肺部毛玻璃病變診斷與治療準則

肺部毛玻璃病變
診斷與治療準則
陸希平醫師
高雄市立民生醫院胸腔暨乳房外科主任
外科學教授國立高雄師範大學兼任教授
台灣胸心外科,胸腔醫學,乳房醫學專科醫師
美國胸腔學會院士 (FCCP)
台大醫學院醫學學士,博士; 中國醫藥大學醫務管理碩士

內容大綱
• 肺癌 (Lung Cancer) 診療上的盲點.
• 毛玻璃陰影 (Ground Glass Opacity, GGO) 的
診斷.
• 毛玻璃陰影 (GGO) 的處置準則, 個人經驗所
見現存盲點.
• 毛玻璃陰影 (GGO) 的治療, 早期局限性切除
的角色.

肺癌, 流行病學現況
• 肺癌在世界許多國家, 包括臺灣, 不分男女,
都位居癌症死因的第一或第二位. (WHO 與
衛生署相關統計資料).
VATS +Minithoracotomy
Lobectomy and MLND for Stage II,III Lung Ca

肺癌的威脅, 被低估與輕視!
• 癌症死亡率國內外男女都高居No.1.
• 但- 相對於乳癌, 子宮頸癌…
• 肺癌如何早期發現, 早期治療.
仍無-
有效篩檢策略
有效防治策略

與吸煙無關導致肺癌的可能致病因
• 說法相當多. 包括各種
遺傳 (致癌或腫瘤抑制
基因的突變, 重組或修
補異常, 染色體變異)
與環境 (汽機車工業廢
氣, 重金屬與砷, 油煙,
病毒等) 因素
• 但迄今都無強有力直
接證據證明其因果關
係

肺癌刻板印象應該改變..
• 只要不抽煙就可以遠離肺
癌…錯!
• 肺癌是老男人的病…錯!
• 肺癌在 X 光上一顆腫
瘤….不盡然也來不及!
常是淡淡一片雲!
(以為無害, 不小心
將遺憾終身).
等X光看得到時已經擴
散, 來不及有效治療.
故大家會誤以為-
肺癌早期看不到! 看
到時無藥可救!

以毛玻璃樣不透光病變 (GGO) 表現的肺腺癌
• 在中國大陸,日,韓的研
究發現其族群肺癌的表
徵有相當高比例(近 50%)
屬毛玻璃樣不透光病變,
這一點與歐美國家有很
大的不同.
• 臺灣, 在筆者的觀察與
其它學者發表的文獻上,
也似乎有類似以上的特
徵
(Henshke 2000; Kaneko et al.,
2000; Sone et al., 2001;
Kodama et al., 2002).
病變 0.8 公分

GGO 肺腺癌, 臨床表徵與診斷:
• 由於電腦斷層可以比
傳統胸部X光片更早發
現肺部微小結節或毛
玻璃樣病變, 故對特定
族群之定期篩檢已被
證實可早期發現肺癌
並降低其死亡率
(Henshke 2000; Kaneko et
al., 2000; Sone et al., 2001).

肺癌篩檢目前果真無符合成本效益
對策? 錯!
• 胸部X光及痰液細胞學- 無實質效益!
• 使用分子生物檢測 – 目前既花成本, 亦無實質效益!
• 使用高階影像-
PET-CT (太貴成本太高)
CT (電腦斷層), 是否有效?
有的! (不作將會產生重大影響).
但– CT品質很重要. (64 切的顯像優點).
CT 是否傷害人體甚大?
不若想像中大! (不打對比劑, 低劑量)
CT 是否貴到高不可攀?
錯! (相當於2-3 次乳房攝影的費用)

肺癌篩檢使用電腦斷層的必要性與
效益
• 根據權威新英格蘭醫學雜誌2009 年報導..
• 使用電腦斷層篩檢, 兩年內檢出肺新生腫
塊的機率是 3/1000. 一年內則為 1/1000.
• 如果以50 歲成人肺新生腫塊癌機率約 50%
而言….
• 兩年一次的電腦斷層檢測, 每千人中有
1.5人有可能檢出早期肺癌!
• 這樣的早期肺癌無法由一般胸部X光判讀!

電腦斷層對於肺腺癌…
• 可早期發現.
• 可早期診斷其特性與風險
1. 由病變化大小.
2. 由病變影像特性.

