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Ground-glass opacity (GGO) nodules are radiologic findings with focal areas of slightly increased computed tomographic attenuation through which the normal lung parenchyma structures are visually preserved. GGOs are potentially malignant, but at the same time it is important to keep in mind that “GGO” is a rather unspecific radiologic feature seen in a number of clinical conditions involving different pathologic processes. In the case of malignancy, GGOs are adenocarcinomas or its precursors, ranging from preinvasive lesions to minimally invasive and invasive carcinoma. Despite favorable prognosis after surgery, their diagnosis and treatment are challenging issues for thoracic surgeons.
First, radiologic features do not distinguish benign from malignant GGOs, nor do they indicate their invasiveness. Unfortunately, transthoracic needle biopsy is affected by unsatisfactory negative predictive value, as shown by Lu and colleagues.
They reported an overall diagnostic accuracy of 91%, with a positive predictive value of 97% but a negative predictive value of 75%, and above all they showed that stromal invasion was underestimated. Furthermore, some studies have shown that the use of positron emission tomography or computed tomography to discriminate between benign and malignant GGOs is inappropriate, especially in the case of pure GGOs.
This means that clinical diagnosis and tumor invasiveness are often not available, and surgical diagnosis is necessary.
Second, GGOs are difficult to detect at parenchymal palpation, especially during video-assisted thoracoscopy surgery, even if in the subpleural area (Figure 1). Effective marking techniques must therefore be adopted, and in the case of centrally located lesions, a diagnostic lobectomy may be required.
Strategies of individual surgical treatment for early stage non–small cell lung cancer and the guidance of intraoperative frozen pathology [in Chinese].
Third, once an intraoperative diagnosis of adenocarcinoma has been made, surgeons have to decide which curative resection is to be performed. In fact, because of GGOs' favorable behavior, some have surgeons consider the evaluation of sublobar resections in patients not at high risk.
This means that surgeons must decide intraoperatively among lobectomy, segmentectomy, or wedge resection, with or without lymphadenectomy, even if invasiveness is unclear. To face these issues, in cases of GGO findings, we adopt a follow-up that is based on computed tomographic surveillance according to National Comprehensive Cancer Network guidelines criteria.
In response to nodal increase in size or consolidation suspicious for malignancy, we opt immediately for video-assisted thoracoscopic wedge resection with intraoperative frozen sections.
For malignant disease, we suggest anatomic resection and nodal dissection. Final recommendations with regard to the these topics are needed but must await the results of ongoing randomized trials in the United States and Japan.
References
Jin C.
Cao J.
Cai Y.
Wang L.
Liu K.
Shen W.
et al.
A nomogram for predicting the risk of invasive pulmonary adenocarcinoma for patients with solitary peripheral subsolid nodules.
Strategies of individual surgical treatment for early stage non–small cell lung cancer and the guidance of intraoperative frozen pathology [in Chinese].
We have read the article by Jin and colleagues1 about the development of a nomogram to predict the risk of invasive pulmonary adenocarcinoma for patients with a solitary peripheral subsolid nodule.
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