肺腺癌亚肺叶切除后复发相关的影像学特征——什么可能是不充分的亚肺叶？

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Predicting Recurrence after Sublobar Resection in Patients with Lung Adenocarcinoma Using Preoperative Chest CT Scans

Jae Kwang Yun*, Ji Yong Kim*, Yura Ahn, Mi Young Kim, Geon Dong Lee, Sehoon Choi, Yong-Hee Kim, Dong Kwan Kim, Seung-Il Park, Hyeong Ryul Kim 

Radiology Oct 29 2024

Abstract: Increased consolidation-to-tumor ratio and maximal diameter of the solid tumor component on preoperative chest CT images were associated with an increased risk of recurrence after sublobar resection in patients with stage IA lung adenocarcinoma.

摘要：IA期肺腺癌患者术前胸部CT图像上实性成分比例和实性最大直径增加和亚肺叶切除术后复发风险增加相关。

Background: Sublobar resection for lung cancer is usually guided by cutoff values for consolidation size (maximal diameter of the solid tumor component) and consolidation-to-tumor ratio (CTR). The effects of these factors as continuous variables and the reason for established cutoffs are, to the knowledge of the authors, unexplored.

背景：肺癌的亚肺叶切除术通常由实性大小（实体瘤成分的最大直径）和实性与肿瘤最大径比（TLR）的临界值来指导。据研究者所知，这些因素作为连续变量的影响以及既定临界点的原因尚未被探讨。

Purpose: To quantitatively assess the predictive value of CTR and consolidation size for cancer recurrence risk after sublobar resection in clinical stage IA lung adenocarcinoma.

目的：定量评估临床IA期肺腺癌的CTR和实性大小对亚肺叶切除术后癌症复发风险的预测价值。

Materials and Methods: This retrospective study reviewed sublobar resection for clinical stage IA lung adenocarcinoma performed between January 2010 and December 2019. A restricted cubic spline function verified linearity by estimating recurrence probabilities using CTR and consolidation size obtained on preoperative CT scans. Statistical analyses included a Cox proportional hazards model to identify risk factors for cancer recurrence and the Cochran-Armitage trend test for the association between CTR and consolidation size.

方法：这项回顾性研究回顾了2010年1月至2019年12月期间对临床IA期肺腺癌进行的叶下切除术。限制性三次样条函数通过使用前CT扫描获得的CTR和实性大小估计复发概率来验证线性。统计分析包括Cox比例风险模型，以确定癌症复发的风险因素，以及Cochran-Armitage趋势检验，以确定CTR和实性大小之间的关系。

Results: Of 1032 enrolled patients (age, 63.9 years ± 9.9 [SD]; 464 male patients), 523 (50.7%) and 509 (49.3%) underwent wedge resection and segmentectomy, respectively. Among patients with a CTR between 1% and 50% (n = 201), 187 (93.0%) had a consolidation size of less than or equal to 10 mm (P < .001). There was a positive association between the risk of recurrence with CTR and consolidation size (r2 = 0.727; P < .001). The recurrence rate showed the greatest increase when CTR was greater than 50% or consolidation size was greater than 10 mm. Specifically, the recurrence rate increased from 2.1% (three of 146) at 26%–50% CTR to 8.3% (nine of 108) at 51%–75% CTR, and from 4.4% (eight of 183) for 6–10-mm consolidation size to 11.9% (23 of 194) for 11–15-mm consolidation size. The probability of recurrence exhibited linearity and increased with CTR and consolidation size.

结果：在1032名入组患者中（年龄，63.9岁± 9.9 [SD]; 464名男性患者），分别有523名（50.7%）和509名（49.3%）接受了楔形切除术和肺段切除术。在CTR在1%至50%之间的患者中（n = 201），187例（93.0%）的实性成分尺寸小于或等于10 mm（P < .001）。复发风险与CTR和实性成分尺之间呈正相关（r2 = 0.727; P < .001）。当CTR大于50%或实性成分尺寸大于10 mm时，复发率增幅最大。具体来说，复发率从2.1%增加（146中的3个）从26%-50%到8.3%（108中的9个）在51%-75%的CTR下，6-10 mm实性成分尺寸的4.4%（183中的8个）到11-15 mm实性成分尺寸的11.9%（23/194）。复发的可能性呈线性，并随着CTR和实性大小的增加而增加。

Conclusions: Cancer recurrence risk after sublobar resection for stage IA adenocarcinoma consistently rises with CTR and consolidation size. Current guideline cutoffs for sublobar resection remain clinically relevant given observed recurrence rates.