早期肺癌,不用電腦斷層難以偵測或判斷
Lung air-bronchogram pattern,
Adenocarcinoma
nchogram pattern,
veolar Carcinoma
Prior Lung Ca s/p Op with Contralater
Ground Glass Opacity (GGO) on F/U
GGO
F/U

早期肺癌,X光幾乎無法偵測
Breast Ca with Second P
Malignant Pulmonary Lesions:
Breast Ca with Second Primary Lung Ca
Malignant Pulmonary L
Breast Ca with Second Prim

發現微小肺結節,如何思考其特性?

Ann Thorac Surg. 2003 May;75(5):1601-5; discussion 1605-6.
Prospective study of thoracoscopic limited resection for ground-glass opacity selected by
computed tomography.
Nakata M, Sawada S, Saeki H, Takashima S, Mogami H, Teramoto N, Eguchi K.
thoracoscopic wedge resection was performed prospectively between June
2000 and December 2001 in 33 patients with pure GGO lesions that were 1
cm or less.
Thoracoscopic wedge resection was completed with complete safety. The
histologic diagnoses of these 33 lesions were adenocarcinoma in 1,
bronchioloalveolar carcinoma (BAC) in 23, and atypical adenomatous
hyperplasia (AAH) in 9.
No patients have had any evidence of tumor recurrence to date.
結果:
治療選擇
GGO < 1cm, 肺腺癌為侵襲性通常較低

96 patients with persistent GGO 2 cm or less in diameter underwent
pulmonary resection from January 1997 to December 2001.
93.0% (53/57) of pure GGO 1 cm or less were BAC or AAH,
whereas
38.5% (15/39) of pure GGO larger than 1 cm or mixed GGO were
adenocarcinoma.
治療選擇
結果:
Ann Thorac Surg. 2008 Feb;85(2):S701-4.
Minimally invasive approach to early, peripheral adenocarcinoma with ground-
glass opacity appearance.
Asamura H.
GGO< 1cm, 肺腺癌為侵襲性通常較低

不同影像特性的肺結節,應有不同的
診治方略

Noguchi Classification:
GGO 從HRCT 上的判別
A
F
E
D
C
B

Jpn J Thorac Cardiovasc Surg. 2005 Jan;53(1):22-8.
Pulmonary nodules 10 mm or less in diameter with ground-glass opacity component
detected by high-resolution computed tomography have a high possibility of malignancy.
Yoon HE, Fukuhara K, Michiura T, Takada M, Imakita M, Nonaka K, Iwase K.
By Tumor Size Only
93%of nodules larger than 20 mm,
75% of nodules 10 to 20 mm,
43% of nodules < or =10 mm were malignant.
If Add GGO pattern assess
88% malignant in GGO(+) 30% malignant in GGO(-)
結果:
94 patients with indeterminate peripheral pulmonary
nodules underwent wedge resection by VATS.
研究設計:
對於小於1cm 的肺結節
用 CT 評估 GGO pattern
可有效預測惡性的機率 (明顯提高)
重要訊息

使用 PET-CT 評估
可做 Wedge resection 條件
1. N0 2. Peripheral 3. Size <2cm 4. GGO%>80%
5. FDG < mediastinum 6. Non-invasive
7. Informed consent

SUV index =
Tumor SUV/ Liver SUV

Korean J Radiol. 2009 Jan-Feb;10(1):12-20.
Malignant pure pulmonary ground-glass opacity nodules: prognostic implications.
Park JH, Lee KS, Kim JH, Shim YM, Kim J, Choi YS, Yi CA.
CONCLUSION: Prognoses in patients with pure GGO malignant pulmonary nodules are
excellent, and not significantly different in terms of nodule number, size, surgical
method, presence of size change before surgical removal and histopathological
diagnosis.
RESULTS: Of the 58 patients, 40 patients (69%) were confirmed to have a
bronchioloalveolar carcinoma (BAC) and 18 patients (31%) were confirmed to have
an adenocarcinoma with a predominant BAC component.
follow-up period of 24 months (range; 12-65 months).
雖說根據 GGO, size 等 criteria 決定術式, 但最近一項
研究顯示其預後與上述因素 (包括術式) 無關
有人認為,只要是Pure GGO, 治療後預後差不多

2014
南韓三星大學
穩定
與否
兩年一次CT 一年一次CT
<0.5cm 0.5-1.0cm >1.0cm
3-6個月一次CT
外科切除

Solid nodule
<0.8cm
評估風險
小
大
CT
明顯良性?
是
比較之前片子
作PET-CT
再評估風險
小
大
CT 追蹤
切片或手術

0.6-0.8 cm
看volume doubling time
0.5-0.6 cm
一年一次 CT
三個月一次 CT
考慮切片,還要病人決定.
1. 病人會想劃刀或刺針? 2. 如果切片良性就不管了?

