肺癌早期診斷與篩查

1、肺癌的早期影像診斷與篩查,復(fù)旦大學(xué)腫瘤醫(yī)院放射診斷科劉 權(quán),肺癌流行病學(xué),全球Leading cause of tumor-related mortality in both men and women我國發(fā)病率以每年26.9%的速度增長(zhǎng)預(yù)計(jì)2025年，我國每年肺癌新發(fā)病例將超過100萬，居世界第一女性發(fā)病逐年上升,預(yù)后與生存,平均5年生存率 （美國）IA 期- 75% IB期 - 55% IIA期 - 50% II

2、B期- 40% IIIA期 - 10-35% (技術(shù)上可切除) IIIB 期- 5% (不可切除) IV 期- 3cm(IB) , 無胸膜侵犯無淋巴結(jié)及遠(yuǎn)處轉(zhuǎn)移普查發(fā)現(xiàn)的小肺癌，多數(shù)小于2cm，甚至厘米以下，5年生存率90以上,影像檢查手段,X線正側(cè)位片（胸片）（篩查）多層螺旋CT (64排)掃描速度快薄層CT(診斷，定性)層厚: 0.6~1.5mm小 FOV靶掃描: 15~20MPR 重建容積測(cè)量動(dòng)態(tài)增強(qiáng)

3、低劑量CT（篩查）PET-CT,X線平片優(yōu)點(diǎn)曝光量小劑量安全經(jīng)濟(jì)篩查,,16個(gè)月后,,,缺點(diǎn)漏診（特殊部位）定性相對(duì)困難,肺結(jié)節(jié)評(píng)估,影像評(píng)估多排螺旋CT（MSCT）, MRIMSCT優(yōu)勢(shì) : 取代傳統(tǒng) HRCT形態(tài)學(xué)評(píng)估血流動(dòng)力學(xué)特征隨訪：生長(zhǎng)率評(píng)估18 F-FDG PET評(píng)估結(jié)節(jié)的生物代謝特點(diǎn)病理學(xué)評(píng)估 經(jīng)皮細(xì)針穿刺活檢電視胸腔鏡手術(shù)微創(chuàng)手術(shù)開胸活檢,MSCT:形態(tài)學(xué)評(píng)價(jià),惡性 分葉狀，毛刺

4、, 不規(guī)則邊緣鈣化偏心，斑點(diǎn)狀無衛(wèi)星結(jié)節(jié)良性邊緣光滑 光滑鈣化 彌漫性, 層狀, 中心結(jié)節(jié)狀, 爆米化樣,男,59歲體檢發(fā)現(xiàn),,腺癌,,腺癌,,硬化型血管瘤,良性結(jié)節(jié)，邊緣光整,慢性炎性結(jié)節(jié),,,TB,,,,M，51,,薄層掃描,多平面重建 MPR,,,,一個(gè)月以后,,,Case 3,M,67Cough No bloody phlegm,,大細(xì)胞神經(jīng)內(nèi)分泌癌,,對(duì)形態(tài)學(xué)不能明確的病變可以進(jìn)一步行動(dòng)態(tài)增強(qiáng)掃描,,動(dòng)態(tài)

5、增強(qiáng)提示惡性：明顯強(qiáng)化，持續(xù)強(qiáng)化提示良性：無強(qiáng)化，<15hu提示炎性：快進(jìn)快出,形態(tài)：不規(guī)則,45Hu,107Hu,78Hu,,,PET-CT惡性腫瘤細(xì)胞代謝、增生增加敏感性： 88–96%特異性： 70–90%假陽性：炎性病變假陰性：BAC, 類癌，小病變（厘米以下）,77,,Ⅱ級(jí)腺癌女，77歲,非實(shí)質(zhì)性及厘米以下肺結(jié)節(jié)的評(píng)估,隨著多層 MSCT 的應(yīng)用，越來越多的小結(jié)節(jié)被檢出，甚至厘米以下或者非實(shí)質(zhì)性結(jié)節(jié)

6、單純磨玻璃樣結(jié)節(jié)，混合型實(shí)質(zhì)性磨玻璃樣結(jié)節(jié)大多數(shù)是良性的部分為肺癌或早期肺癌肺小結(jié)節(jié)的評(píng)價(jià)綜合多種因素薄層CT是非常重要的影像檢查手段,,男,67咳嗽無痰血,,,,,腺癌,,Section thickness 10mm,,Thin section CT,,,Section thickness 5mm,Thin section,Case 1,55-year-old manNodule detected by a scree

