What are lesions in the lungs and why are they dangerous? What do pulmonary lesions mean on CT? Single focal formations of the right lung

It is possible to detect a tumor in the lungs and determine what it may be with a detailed examination. People of different ages are susceptible to this disease. Formations arise due to disruption of the process of cell differentiation, which can be caused by internal and external factors.

Neoplasms in the lungs are a large group of different formations in the lung area, which have a characteristic structure, location and nature of origin.

Neoplasms in the lungs can be benign or malignant.

Benign tumors have different genesis, structure, location and different clinical manifestations. Benign tumors are less common than malignant tumors and make up about 10% of the total. They tend to develop slowly and do not destroy tissue, since they are not characterized by infiltrating growth. Some benign tumors tend to transform into malignant ones.

Depending on the location there are:

1. Central - tumors from the main, segmental, lobar bronchi. They can grow inside the bronchus and surrounding lung tissue.
2. Peripheral - tumors from surrounding tissues and walls of small bronchi. They grow superficially or intrapulmonarily.

Types of benign tumors

There are the following benign lung tumors:

Briefly about malignant tumors

Increase.

Lung cancer (bronchogenic carcinoma) is a tumor consisting of epithelial tissue. The disease tends to metastasize to other organs. It can be located in the periphery, the main bronchi, or grow into the lumen of the bronchus or organ tissue.

Malignant neoplasms include:

1. Lung cancer has the following types: epidermoid, adenocarcinoma, small cell tumor.
2. Lymphoma is a tumor that affects the lower respiratory tract. It may occur primarily in the lungs or as a result of metastases.
3. Sarcoma is a malignant formation consisting of connective tissue. Symptoms are similar to those of cancer, but develop more quickly.
4. Pleural cancer is a tumor that develops in the epithelial tissue of the pleura. It can occur primarily, and as a result of metastases from other organs.

Risk factors

The causes of malignant and benign tumors are largely similar. Factors that provoke tissue proliferation:

• Smoking active and passive. 90% of men and 70% of women who have been diagnosed with malignant tumors in the lungs are smokers.
• Contact with hazardous chemicals and radioactive substances due to professional activities and environmental pollution in the area of ​​residence. Such substances include radon, asbestos, vinyl chloride, formaldehyde, chromium, arsenic, and radioactive dust.
• Chronic respiratory diseases. The development of benign tumors is associated with the following diseases: chronic bronchitis, chronic obstructive pulmonary disease, pneumonia, tuberculosis. The risk of malignant neoplasms increases if there is a history of chronic tuberculosis and fibrosis.

The peculiarity is that benign formations can be caused not by external factors, but by gene mutations and genetic predisposition. Malignancy and transformation of the tumor into malignant also often occur.

Any lung formations can be caused by viruses. Cell division can be caused by cytomegalovirus, human papillomavirus, multifocal leukoencephalopathy, simian virus SV-40, and human polyomavirus.

Symptoms of a tumor in the lung

Benign lung formations have various signs that depend on the location of the tumor, its size, existing complications, hormonal activity, the direction of tumor growth, and impaired bronchial obstruction.

Complications include:

• abscess pneumonia;
• malignancy;
• bronchiectasis;
• atelectasis;
• bleeding;
• metastases;
• pneumofibrosis;
• compression syndrome.

Bronchial patency has three degrees of impairment:

• 1st degree – partial narrowing of the bronchus.
• 2nd degree – valvular narrowing of the bronchus.
• 3rd degree – occlusion (impaired patency) of the bronchus.

Symptoms of the tumor may not be observed for a long time. The absence of symptoms is most likely with peripheral tumors. Depending on the severity of the symptoms, several stages of the pathology are distinguished.

Stages of formations

Stage 1. It is asymptomatic. At this stage, partial narrowing of the bronchus occurs. Patients may have a cough with a small amount of sputum. Hemoptysis is rare. During examination, the x-ray does not reveal any abnormalities. Tests such as bronchography, bronchoscopy, and computed tomography can show the tumor.

Stage 2. Valve narrowing of the bronchus is observed. At this point, the lumen of the bronchial tube is practically closed by the formation, but the elasticity of the walls is not impaired. When you inhale, the lumen partially opens, and when you exhale, it closes with the tumor. In the area of ​​the lung that is ventilated by the bronchus, expiratory emphysema develops. As a result of the presence of bloody impurities in the sputum and swelling of the mucous membrane, complete obstruction (impaired patency) of the lung may occur. Inflammatory processes may develop in the lung tissues. The second stage is characterized by a cough with the release of mucous sputum (pus is often present), hemoptysis, shortness of breath, increased fatigue, weakness, chest pain, fever (due to the inflammatory process). The second stage is characterized by alternation of symptoms and their temporary disappearance (with treatment). An X-ray image shows impaired ventilation, the presence of an inflammatory process in a segment, lobe of the lung, or an entire organ.