民眾對積極性醫療存有成見…
導致在決策上的盲點

SubSolid nodule
比0.5cm小,
就可高枕無憂?
之前影像比較
穩定就可放心?
不知穩定與否,
每三個月追蹤一次,
And then?
比0.5cm 大
還要評估風險
還要追蹤?
還要用不精準,風險不小的
穿刺切片,如果
Negative, 就放心?

Screening
Detection
Assess Risk
F/U
Biopsy
Surgery or R/T

• 目前並無有效預防之
策.
• 但因其表現早期相對
一般肺癌較為溫和的
病程而言, 如果能夠早
期偵測並給予有效治
療, 其預後將比一般肺
癌病患來得佳 (Sagawa
et al., 2009). 病變 0.3cm

Why? 看到GGO 追蹤,而不及早
處理?
AAH, Adeno Ca CIS,
即便是Pre-Malignant 或 Non-Invasive
Why Not 切掉以絕後患,更何況,如果是
Invasive Adeno Ca? 豈非事情大條?

肺癌早期診斷治療的可行性,
被嚴重低估
• 乳癌, 子宮頸癌-
看得到 (攝影與抹片),
摸得到 (切除).
• 肺癌-
即便看得到 (用 CT)
也摸不到 (要大費周章
開胸取出? 找得到嗎?
當然能!!
• 關鍵在於有沒有用對方
法!

Hook wire Localization for very early Lung Ca
實際案例

Localization (定位法): Literature review
Hookwire, Lipiodol injection,
Radiotracer injection
85-98% 成功率疼痛,氣血胸,肺出血
Hookwire 脫落

Hookwire Localization
高難度定針案例

• （中央社記者陳清芳台北23日電）肺癌是國人首要的癌症死因，
隨著低劑量電腦斷層掃描儀器的應用，愈來愈多早期肺癌可在2
公分以下且無轉移時即發現，患者藉由內視鏡手術切除癌細胞，
術後復原快。
50多歲張姓婦女即是早期檢驗的受惠者，平日打太極的她，某
天使用友人介紹的氣血循環器材後，突然大量咳血，趕緊做胸
部電腦斷層檢查，發現僅0.7公分大的毛玻璃樣陰影，疑似有個
腫瘤長在肺臟3.5到4公分深處大血管附近。
張女士在新光醫院腫瘤科、胸腔內外科醫療團隊的合作下，以
「電腦勾針合併內視鏡手術」小範圍切除，病變被精確定位且
順利切除，證實為極早期肺腺癌，術後恢復良好。
新光醫院胸腔外科主任陸希平表示，低劑量電腦斷層掃描儀器
的應用，發現小於2公分以下而無轉移的肺部腫瘤，呈毛玻璃樣
的肺部陰影，有3到4成可能是良性病變，6到7成是惡性腫瘤，
採用「電腦勾針合併內視鏡手術」，像是在一碗山粉圓裡面，
精準地戳中一粒山粉圓，可做為病灶組織採樣兼治療的工具。
• 陸希平說，高風險族群，有家族病史、菸齡逾20年、55歲以上
民眾，都是肺腺癌的高危險群，可藉低劑量的胸部電腦斷層篩
檢，早期發現，利用影像精確定位與胸腔鏡微創切除，達到早
期治療效果。1010523

實際案例
腫瘤 0.7 公分

實際案例
腫瘤 0.4公分

實際案例
chogram pattern,
olar Carcinoma
Lung Air bronchogram pattern,
Bronchoalveolar Carcinoma
Lung Mass, Adenocarcinoma
腫瘤 0.8公分