7、n,,Silice thickness 5mm,,,Small,MPR,,居灶性間質(zhì)纖維化,細(xì)支氣管肺泡癌,,,腺癌和不典型增生,嗜酸細(xì)胞性肺炎,,局灶性間質(zhì)纖維化,,細(xì)支氣管肺泡癌細(xì)支氣管肺泡癌為主的腺癌,,混合型磨玻璃樣結(jié)節(jié)80％以上為癌,,肺癌發(fā)生率:磨玻璃樣結(jié)節(jié)（GGO）: (73%)混合型GGO ：63~ 89.6%單純GGO 18~38%,不典型腺瘤樣增生：癌前病變，病理上<1cm,肺結(jié)節(jié)的隨訪,對(duì)不能定性的

8、結(jié)節(jié)隨訪觀察非常重要,,炎性病變：自發(fā)吸收或抗炎治療后吸收,,3年后,02年,6年后（08年）,AC,,,,80,y, m,After 12 months,After 16 months,AC,,,惡性結(jié)節(jié)病變?cè)龃笠槐兜臅r(shí)間為30～400天倍增時(shí)間大于600天，惡性概率很低大多數(shù)結(jié)節(jié)一般來說結(jié)節(jié)在兩年內(nèi)未觀察到生長(zhǎng)，可視為良性腫瘤也可表現(xiàn)為一個(gè)S形的生長(zhǎng)方式，即在一段相當(dāng)長(zhǎng)的時(shí)期內(nèi)無明顯生長(zhǎng)，然后突然出現(xiàn)生長(zhǎng)加速BAC和類癌偶爾

9、可穩(wěn)定2年甚至更長(zhǎng)時(shí)間,肺癌早期篩查,肺癌的早期發(fā)現(xiàn)只能通過健康體檢和肺癌普查,,高危人群年齡范圍50歲～80歲、無臨床癥狀(不斷惡化的咳嗽、痰血、不明原因體重減輕)吸煙史：≥20 pack-years（pack-years被定義為每天吸煙的包數(shù)x年數(shù)），其中包括曾經(jīng)吸煙，但戒煙時(shí)間不到5年近5年無癌癥病史（非黑色素性皮膚癌、宮頸原位癌、局限性前列腺癌除外）能夠承受可能的肺部手術(shù)無嚴(yán)重的影響生命的疾病。,,,普查結(jié)果,肺癌檢出

10、率：1～2%ⅠA期肺癌占79.1~85.1%5年生存率90％以上,International Eerly Lung Cancer Action ProgramI-ELCAP,,,,,Mission early diagnosis, treatment, and ultimate cure of lung cancerInternational, collaborative groupExperts on lung canc

11、er and related issues from around the world Background1991，Weill Medical College of Cornell University1992, ELCAP (Early Lung Cancer Action Program) was bornFirst conferrence: Oct,2019,Weill Medical College of Corne

12、ll University, NY,,Annual CT screening allows at least 80% of lung cancers to be diagnosed at Stage I 85%, 23/25,LANCET,2019IA(80%Cancer 2019 Curability Stage I lung cancers 80~90%,Publications,International Early L

13、ung Cancer Action Program Investigators. Survival of Patients with Stage I Lung Cancer Detected on CT Screening. New England Journal of Medicine 2019; 355:1763-1771 International Early Lung Cancer Action Program Investi

14、gators. Women's susceptibility to tobacco carcinogens and survival after diagnosis of lung cancer. JAMA 2019; 296:180-184 The International Early Lung Cancer Action Program Investigators. CT Screening for Lung Cance

15、r: The relationship of disease stage to tumor size. Archives of Internal Medicine 2019; 166: 321-325 Totally more than 40 articles,,National Lung Screening Trial (NLST)National Cancer Institute(2019-2019，3 y)a randomi

16、zed controlled trial Comparing CT screening with chest radiographyLung cancer mortality as the end point50,000 participants across the United StatesEnded in 2019final results expected around 2019large enough to det

17、ermine if there is a 20 percent or greater drop in lung cancer mortality,NELSON study-R. van Klaveren,,A second randomized trial of CT screening,the NELSON trial，20000,,Baseline, 7556, 2.6% 51% had at least one nodule;

18、 79.1% negative, 19.3% indeterminate, and 1.6% positive,3 m, 96.6% negative, 1.8% indeterminate, 2.6% positive.LC prevalence rate 0.9%, （72）Resected benign 0.3%,30% of resections Second-round screening (n = 7,264), 2