To be able to make an accurate diagnosis, bronchography, computed tomography, and linear tomography are required.

Stage 3. Complete obstruction of the bronchial tube occurs, suppuration develops, and irreversible changes in lung tissue and their death occur. At this stage, the disease has such manifestations as impaired breathing (shortness of breath, suffocation), general weakness, excessive sweating, chest pain, elevated body temperature, cough with purulent sputum (often with bloody particles). Sometimes pulmonary hemorrhage may occur. During examination, an x-ray may show atelectasis (partial or complete), inflammatory processes with purulent-destructive changes, bronchiectasis, and a space-occupying lesion in the lungs. To clarify the diagnosis, a more detailed study is necessary.

Symptoms

Symptoms of low-quality tumors also vary depending on the size, location of the tumor, the size of the bronchial lumen, the presence of various complications, and metastases. The most common complications include atelectasis and pneumonia.

At the initial stages of development, malignant cavitary formations that arise in the lungs show few signs. The patient may experience the following symptoms:

• general weakness, which intensifies as the disease progresses;
• increased body temperature;
• fatigue;
• general malaise.

Symptoms of the initial stage of neoplasm development are similar to those of pneumonia, acute respiratory viral infections, and bronchitis.

The progression of a malignant formation is accompanied by symptoms such as cough with sputum consisting of mucus and pus, hemoptysis, shortness of breath, and suffocation. When the tumor grows into the vessels, pulmonary hemorrhage occurs.

A peripheral lung mass may not show signs until it invades the pleura or chest wall. After this, the main symptom is pain in the lungs that occurs when inhaling.

In later stages, malignant tumors appear:

• increased constant weakness;
• weight loss;
• cachexia (depletion of the body);
• the occurrence of hemorrhagic pleurisy.

Diagnostics

To detect tumors, the following examination methods are used:

1. Fluorography. A preventive diagnostic method, x-ray diagnostics, which allows you to identify many pathological formations in the lungs. read this article.
2. Plain radiography of the lungs. Allows you to identify spherical formations in the lungs that have a round outline. X-ray images reveal changes in the parenchyma of the examined lungs on the right, left or both sides.
3. Computed tomography. Using this diagnostic method, the lung parenchyma, pathological changes in the lungs, and each intrathoracic lymph node are examined. This study is prescribed when differential diagnosis of round formations with metastases, vascular tumors, and peripheral cancer is necessary. Computed tomography allows a more accurate diagnosis to be made than x-ray examination.
4. Bronchoscopy. This method allows you to examine the tumor and perform a biopsy for further cytological examination.
5. Angiopulmonography. It involves performing invasive radiography of blood vessels using a contrast agent to detect vascular tumors of the lung.
6. Magnetic resonance imaging. This diagnostic method is used in severe cases for additional diagnostics.
7. Pleural puncture. Study in the pleural cavity with a peripheral tumor location.
8. Cytological examination of sputum. Helps determine the presence of a primary tumor, as well as the appearance of metastases in the lungs.
9. Thoracoscopy. It is carried out to determine the operability of a malignant tumor.

Fluorography.

Bronchoscopy.

Angiopulmonography.

Magnetic resonance imaging.

Pleural puncture.

Cytological examination of sputum.

Thoracoscopy.

It is believed that benign focal formations of the lungs are no more than 4 cm in size; larger focal changes indicate malignancy.

Treatment

All neoplasms are subject to surgical treatment. Benign tumors must be immediately removed after diagnosis in order to avoid an increase in the area of ​​affected tissue, trauma from surgery, the development of complications, metastases and malignancy. For malignant tumors and benign complications, a lobectomy or bilobectomy may be required to remove a lobe of the lung. With the progression of irreversible processes, a pneumonectomy is performed - removal of the lung and surrounding lymph nodes.

Bronchial resection.

Central cavity formations localized in the lungs are removed by resection of the bronchus without affecting the lung tissue. With such localization, removal can be done endoscopically. To remove tumors with a narrow base, a fenestrated resection of the bronchial wall is performed, and for tumors with a wide base, a circular resection of the bronchus is performed.