實際案例
腫瘤 0.4 公分

實際案例
Ca s/p Op with Contralateral
ass Opacity (GGO) on F/U
Carcinoma
GGO
y
/U
VATS
ocalization
LL Lung Ca s/p Lobectomy
Localization
Op with Contralateral
acity (GGO) on F/U
Carcinoma
GGO
VATS

實際案例
Prior Lung Ca s/p Op with Ipsil
lesion on F/U (Adhesion was
Post Op F/U
1yr later
Using CT localization
Before Op
Post Op F/U
1yr later
Using CT localization
Before Op
VATS
TB

• 多為沿肺泡壁生長之支氣管肺
泡癌 (broncho-alveolar
carcinoma, BAC)
• 在早期臨床表現上近似於原位
零期癌 (Stage 0 carcinoma in
situ)的表現
• 少見淋巴結轉移, 基底層或血
管侵犯, 遠處轉移更是罕見.
• 故而外科切除後, 即便僅是局
限性切除, 預後也比一般肺癌
來得好很多
(Noguchi et al., 1995; Sakural et al.,
2004; Sagawa et al., 2009).

肺切除手術選擇
• 肺全切除術 (Pneumonectomy).
• 肺葉切除術 (Lobectomy).
• 肺小葉切除術 (Segmentectomy).
• 楔形切除術 (Wedge resection).

Thorac Surg Clin. 2007 May;17(2):191-201, viii.
Management of the peripheral small ground-glass opacities.
Yoshida J.
Pure ground-glass opacities (GGO) with a small consolidation area are mostly
bronchioloalveolar carcinomas that have not yet become invasive, whereas a minority
represents only inflammatory changes. Even if they are cancers, they are slow-
growing and often remain unchanged for several years. There is no need for
immediate resection of GGO lesions and a watchful waiting strategy is recommended.
It seems that a lower-impact surgery (eg, wedge resection or segmentectomy) is
curative for these lung cancers. Because high-resolution CT seems to predict
noninvasive or minimally invasive GGO lung cancers with high reliability, less invasive
treatments like radiofrequency ablation have greater appeal.
Pure type GGO (type A or B) 使用 lower impact
Of surgery 即足夠

Br J Cancer 2005
Sublobular resection= Wedge or Segmentectomy

Stage IA Lung Adeno Ca,
Limited Resection vs Lobectomy
1y, 3y survivial 接近,直到5y survival 才稍有diff

GGO 肺腺癌, 治療準則:
• 即便以毛玻璃樣不透光病變為表現的肺癌多侵襲
性低, 但也並非沒有例外.
• 在大型研究中針對第一期A (Stage IA, cT1N0M0, 臨
床無淋巴及遠處轉移, 腫瘤小於3公分)
• 使用局限切除的病人, 仍有部份療效不及傳統肺葉
切除及淋巴清掃者 (Lung Cancer Study Group, 1995).
• 故對於早期肺癌病人而言更精細的型態特徵辨認
就顯得更加重要.

GGO Lung BACs /Adenocarcinoma:
治療原則
• GGO type A or B, <2cm, Peripheral type:
Wedge resection.
• GGO type C 以上, or >2cm, or Central type:
Segmentectomy or Lobectomy + LN sampling
or dissection.

Ann Thorac Cardiovasc Surg. 2009 Apr;15(2):82-8.
Selection of sublobar resection for c-stage IA non-small cell lung cancer based on a
combination of structural imaging by CT and functional imaging by FDG PET.
Yoshioka M, Ichiguchi O.
Four types of data were collected:
(1) tumor size based on HR/TSCT (0-10 mm, 11-20 mm or 21-30 mm);
(2) percentage of ground-glass opacity (GGO) region (GGO type or solid type);
(3) pathological type (invasive cancer [INVC] or non-INVC [NINVC]);
(4) FDG uptake in the tumor (grades 0, 1, and 2).
選擇手術式的考量

