Solitary pulmonary nodule; Hook-wire; Ground-glass opacity

Long-Term Outcomes of Wedge Resection for Pulmonary Ground-Glass Opacity Nodules

We aimed to characterize ground-glass opacity (GGO) nodules and evaluate the prognosis of clinical stage IA lung adenocarcinoma with GGO nodules after wedge resection. Patients who underwent wedge resection for early stage lung cancer and proven adenocarcinoma on postoperative pathologic report were enrolled in the study between 2004 and 2010. Radiologic findings of the main tumor were evaluated for ground-glass opacities with chest computed tomography (CT). We divided patients into two groups based on the consolidation-to-tumor ratio (C/T ratio ≤ 0.25, pure GGO group; C/T ratio > 0.25, mixed GGO group). Overall survival and recurrence-free survival were analyzed for all patients. A total of 97 patients were included in our study. Among these, 71 patients were categorized into the pure GGO group and 26 patients into the mixed GGO group. The 5-year overall survival rate was 98.6% in the pure GGO group and 95.5% in the mixed GGO group (p = 0.663). Five patients (5.1%) experienced recurrences; only 1 patient (1/71, 1.4%) in the pure GGO group and 4 patients (4/26, 15.3%) in the mixed GGO group had recurrence. GGO-dominant clinical stage IA lung adenocarcinoma (pure GGO group) showed an excellent prognosis. Wedge resection should be carefully considered for patients with mixed GGO nodules (C/T ratio >0.25) because of the high recurrence rate. Radiologic noninvasiveness (C/T ratio ≤ 0.25) might be a good indicator for candidates for sublobar resection in cases of early stage lung adenocarcinoma.