327.4 📋 章末速記 Summary

327.4.1 🔑 一句話總結

SPN (solitary pulmonary nodule) = 單一肺野 ≤ 3 cm rounded opacity；etiology：benign (~60-70% 在 incidental setting) 含 granulomas (TB, NTM, fungal — central/popcorn/laminated calcification), hamartoma (popcorn + fat), AVM, inflammatory；malignant (~30-40% in screened) 含 primary lung cancer (NSCLC, SCLC, carcinoid, LCNEC) + metastases；sub-solid nodules (pure GGN vs part-solid) higher malignancy risk than purely solid for same size — adenocarcinoma spectrum (AAH → AIS → MIA → IA)；risk stratification：age + smoking + size > 8 mm + spiculation + upper lobe + sub-solid + growth；Brock + Mayo models predict probability；Fleischner Society 2017 guidelines：size + risk + solid/sub-solid drives follow-up；Lung-RADS for LDCT screening (categories 1-4X + S)；PET-CT SUVmax > 2.5 concerning (false negatives for AIS, carcinoid, < 8 mm)；diagnostic biopsy options：CT-guided percutaneous (peripheral, 80% yield, 25% pneumothorax)、robotic bronchoscopy (Monarch, Ion) 70-80% yield for peripheral、VATS wedge resection definitive。

327.4.2 💊 治療精要

  • first step：compare to prior imaging (stable > 2 yr → likely benign)
  • benign features：central / laminated / popcorn (hamartoma) / diffuse calcification + smooth margins + no fat content + no growth
  • malignant features：spiculation + lobulation + upper lobe + size > 8 mm + sub-solid + growth + smoker + age > 60
  • Fleischner 2017 solid：< 6 mm no follow-up；6-8 mm CT 6-12 mo；> 8 mm CT/PET/biopsy
  • Fleischner 2017 pure GGN ≥ 6 mm：CT 6-12 mo then q2 yr × 5 yr (long-term surveillance for slow adenocarcinoma)
  • Fleischner 2017 part-solid ≥ 6 mm：CT 3-6 mo (focus on solid component growth)
  • PET-CT：SUVmax > 2.5 concerning; high NPV
  • biopsy methods：CT-guided (peripheral)、robotic bronchoscopy (Monarch, Ion — 70-80% peripheral yield)、VATS wedge resection (definitive)
  • Lung-RADS for LDCT screening — guides follow-up + workup

327.4.3 🎯 盧醫師的考前提醒

  1. SPN ≤ 3 cm vs mass > 3 cm：分水嶺重要；mass 自動 high suspicion
  2. calcification 3 經典 benign patterns：central / laminated / “popcorn” (hamartoma) / diffuse；eccentric or none → indeterminate
  3. hamartoma：most common benign lung tumor；popcorn calcification + fat tissue = pathognomonic；no further workup if classic
  4. sub-solid nodules higher malignancy probability than solid for same size：pure GGN vs part-solid；adenocarcinoma spectrum (AAH → AIS → MIA → IA) — 長期 surveillance 重要
  5. PET-CT SUVmax > 2.5 concerning；但 false negatives for AIS, carcinoid, sub-solid, < 8 mm — 不能 rule out malignancy 在這些 setting
  6. Fleischner Society 2017 is incidental nodule guideline (not screening)：solid < 6 mm no follow-up；solid 6-8 mm CT 6-12 mo；solid > 8 mm aggressive；sub-solid ≥ 6 mm long-term surveillance
  7. Lung-RADS for LDCT screening specifically — categories 1-4X + S；4X = concerning features (spiculation, distortion)
  8. robotic bronchoscopy (Monarch, Ion) 改寫 peripheral nodule diagnosis：70-80% yield vs standard 20-30% peripheral；reduced complications vs CT-guided
  9. growth rates：doubling time < 30 d (inflammatory)；30-450 d (concerning malignancy)；> 450 d (usually benign)；sub-solid slower
  10. adenocarcinoma in situ (AIS) / minimally invasive adenocarcinoma (MIA)：90-100% 5-year survival；slow growth + wedge resection curative；favorable subset of lung cancer