One of 42 tumors (2.4%) less than 1 cm in size, 29 of 132 tumors (22.0%) 1-2 cm in size, and
25 of 74 tumors (33.8%) 2-3 cm in size were judged to be INVC (p = 0.0002). (size 愈大,
invasive Ca 的機率愈大)
GGO type tumors (2.3%) were less likely to be INVC than
solid type tumors (32.9%) (p <0.0001). (GGO 是 invasive Ca 的機率很低)
None of the 28 GGO tumors less than 1 cm in size was INVC;
however, the possibility of INVC remained in solid type tumors less than 1 cm in size. (GGO
小於1cm 幾乎都是 non-invasive, 但 solid type 就不然)
In tumors whose diameter was more than 1 cm, INVC was possible regardless of their size or
character (GGO or solid). (大於1cm 要小心, 即便是 GGO)
One of 23 (4.3%), 4 of 33 (12.1%) and 14 of 43 tumors (32.6%) whose FDG uptake
showed grades 0, 1, and 2, respectively, microscopically revealed INVC (p = 0.0028).
All tumors whose FDG uptake was grade 0 and whose size was less than 1 cm were NINVC.
All 5 tumors (5.0%) which were found to have lymph node metastasis showed
grade 2 FDG uptake.

The criteria for operation for cT1N0M0 NSCLC based on HR/TSCT and FDG PET
findings are the following:
a tumor less than 1 cm in size and either a GGO type or whose PET grade is 0
(wedge resection);
a tumor greater than 1 cm in size and whose PET grade is 0 or 1 (segmentectomy
with lymph node dissection);
a tumor whose PET grade is 2
(lobectomy with systemic lymph node dissection).
結論不同的情境, 不同的手術式

Kyobu Geka. 2009 Apr;62(4):277-80.
Video-assisted thoracic surgery (VATS) for clinical stage I lung cancer in consideration of the
diameters and characteristcs of each tumor and the technical limitations of VATS]
Article in Japanese]
Sugi K, Kobayashi S, Sudou M, Sakano H, Tao H, Matsuda E, Okabe K.
Department Chest Surgery, Yamaguchi-Ube Medical Center, Ube, Japan.
We planned an intervention study to investigate the late outcome of limited surgery for cStage IA
ung cancer by several video-assisted thoracic surgery (VATS) procedures. METHODS: VATS partial
esection was done for non-solid tumors less than 1.5 cm in maximum diameter with non-solid
omponent on high resolution computed tomography (HRCT) [group A]. VATS segmentectomy
with minor thoracotomy with ND1 + alpha lymph node dissection was done for tumors less than
2.0 cm in maximum diameter that was not included in the group A (group B). Tumors of less than
3.0 cm in diameter that did not fit into the other 2 groups were treated by VATS lobectomy with
minor thoracotomy plus ND2 lymph node dissection (group C). RESULTS: A total of 159 patients
were enrolled during the 5-year enrollment period (group A: 21 patients, group B: 43 patients,
group C: 95 patients). The recurrence-free 5-year survival rate was 100% in the group A, 82.8% in
he group B, and 78.4% in the group C, showing no significant differences between the groups.
Twenty-eight % of patients was switched to surgical techniques involving more extensive resection
n the group A and B. while 6% of the patients was switched to thoracotomy overall. The overall
ecurrence rate was 10.7% (n=17), while the locoregional and distant recurrence rate was 5.7%
n=9) and 5.0% (n=8), respectively. CONCLUSIONS: This controlled intervention study suggested
hat limited surgery by VATS approaches for cStage IA lung cancer are acceptable as cancer
operation.
不同的情境, 不同的VATS 術式

可以用胸腔鏡微創手術診斷加治療一次完成
Lung Nodule, Indeterminate
over RUL
Nodule
Mediastinal LNs

外科手術過程..
Lobectomy + LND (ND2)
RUL Lobectomy
Three ports
Mediastinal LN Dissection

Lung Segmentectomy
+ LN dissection

LIMITED RESECTION FOR LUNG CANCER
I. Inability to tolerate lobectomy because of
pulmonary or other co-morbidities;
II. Small tumors up to 2 cm diameter;
III. Peripheral location of tumor in the lung;
IV. Confirmed stage IA disease only;
V. Predominantly GGO appearance on CT
imaging.
Alan Dart Loon Sihoe 2012
Division of Cardiothoracic Surgery, Department of
Surgery, Li Ka Shing Faculty of Medicine, The University
of Hong Kong, Queen Mary Hospital, Hong Kong, China

