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Boksoon Chang, MD; Sang-Won Um, MD, PhD
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From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine.

Correspondence to: Sang-Won Um, MD, PhD, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-Dong, Kangnam-Gu, Seoul 135-710, South Korea; e-mail: sangwonum@skku.edu


Financial/nonfinancial disclosure: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(2):577-578. doi:10.1378/chest.12-2238
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To the Editor:

We thank Drs Liu and Liang for their comments on our article in CHEST.1 First, they commented that the 9.0% (11 of 122) malignancy rate of pure ground-glass opacity (GGO) lung nodules in the present study was lower than the 18% reported in a previous study.2 In our study, tissue confirmation was performed only in the patients with growing lesions; therefore, we were unable to calculate the prevalence of primary lung cancer. We stated this as a limitation of our study.1 Primary lung cancer could be confirmed in a portion of patients with stable pure GGO if they underwent aggressive tissue confirmation. However, the important issue in our study is that the patients with pure GGO did not show any change in nodule size during a median follow-up of 59 months. We speculate that these stable GGO lesions can be attributed to overdiagnosis bias, even if the lesions were diagnosed as malignant on tissue confirmation.

Second, Drs Liu and Liang commented that CT scan-guided biopsy is the option for patients with lesions of a relatively large diameter when the nature of GGO is still uncertain 3 months later. However, CT scan-guided biopsy has potential limitations in the diagnosis of GGO lung nodules. The sensitivity of CT scan-guided biopsy has been reported to be about 50% to 90%, but is about 50% to 75% if indeterminate results are included.3-5 The sensitivity seems lower for pure GGO lesions (50%) than for mixed GGO lesions (80%).5 Moreover, the sensitivity is lower for smaller lesions (35%-67% for those ≤10 mm) than larger lesions.4,5 False-negative rates were reported to be about 20% to 30%.3,5 The rate of concordance between core needle and surgical biopsies in malignant and premalignant lesions was only 73%, and core biopsy failed to identify the area of invasion.3

We recommend that persistent pure GGO lesions ≥10 mm be surgically resected for histologic examination and treatment, based on the high probability (42.9%) of growth during follow-up in our study,1 although there remains the possibility of overdiagnosis in a portion of the patients who undergo surgery. For pure GGO lesions measuring <10 mm, a strategy of long-term follow-up and selective surgery for growing lesions seems reasonable considering the low probability of growth. However, we agree that CT scan-guided biopsy could be considered in pure GGOs of ≥10 mm for which surgery is contraindicated or in patients who refuse surgery.

References

Chang B, Hwang JH, Choi Y-H, et al. Natural history of pure ground-glass opacity lung nodules detected by low-dose CT scan. Chest. 2013;143(1):172-178.
 
Henschke CI, Yankelevitz DF, Mirtcheva R, McGuinness G, McCauley D, Miettinen OS; ELCAP Group ELCAP Group. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol. 2002;178(5):1053-1057. [PubMed]
 
Kim TJ, Lee JH, Lee CT, et al. Diagnostic accuracy of CT-guided core biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2008;190(1):234-239. [CrossRef] [PubMed]
 
Shimizu K, Ikeda N, Tsuboi M, Hirano T, Kato H. Percutaneous CT-guided fine needle aspiration for lung cancer smaller than 2 cm and revealed by ground-glass opacity at CT. Lung Cancer. 2006;51(2):173-179. [CrossRef] [PubMed]
 
Hur J, Lee HJ, Nam JE, et al. Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2009;192(3):629-634. [CrossRef] [PubMed]
 

Figures

Tables

References

Chang B, Hwang JH, Choi Y-H, et al. Natural history of pure ground-glass opacity lung nodules detected by low-dose CT scan. Chest. 2013;143(1):172-178.
 
Henschke CI, Yankelevitz DF, Mirtcheva R, McGuinness G, McCauley D, Miettinen OS; ELCAP Group ELCAP Group. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol. 2002;178(5):1053-1057. [PubMed]
 
Kim TJ, Lee JH, Lee CT, et al. Diagnostic accuracy of CT-guided core biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2008;190(1):234-239. [CrossRef] [PubMed]
 
Shimizu K, Ikeda N, Tsuboi M, Hirano T, Kato H. Percutaneous CT-guided fine needle aspiration for lung cancer smaller than 2 cm and revealed by ground-glass opacity at CT. Lung Cancer. 2006;51(2):173-179. [CrossRef] [PubMed]
 
Hur J, Lee HJ, Nam JE, et al. Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2009;192(3):629-634. [CrossRef] [PubMed]
 
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