Identification characteristic of benign and malignant pulmonary nodules and differential diagnostic indicators of the infiltration degree of malignant ground-glass nodules
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摘要:目的
探讨鉴别肺结节良恶性的临床特征、CT影像特征以及诊断恶性磨玻璃结节(GGN)浸润程度的指标。
方法选取行胸腔镜手术治疗的205例肺结节患者作为研究对象, 根据术后病理结果分为良性结节组、恶性结节组，分析2组患者的临床特征、影像学特征。根据术后病理结果(浸润程度)，将恶性GGN患者进一步分为侵袭前病变(PL)组、微浸润性腺癌(MIA)组、浸润性腺癌(IAC)组，进行定量分析和定性分析，筛选恶性GGN浸润程度的独立影响因素并评估其诊断价值。
结果良性结节组与恶性结节组的结节位置、结节类型、胸膜凹陷征、血管集束征比较，差异有统计学意义(P < 0.05); 多因素Logistic回归分析结果显示，结节类型、胸膜凹陷征、血管集束征均为肺结节良恶性的独立影响因素(P < 0.05)。PL组与MIA组年龄、血管集束征、结节长径、平均CT值、结节类型比较，差异有统计学意义(P < 0.05); MIA组与IAC组结节长径、平均CT值、实性成分长径、血管集束征、胸膜凹陷征比较，差异有统计学意义(P < 0.05); 多因素Logistic回归分析结果显示，结节长径、平均CT值为恶性GGN浸润程度的独立影响因素(P < 0.05)。受试者工作特征曲线分析结果显示，结节长径、平均CT值单独鉴别诊断PL与MIA的曲线下面积(AUC)分别为0.805、0.857, 截断值分别为7.2 mm、-612.3 HU, 两者联合鉴别诊断的AUC为0.923; 结节长径、平均CT值单独鉴别诊断MIA与IAC的AUC分别为0.860、0.703, 截断值分别为16.2 mm、-338.1 HU, 两者联合鉴别诊断的AUC为0.893。
结论对于GGN, 特别是存在胸膜凹陷征、血管集束征者，应高度怀疑恶性肺结节的可能。肺结节长径、平均CT值均对恶性GGN浸润程度具有一定鉴别诊断价值，且两者联合应用的价值更高。
Abstract:ObjectiveTo investigate the clinical features, CT imaging features of benign and malignant pulmonary nodules, as well as the indicators for diagnosing the infiltration degree of malignant ground-glass nodules (GGN).
MethodsA total of 205 patients with pulmonary nodules who underwent thoracoscopic surgery were selected as research subjects. According to the postoperative pathological results, they were divided into benign nodule group and malignant nodule group. The clinical features and imaging features of the two groups were analyzed. Based on the postoperative pathological results (infiltration degree), the patients with malignant GGN were further divided into preinvasive lesion (PL) group, minimally invasive adenocarcinoma (MIA) group, and invasive adenocarcinoma (IAC) group. Quantitative and qualitative analyses were conducted to screen for independent influencing factors of malignant GGN infiltration degree and evaluate their diagnostic value.
ResultsThere were significant differences in nodule location, nodule type, pleural indentation sign, and vascular clustering sign between the benign nodule group and the malignant nodule group (P < 0.05). Multivariate Logistic regression analysis showed that nodule type, pleural indentation sign, and vascular clustering sign were independent influencing factors of benign and malignant pulmonary nodules (P < 0.05). There were significant differences in age, vascular clustering sign, nodule length, average CT value, and nodule type between the PL group and the MIA group (P < 0.05); there were significant differences in nodule length, average CT value, solid component length, vascular clustering sign, and pleural indentation sign between the MIA group and the IAC group (P < 0.05). Multivariate Logistic regression analysis showed that nodule length and average CT value were independent influencing factors of malignant GGN infiltration degree (P < 0.05). The receiver operating characteristic curve analysis showed that the area under the curve (AUC) of nodule length and average CT value for differential diagnosis of PL and MIA were 0.805 and 0.857, respectively, with cutoff values of 7.2 mm and -612.3 HU, respectively. The AUC of their combined diagnosis was 0.923; the AUC of nodule length and average CT value for differential diagnosis of MIA and IAC were 0.860 and 0.703, respectively, with cutoff values of 16.2 mm and -338.1 HU, respectively. The AUC of their combined diagnosis was 0.893.
ConclusionFor GGN, especially those with pleural indentation sign and vascular clustering sign, a high suspicion of malignant pulmonary nodules should be raised. The length and average CT value of pulmonary nodules have certain diagnostic value for the infiltration degree of malignant GGN, and their combined application has higher diagnostic value.