Tohoku J Exp Med. 2009 Feb;217(2):133-7.
Curative wedge resection for non-invasive bronchioloalveolar carcinoma.
Sagawa M, Higashi K, Usuda K, Aikawa H, Machida Y, Tanaka M, Ueno M, Sakuma T.
The criteria for wedge resection were;
1) clinically no nodal or distant metastasis,
2) the location of the tumor was peripheral enough to undergo wedge resection,
3) the diameter of the shadow was 8-20 mm,
4) GGO% (diameter of GGO area/diameter of whole tumor) was 80% or over,
5) FDG uptake of the tumor was less than that of the mediastinum,
6) the intraoperative pathological diagnosis was non-invasive bronchioloalveolar
carcinoma,
7) informed consent was obtained.
可以使用 Wedge resection 的準則如上

<2cm T1N0M0, pure or partial GGO
2015
對於早期GGO
可先考慮使用
保守切除治療的方式
看結果
決定後續治療的策略

T ≤ 1cm
1cm<T ≤ 2cm
Pleural retraction
(-)
(+)
Noguchi A,B
Others
影像
病理 Limited Resection
Lobectomy
日本
2011
<1cm 採用
保守切除
1-2cm 採用
有條件保守
切除

2014
T1a
日本
對於 T1a, 保守vs 標準切除
在 RFS & OS 皆無統計上差別

T1b
對於 T1b, 保守vs 標準切除
在 RFS & OS 皆無統計上差別

在外科處理上
仍然未有
強調
Limited Resection
角色
只有大開刀 vs R/T
英國 2018

南韓
因身體因素不得不做LR LR作為標準治療
Tumor
Size
Outcome

使用Limited resection vs Ablative R/T
結果差不多.

In conclusion:
(1) patient survival after wedge/sublobar resection of stage I
NSCLC is improving, and is not significantly different
globally for peripheral small-sized tumors;
(2) there are phase III studies comparing lobectomy and
segmentectomy but not wedge resection;
(3) survival probability of wedge resection seems to be
similar to that of SBRT, but SBRT has limitations such as
“no-fly-zone”, irradiation of hilar tumors and associated
complications such as pulmonary fibrosis and hemoptysis;
and
(4) a suitable subgroup of patients for wedge/sublobar
resection may be found based on tumor size, location,
margindistance, M/T ratio, and margin cytology.

非小細胞肺癌 (NSCLC), T4-M
Heart, Great Vessels.
Carina, Trachea.
Vertebrae. 侵犯
T3
T4
M1
M1a
M1b: Distant Metastasis
T4
AJCC 6th Ed
AJCC 7th Ed
Lung NSCLC: AJCC T Stage
7th 與6th Ed 的差異

Ann Thorac Surg. 2004 Oct;78(4):1194-9.
Surgical treatments for multiple primary adenocarcinoma of the lung.
Nakata M, Sawada S, Yamashita M, Saeki H, Kurita A, Takashima S, Tanemoto K.
31 / 369 patients (8.4%) were determined multiple primary adenoCa.
26 patients were synchronous and
5 patients were metachronous with a median interval of 59.0 months.
49 /68 (72.1%) of lesions exhibited ground-glass opacity (GGO) on high-
resolution CT (HRCT).
Pathologically well-differentiated adenocarcinoma with mixed bronchioloalveolar
pattern 39.7%
以為Multiple GGO 或 Adeno Ca 就不適合開刀切除,
錯!

Taking into consideration pulmonary function, size, location, and HRCT findings of the
lesions the procedures performed were
lobectomy with mediastinal lymph-node dissection for 32 patients, segmentectomy
with hilar node dissection for 8 patients, and
wedge resection for 28 patients.
Of 17 patients with bilateral synchronous cancers, simultaneous bilateral pulmonary
resection was performed in 14 patients including simultaneous bilateral video-
assisted thoracic surgery (VATS) in 11 patients.
After a median follow-up period of 27.7 months,
the 3-year overall survival rate was 92.9% and
the 3-year disease-free survival rates of synchronous cancer and metachronous
cancer were 77.9% and 100%, respectively.
誰說, 外科治療不適用於Multifocal GGO or Adeno Ca?

