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2016 亚洲共识指南:肺结节的评估

时间:2017-09-23    点击: 次    来源:网络投稿    作者:网络投稿 - 小 + 大

evaluation of PulmonaryNodules

1.1 In an individual with an indeterminatenodule that is visible on chest radiography,review  prior imaging tests.

1.2 In an individual with an indeterminatenodule that has been stable for at least 2 years,annual low - dose CT screeningbeyond 2 years for high - risk patients for early detection of lung cancershould be individualized.

1.3 In an individual with an indeterminatenodule identified by chest radiography,perform low - dose chest CT ( preferablywith thin sections through the nodule ) to characterize the

nodule and assess the likelihood ofmalignancy .

2.1 Individuals with solid , indeterminatenodules > 8 mm should be referred to a center for management by amultidisciplinary team . Diagnostic capabilities of the center should includeCT /PET  scans , tests for benigndiseases ( eg , TB) , and biopsy ( surgical or minimally invasive ) .

2.2 In an individual with a solid ,indeterminate nodule > 8 mm in diameter , estimate the probability ofmalignancy using clinical judgement.If possible,make a quantitative assessmentusing a validated model with appropriate regional caveats.

2.3 In an individual with a solid,indeterminatenodule > 8 mm in diameter,perform surveillance with serial low - dose CT scansin the following circumstances :

.The clinical probability of malignancy isdeemed low ( < 5 % )

.Biopsy is non-diagnostic and the lesion isnot hypermetabolic as assessed by PET

.A fully informed patient prefers thisnonaggressive management approach , despite the potential risk of diseaseprogression.

2.4 In an individual with a solid ,indeterminate nodule > 8 mm in diameter who undergoes surveillance,serial CTscans using thin sections and non-contrast,low-dose techniques should be perfomedat 3 to 6 months , 9 to 1 2 months , 1 8 to 2 4 months,and ,depending onclinical judgement and patient preference , annually thereafter.

2.5 In an individual with a solid ,indeterminate nodule > 8

in diameter with moderate(5-60%) probabilityof malignancy,

consider functional imaging,preferably withPET,to characterize the nodule before surgical resection or continuedradiological surveillance. Consider caveats to PET screenlng.

2.6 In an individual with a solid,indeterminatenodule > 8 mm in diameter with high ( > 6 0 % ) probability of malignancy,functional imaging has a greater role in preoperative staging than in characterizingthe nodule.

2.7 In an individual with a solid ,indeterminate nodule that measures > 8 mm in diameter , the expert panelsuggests nonsurgical biopsy in the following circumstances:

.The clinical (pretest) probability ofmalignancy is moderate ( 5 - 6 0 % )

.When the clinical (pretest) probability andthe findings on imaging are discordant

.A benign diagnosis such as TB requiringspecific medical treatment is suspected

.A fully informed patient desires proof of amalignant diagnosis before surgery , especially when the risk of surgicalcomplications is high

2.8 In an individual with a solid ,indeterminate nodule that measures > 8 mm in diameter , surgical biopsy (and possibly resection) in a patient with suitable surgical risk is suggestedin the following circumstances:

.The clinical probability of malignancy ishigh ( > 6 0 % )

.There is clear evidence of growth on serialimaging suggestive of malignancy

.The nodule is intensely  hypermetabolic as assessed by PET

.Nonsurgical biopsy is suspicious formalignancy

.A fully informed patient prefers undergoinga definitive diagnostic procedure

2.9 In an individual with a solid ,indeterminate nodule > 8 mm in diameter who chooses surgical biopsy,theexpert panel recommends minimally invasive surgery where appropriate.

2.10 In an individual with a solid,indeterminatenodule > 8 mm in diameter , clinicians should elicit preferences formanagement,and consider family input where appropriate before offering managementoptions.

3.1 In an individual with a solid nodule8 mm in diameter and low risk for lung cancer,perform low-dose CTsurveillance according to the size of the nodule:

.Nodules measuring 4 mm in diameter : consider ongoing annual CT depending on clinical judgementand patient preference

.Nodules measuring > 4 mm to 6 mm :re-evaluate by low - dose CT annually if stable depending on clinicaljudgement and patient preference

.Nodules measuring > 6 mm to 8 mm :re-evaluate by low - dose CT at 6 to 1 2 months , 1 8 to 2 4 months,andthen annually if stable depending on clinical judgement and patient preference

3.2 In an individual with a solid nodulethat measures 8 mm in diameter who hasmoderate to high risk for lung cancer , perform low-dose CT surveillanceaccording to the size of the nodule:

.Nodules measuring 4 mm in diameter:re-evaluate by low - dose CT at 1 2 months and thenconsider annual CT surveillance depending on clinical judgement and patientpreference

.Nodules measuring > 4 mito 6 mm :re-evaluate by low-dose CT between 6 and 1 2 months and thenagain between 1 8 and 2 4 months if unchanged , and then annually if stabledepending on clnical judgement and patient preference

.Nodules measuring > 6 mm to 8 mm: re-evaluate by low-dose CT at 3 months,6 months,1 2 months ,and then annually if stable depending on clinical judgement and patient preference

4.1 In an individual with a nonsolid(pureground glass) nodule measuring 5mm in diameter,consider ongoing annual CT surveillance depending on clinicaljudgement and patient preference.

4.2 In an individual with a nonsolid (pureground glass) nodule measuring > 5 mm in diameter , reevaluate by annual CTsurveillance for at least 3 years , and then consider ongoing annual CT surveillancedepending on clinical judgement and patient preference.

5.1 In an individual with a partsolid nodulemeasuring 8 mm in diameter,theexpert panel suggests low-dose CT surveillance at approximately 3 , 1 2 and 2 4months , with consideration given to ongoing annual low-dose CT surveillancedepending on clinical judgement and patient preference .

Consideration should also be given toempiric antimicrobial therapy if there are symptoms or signs of bacterialinfection at the time of detection .

5.2 In an individual with a partsolid nodulemeasuring > 8 mm in diameter , repeat CT at 3 months and consider empiric antimicrobialtherapy if deemed clinically appropriate at the time of detection.Performfurther evaluation with nonsurgical biopsy and/or surgical resection fornodules that persist

beyond 3 months , with the additional optionof PET scanning for staging of disease before surgical intervention

6.1 In an individual with a dominant noduleand one or more additional small nodules , the expert panel suggests that eachnodule be evaluated individually,curative treatment not be denied , and histopathologicalconfirmation of metastasis be considered where appropriate .

7.1 When considering nonsurgical biopsy ,base the choice of technique on factors related to the patient and nodule aswell as resources:

.Consider use of TINA or TTNB for nodulesclose to the chest wall or deeper lesions especially fissures do not need to betraversed and there is no surrounding emphysema

.Consider use of bronchoscopy techniques fornodules closer to a patient bronchus and with a visible bronchus sign or forindividuals at high risk of pneumothorax

.Consider use of advanced bronchoscopictechniques, if available, over traditional bronchoscopy especially for smallernodules , and over TINA or TINB if there is surrounding emphysema.

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