结论：IA期腺癌亚肺叶切除术后的癌症复发风险随着CTR和实性大小的增加而持续上升。考虑到观察到的复发率，当前的亚肺叶切除术指南临界值仍然具有临床意义。

目录

1. INTRODUCTION

2. Material and Methods

    2.1 Study Sample (Fig 1)

    2.2 CT Imaging and Analysis (Fig 2A)(Appendix S1; Fig 2B–2D)

    2.3 Sublobar Resection Procedure and Follow-up

    2.4 Definitions

    2.5 Statistical analysis

3. Results

    3.1 Baseline Patient Characteristics (Fig 1)(Tables 1 and 2)

    3.2 CTR and Consolidation Size (Appendix S1 and Figure S1)(Fig 3)(Table 3)

    3.3 Recurrence Rate within 5 Years (Fig 4)(Fig 5)

    3.4 Risk Factors of Cancer Recurrence (Table S1)(Table 4)(Figure 6)

4. Discussion

— 图表汇总—

    2.1 Study Sample

Fig 1. Flowchart depicting patient selection.

DLCO = diffusing capacity for carbon monoxide, FEV1 = forced expiratory volume in 1 second, GGO = ground-glass opacity.

    2.2 CT Imaging and Analysis

Fig 2. Calculation of the consolidation-to-tumor ratio (CTR) and representative examples.

(A) Schematic diagram shows the calculation of the CTR in the lung window setting. 

(B) Axial contrast-enhanced CT scans in a 46-year-old female patient show a pure ground-glass opacity (GGO) nodule in the left upper lobe. The maximal GGO diameter was measured as 16.02 mm, with no identifiable consolidation (ie, consolidation diameter [maximal diameter of the solid tumor component] = 0 mm), resulting in a CTR of 0%. 

(C) Axial contrast-enhanced CT scans in a 70-year-old female patient show a partly solid nodule in the left upper lobe. The maximal GGO diameter was 13.02 mm, and the consolidation diameter was 9.19 mm, yielding a CTR of 71%. 

(D) Axial contrast-enhanced CT scans in a 70-year-old male patient show a pure solid nodule in the left upper lobe. The maximal consolidation diameter, measuring 14.94 mm, was identical to that of the total tumor diameter, and therefore the CTR was 100%.

    2.3 Sublobar Resection Procedure and Follow-up

    2.4 Definitions

    2.5 Statistical analysis

3. Results

    3.1 Baseline Patient Characteristics

    3.2 CTR and Consolidation Size

Figure S1

Fig 3. Bar graph shows the distribution plots for consolidation size (maximal diameter of the solid tumor component) according to the consolidation-to-tumor ratio (CTR). The majority (93.0%; 187 of 201) of patients with a CTR of 50% or smaller had a consolida-tion size of 10 mm or smaller.

    3.3 Recurrence Rate within 5 Years

Fig 4. Bar graphs show actual cancer recurrence rate after sublobar resection based on consolidation-to-tumor ratio (CTR) and consolidation size (maximal diameter of the solid tumor component) in patients with stage IA adenocarcinoma.

The rate of cancer recurrence within 5 years showed a statistically significant increase when (A) the CTR was larger than 50% or when (B) the consolidation size was larger than 10 mm in all patients, and in patients who underwent (C, D) wedge resection and  (E, F) segmentectomy.

Fig 5. Scatter plots show the cutoff values of tumor size based on the maximally selected rank test, with the optimal cutoff points visually indicated by the vertical dotted lines. The y-axis represents the standardized log-rank statistic, a dimensionless measure used to evaluate the significance of differences between groups, with higher values indicating stronger statistical significance.

(A) Consolidation-to-tumor ratio. (B) Consolidation size (maximal diam-eter of the solid tumor component).

    3.4 Risk Factors of Cancer Recurrence

Table S1. Univariable Analysis of Cancer Recurrence in Patients with Clinical Stage IA Adenocarcinoma Who Underwent Sublobar Resection

Figure 6. Plots show the probability of cancer recurrence within 5 years after sublobar resection based on consolidation-to-tumor ratio (CTR) and consolidation size (maximal diameter of the solid tumor component) in patients with stage IA adenocarcinoma. The probability of cancer recurrence within 5 years, according to CTR and consolidation size, showed a positive linear relationship in the overall patients (A, B) and subgroups based on surgical extent (C–F).

The solid lines represent the predicted probabilities, whereas dashed lines show the 95% CIs. The y-axis represents the predicted probability of cancer recurrence, a value between 0 and 1, where 0 means no probability of recurrence and 1 means certainty of recurrence.

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