J Thorac Cardiovasc Surg. 2007 Oct;134(4):877-82.
Efficacy of thoracoscopic resection for multifocal bronchioloalveolar carcinoma showing
pure ground-glass opacities of 20 mm or less in diameter.
Mun M, Kohno T.
結論
Video-assisted thoracic surgery management of multifocal bronchioloalveolar
carcinoma yielded satisfactory results.
However, the appearance of new lesions remains a problem.
研究內容
27patients (10 male and 17 female) with a median age of 64 years (range, 41-78 years) had
91 ground-glass opacity lesions on high-resolution computed tomography. Sixteen patients
(59%) were women with no history of smoking. The distribution of bronchioloalveolar
carcinoma lesions was unilateral in 14 patients and bilateral in 13 patients. 10 patients
underwent wedge resection. 17patients underwent single-stage segmentectomy or
lobectomy (alone or with wedge resection) for technical reasons.
結果
The median postoperative observation period was 46 months. All
patients have survived to date, but new lesions have developed in 7 (26%).
(但多為很小 ,3mm lesion 或是low malig)
All patients had N0 disease.
cN0 (for type A,B).

高雄市立民生醫院
毛玻璃病變確診為原位肺腺癌
臨床案例

喜賀肺癌術後存活超過 19 年, 病人開春報平安與回憶感言
陸希平
早上, 看完門診開完手術, 在寫記錄時接到病人秀嫂的新春報
平安. 19年前, 她從嘉義北上找我, 一個看似不起眼的腫瘤, 開刀
切除赫然發現是肺腺癌, 所幸是早期, 術後並未作任何治療只有
追蹤. 經過15 年的平靜歲月, 4年前她抽血癌指數緩步上升, 到大
醫院作檢查卻不知問題在那裡. 後來針對肺部內一個正子攝影認
為不像腫瘤的一個陰影, 進行穿刺切片, 無奈沒有診斷出癌細胞.
後來她來找我, 我決定將該陰影位置肺部作局部切除. 後來證實
是第二原發性肺腺癌. 當時曾被質疑為何不順勢清除正子攝影見
到的雙側縱隔淋巴結? 我理性分析如果該淋巴有問題, 那就是 N3
三期後不適合根治切除; 反之如果沒問題則多此一舉. 實際上過
去這些淋巴陰影固有存在, 而在台灣這種表現常見於慢性肺炎或
結核病人, 所以基於對病人的了解與判斷, 我不願因此作大規模
無效的手術. 雖不免因此承受壓力, 但為病人權益, 我從不後悔為
他們承擔壓力苦難.

從第二個腫瘤被發現至今又過了4年了, 病人平安的溫暖問候,
19 年的緣份,病人健康說明了誰是誰非. 對於肺腺癌的治療, 就
如同乳癌的發展一般, 有趨向多元性保守的趨勢. 醫學科技的
快速發展, 任何醫療處置, 如果死抱舊傳統, 故步自封. 最終必
會被淘汰.
正好寫到乳癌病人手術病歷. 乳癌20 年來治療趨勢的巨變,
正是肺腺癌走向正確診療的借鏡. 不過訝異的是, 上個月, 已發
現四個乳房腫瘤在他處延遲或無法得到正確訊息者, 最終能被
發現並及時治療, 實屬不幸中之大幸. 如何在國健署大力倡導
的乳房篩檢中得到真正的效果? 我想對於疑似惡性病人千萬不
可輕忽放過, 以免努力推動的政策徒勞無功. 未來, 如果有一天
政府想推廣肺癌篩檢這塊, 也應抱持同樣的心態, 積極任事.

國際學會有關肺癌的重要演講

2009 亞太與美國胸腔學會得獎海報經驗
分享

獲2009, 2010 國際學術榮譽獎

肺癌, 重要觀念
• 預防重於治療這句話, 不適用於肺癌!
• 早期發現並有效治療才能掌握最好時機! (CT
的角色)
• 根據精確的組織特性採取的治療將會產生
更好的效果. (VATS 的角色)
• 肺癌無論早中晚期, 多科會診與合作是十分
重要的! (勿忽視外科多重的角色)

胸腔鏡手術的角色
• 對於確診為肺癌者-
可為 T, N, M 提供高準確度的診斷.
依此作為治療選擇依據
• 對於某些早期, 週邊, 未確診肺結節可提供
有效的診斷, 鑑別診斷.
治療, 輔助治療.
• 合併 CT 定位可以
精確命中病灶, 達成目標.