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表 1 良性结节组与恶性结节组患者临床资料比较(x±s)[n(%)]
指标 分类 良性结节组(n=32) 恶性结节组(n=173) t/χ2 P 年龄/岁 60.3±9.0 61.2±10.2 -0.557 0.578 性别 男 16(50.0) 66(38.2) 1.580 0.209 女 16(50.0) 107(61.8) 高血压病 有 14(43.8) 64(37.0) 0.523 0.470 无 18(56.2) 109(63.0) 糖尿病 有 5(15.6) 21(12.1) 0.065 0.799 无 27(84.4) 152(87.9) 肿瘤史 有 1(3.1) 15(8.7) 0.512 0.474 无 31(96.9) 158(91.3) 结节类型 纯磨玻璃结节 0 14(8.1) 21.115 < 0.001 混合性磨玻璃结节 8(25.0) 103(59.5) 实性结节 24(75.0) 56(32.4) 结节长径/mm 14.8±5.8 17.3±7.6 -1.133 0.259 结节短径/mm 11.2±4.4 13.2±6.3 -1.178 0.087 胸膜凹陷征 有 10(31.2) 99(57.2) 7.318 0.007 无 22(68.8) 74(42.8) 结节形态 分叶征 11(34.4) 84(48.6) 2.184 0.139 毛刺征 3(9.4) 40(23.1) 3.079 0.079 血管集束征 有 11(34.4) 117(67.6) 12.734 < 0.001 无 21(65.6) 56(32.4) 结节位置 左上叶 4(12.5) 45(26.0) 10.108 0.039 左下叶 13(40.6) 30(17.4) 右上叶 10(31.3) 63(36.4) 右中叶 2(6.2) 8(4.6) 右下叶 3(9.4) 27(15.6) 
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表 2 肺结节良恶性的多因素Logistic回归分析结果
变量 回归系数 标准误 Wals P OR 95%CI 结节位置 0.108 0.162 0.442 0.506 1.114 0.810~1.532 结节类型 0.927 0.252 13.511 <0.001 2.526 1.541~4.141 胸膜凹陷征 1.063 0.464 5.259 0.022 2.895 1.167~7.180 血管集束征 0.971 0.441 4.841 0.028 2.641 1.112~6.272 常量 -1.211 0.708 2.924 0.087 0.298 —
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表 3 不同浸润程度恶性GGN患者的临床资料比较(x±s)[n(%)]
指标 分类 PL组(n=11) MIA组(n=45) IAC组(n=61) PL组对比MIA组 MIA组对比IAC组 t/χ2 P t/χ2 P 年龄/岁 51.9±12.0 59.6±9.7 62.3±9.9 -2.252 0.028 -1.400 0.165 性别 男 2(18.2) 14(31.1) 29(47.5) 0.229 0.632 2.899 0.089 女 9(81.8) 31(68.9) 32(52.5) 结节位置 左上叶 4(36.3) 8(17.8) 17(27.9) 4.999* 0.256* 3.210 0.546 左下叶 2(18.2) 7(15.6) 7(11.5) 右上叶 3(27.3) 20(44.4) 26(42.6) 右中叶 2(18.2) 3(6.6) 1(1.6) 右下叶 0 7(15.6) 10(16.4) 结节长径/mm 8.2±2.1 11.6±3.7 19.5±7.0 -2.922 0.005 -6.888 < 0.001 平均CT值/HU -627.3±75.6 -472.4±127.2 -352.1±176.1 -3.859 < 0.001 -3.892 < 0.001 实性成分长径/mm — 4.4±1.4 10.1±3.6 — — -10.065 < 0.001 胸膜凹陷征 有 1(9.1) 13(28.9) 42(68.9) 0.943 0.332 15.567 < 0.001 无 10(90.9) 32(71.1) 19(31.1) 结节形态 分叶征 0 13(28.9) 29(47.5) 2.676 0.102 3.766 0.052 毛刺征 0 2(4.4) 10(16.4) — 1.000* 3.683 0.055 血管集束征 有 1(9.1) 23(51.1) 50(82.0) 4.773 0.029 11.500 0.001 无 10(90.9) 22(48.9) 11(18.0) 结节类型 pGGO 11(100.0) 3(6.7) 0 36.240 < 0.001 — 0.074* mGGO 0 42(93.3) 61(100.0) *: Fisher确切概率法。
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表 4 PL与MIA的多因素Logistic回归分析结果
变量 回归系数 标准误 Wals P OR 95%CI 结节长径 0.621 0.298 4.347 0.037 1.860 1.038~3.334 平均CT值 0.019 0.008 5.849 0.016 1.019 1.004~1.034 血管集束征 1.187 1.392 0.727 0.394 3.277 0.214~50.207 年龄 0.072 0.053 1.866 0.172 1.075 0.969~1.191 常量 2.113 4.040 0.273 0.601 8.272 —
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表 5 MIA与IAC的多因素Logistic回归分析结果
变量 回归系数 标准误 Wals P OR 95%CI 结节长径 0.322 0.077 17.355 < 0.001 1.380 1.186~1.605 平均CT值 0.006 0.002 6.899 0.009 1.006 1.001~1.010 血管集束征 0.059 0.628 0.009 0.925 1.061 0.310~3.633 胸膜凹陷征 1.014 0.554 3.359 0.067 2.758 0.932~8.161 常量 -2.536 1.208 4.409 0.036 0.079 —
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表 6 结节长径、平均CT值单独及联合应用对恶性GGN浸润程度的鉴别诊断效能
变量 PL与MIA MIA与IAC AUC 敏感度 特异度 截断值 AUC 敏感度 特异度 截断值 结节长径/mm 0.805 0.978 0.545 7.2 0.860 0.689 0.889 16.2 平均CT值/HU 0.857 0.844 0.818 -612.3 0.703 0.492 0.844 -338.1 联合 0.923 0.778 0.956 — 0.893 0.885 0.778 —
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