European Radiology

, Volume 29, Issue 1, pp 279–286 | Cite as

CT diagnosis of pleural and stromal invasion in malignant subpleural pure ground-glass nodules: an exploratory study

  • Qing Zhao
  • Jian-wei WangEmail author
  • Lin Yang
  • Li-yan Xue
  • Wen-wen Lu



To assess the risk of visceral pleural invasion (VPI) and improve the diagnosis of invasive adenocarcinoma (IA) in pure ground-glass nodules (pGGNs) in contact with pleura, through a comprehensive analysis of the thin-section CT features of subpleural malignant pGGNs.


CT findings and clinical information of 115 consecutive patients in our hospital between January 2012 and December 2015 who met the following criteria were retrospectively studied: (a) thin-section CT within 1 month before surgery proved pGGN in contact with pleura, and (b) the pGGN was confirmed as malignancy by surgery. Univariate analysis and a multivariate logistic regression analysis were conducted to identify the independent risk factors of IA and VPI.


No pleural invasion was observed microscopically in any of the pGGNs. Univariate analysis indicated that tumour shape (p = 0.004), relative density (p = 0.038) and the existence of pleural retraction (p < 0.001) were significantly different between the invasive group and pre- or minimally invasive group. Multivariate logistic regression analysis revealed that pleural retraction (OR, 5.663; p < 0.001), lobulated tumour shape (OR, 4.812; p = 0.016) and tumour relative density greater than 1.60 (OR, 4.449; p = 0.001) were independent risk factors of IA.


Pulmonary adenocarcinoma manifesting as pGGN generally does not invade the pleura. A comprehensive consideration of tumour shape, relative density and tumour–pleural relationship can independently predict IA.

Key Points

• This study showed that pGGN-like adenocarcinoma generally does not invade the pleura.

• This study suggested that persistent pGGN with pleural retraction, lobulated shape and high relative density (> 1.60) may very likely be invasive adenocarcinoma.

• Using “relative density” can reduce confounding of contrast agent and respiratory status in analysis of CT images.


Lung neoplasms Solitary pulmonary nodule Visceral pleura Relative density 



Adenomatous hyperplasia


Adenocarcinoma in situ


Ground-glass nodule




High-resolution computed tomography


Invasive adenocarcinoma


Mixed ground-glass nodule


Minimally invasive adenocarcinoma


Non-small cell lung carcinoma


Picture Archiving and Communication System


Pure ground-glass nodule


Pre-invasive adenocarcinoma


Visceral pleural invasion



This study has received funding by the National Natural Science Foundation of China (Grant No. 81171344).

Compliance with ethical standards


The scientific guarantor of this publication is Jian-wei Wang.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was obtained.


• retrospective

• diagnostic, observational

• performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Qing Zhao
    • 1
  • Jian-wei Wang
    • 1
    Email author
  • Lin Yang
    • 2
  • Li-yan Xue
    • 2
  • Wen-wen Lu
    • 1
  1. 1.Department of Diagnostic RadiologyNational Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
  2. 2.Department of Diagnostic PathologyNational Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina

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