醫病共享決策 (Dr.- P’t SDM)
肺部毛玻璃陰影 (GGO of Lung)
病人有權為自己的健康做出選擇
高雄市立民生醫院
外科部乳房及胸腔外科
陸希平

共享模式
(醫主自主模式)
• 醫療團隊間
心智共享
(Shared Mental Model)
• 醫病之間
決策共享
(Shared Decision Making)

肺部毛玻璃病變 (Ground Glass Opacity, GGO)
是甚麼 (What)?
• 肺部毛玻璃病變 (GGO)
是在肺腺癌篩檢中, 於
胸部低劑量高解析電
腦斷層 (LD-HRCT)中找
出的異常顯影.
• 根據國際文獻證據, 毛
玻璃的形成與極早期
肺腺癌 (或稱零期原位
癌)有密切相關.

肺部毛玻璃病變 (GGO)
有效評估處置的效益與目標
• 如能及早發現與處置, 將
有利於肺腺癌的防治成
果, 改善存活期間與生活
品質.
• 如何區別電腦斷層影像
中毛玻璃病變 (大小、位
置, 數量), 加以風險分類,
並依民眾年齡、健康狀
況、家族史與過去病史,
以及其檢驗及影像追蹤
資料，經專業評估後並
根據分類擬定追蹤/處置
模式.

如何評估, 處置 (How)?
 確診前
• 低風險者採定期電腦斷層
追蹤模式.
• 中/高風險者採行胸腔鏡肺
部局部切除手術, 進行確診
及擬定後續治療的方針.
 確診後, 如為惡性的治療選
擇.
• 根據前項手術後的病理化
驗, 如為惡性, 將加做全身
系統性檢查檢驗, 確認臨床
分期.
• 後續治療與追蹤模式, 包括
進一步的外科手術切除
(肺葉切除及淋巴廓清), 輔
助電療, 化療或標靶治療等.

處置可能選擇
 確診前
• 定期電腦斷層追蹤. 目標, 追蹤病變的變化, 包括密度, 大小, 數量等.
• 胸腔鏡肺部局部切除手術. 目標, 確診及治療. 使用胸腔內視鏡微創手
術 (VATS), 將病變處做切除後進行化驗. 對於較不易術中定位個案, 會
使用電腦勾針技術進行定位 (hookwire localization).
• 針對胸腔鏡手術局部切除, 病理切片可使用冰凍與正式石蠟包埋式切
片的模式. 前者可快速判斷組織良惡性 (但準確性較後者低). 後者則
需要 5-7 天的判讀時間 (準確性高). 使用一階段 (切片與大範圍切除
手術), 必須以冰切作為判定基準, 而使用二階段, 則可在正式報告出
來後, 再擬定後續的治療方式.
 確診後, 如果惡性.
• 肺葉切除及淋巴廓清 (lobectomy and lymph node dissection). 針對已
非早期的毛玻璃病變, 選擇廣泛根治的手術方式.
• 電療: 局部輔助治療的方式 (adjuvant therapy for local control)
• 化療與標靶治療: 輔助治療防止復發與轉移.

提供以下資訊, 提供病人判斷
1. 肺癌早期接受治療的患者，與晚期接受治療者相較, 存活率
有明顯差異。
2、肺部毛玻璃病變是目前肺癌早期發現的唯一最重要徵候.
3. 肺部毛玻璃病變的確診, 以及決定後續治療的模式確認, 外科
手術切片是目前唯一的方式.
4. 早期肺癌的外科治療, 使用局部性切除與大範圍切除相較, 長
期存活率無明顯區別.
5. 中, 晚期肺癌的治療, 無論採行何種模式, 均無法達到滿意的
長期存活率.
6. 使用內視鏡微創手術切除肺部病變, 可以有效減少傷口, 降低
疼痛, 縮短住院時間, 恢復快, 長期功能恢復良好, 少併發症與低
手術死亡率.
7. 肺癌如果發現並非早期, 除外科手術外, 還可併行其他輔助治
療, 包括標靶治療, 化學治療, 放射治療, 冷凝燒灼治療, 免疫治
療等.

處置風險:
傷口感染與麻醉風險。
手術本身風險.
術後如為大範圍切除, 肺功能及肺炎的風險
提高.
輔助治療本身的風險.

肺部毛玻璃病變診斷與治療準則

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