For peripheral tumors, surgical treatment methods such as enucleation, marginal or segmental resection are used. For large tumors, lobectomy is used.

Lung formations are removed using thoracoscopy, thoracotomy and videothoracoscopy. During the operation, a biopsy is performed, and the resulting material is sent for histological examination.

For malignant tumors, surgical intervention is not performed in the following cases:

• when it is not possible to completely remove the tumor;
• metastases are located at a distance;
• impaired functioning of the liver, kidneys, heart, lungs;
• The patient's age is more than 75 years.

After removal of the malignant tumor, the patient undergoes chemotherapy or radiation therapy. In many cases, these methods are combined.

A single focal formation of the lung is an independent radiological syndrome. In the picture, such darkening has small dimensions (up to 1 cm), different intensity and contours. To determine the nature, differential diagnosis of focal formations in the lungs is required, which we will discuss below.

It is not necessary to determine the nosological form when decoding the image. It is necessary to carefully describe the structure of the darkening and order additional examinations. The X-ray method is not characterized by a high degree of sensitivity, but is characterized by less radiation compared to computed tomography. It is used to identify pathological syndromes; for additional study of the darkening structure, other radiation and clinical-instrumental methods are used. At the final stage, a biopsy is used, and methods for dynamic monitoring of focal shadows measuring up to 5 and 10 mm have been developed.

Single focal formation of the lung

Most single focal formations of one or both lungs are not accompanied by pronounced clinical signs. An asymptomatic course does not allow the disease to be detected at an early stage.

A single focus is a local area of ​​compaction of the pulmonary parenchyma, which is reflected in the image as a shadow of a round or similar shape. According to international standards, a lesion up to 3 cm in diameter can be considered a lesion. By domestic standards - up to 1 cm.

If we approach the differential diagnosis of the disease based on phthisiatric indicators, we can establish the following characteristics of pathological shadows:

Tuberculoma;
Infiltrate;
Focal tuberculosis.

If we approach the interpretation of a chest X-ray according to international standards, then a cancerous node up to 3 cm in diameter should be included in the differentiation. This shadow on the image is most often caused by non-small cell cancer in stage T1. For domestic radiologists and radiology doctors, visualization of shadows up to 10 mm in diameter presents significant difficulties.

The term “single” does not imply the presence of a single entity. There can be from one to six individual shadows. If there are more blackouts - multiple blackouts. Radiologists often call such lesions disseminated, since they are located in both lungs.

An important clinical characteristic of the “focal lung formation” syndrome is the presence of signs of malignancy. According to statistics, about 70% of nodes at autopsy show malignancy. X-ray examination allows you to identify signs of malignancy when the size of the node is more than 1 cm. With a dynamic study (taking several consecutive radiographs), the specialist has the ability to differentiate foci of benign and malignant etiology.

Focal formations in the lungs on CT (computed tomography) are determined quite clearly. The study makes it possible to differentiate benign and malignant growth. The specificity of symptoms is determined by the foci of decay, infiltration of lymphatic vessels, and enlargement of the lymph nodes located near the lesion.

To correctly verify the cause of solitary lung formation syndrome, additional research methods and alternative methods should always be used.

Signs of focal formations of lung tissue

When radiographs are taken in patients with suspected tumors, dynamic monitoring of the syndrome is recommended. Practice shows that one radiograph is not enough to reliably verify a tumor. If a series of images is available, it is possible to assess the progression of the lesion, despite active anti-inflammatory treatment.

Positron emission tomography with 18-fluorodeoxyglucose allows us to identify the functional and organic structure of a malignant or benign neoplasm.

X-ray and tomogram of a patient with single formations on the apexes due to tuberculosis

Morphological examination of material from patients in all clinical situations using a single algorithm allows for accurate verification. Under a microscope, atypical cells look quite specific. The use of this method makes it possible to determine the morphological substrate of cancer. A biopsy is an invasive procedure and is therefore performed only for strict indications. Before its use, differential diagnosis is carried out by radiation, laboratory, instrumental, and clinical examinations.

There is no single algorithm for analyzing the signs of focal lung formations. Each radiologist develops x-ray analysis schemes in practice.

Until recently, radiography and fluorography were considered the main method of primary tumor detection. Lesions are detected in 1% of patients who undergo chest x-ray examination.

General fluorograms and radiographs do not show signs of a single formation up to 1 cm in diameter. In practice, specialists miss larger lesions from overlapping anatomical structures: ribs, roots of the lungs, cardiac shadow. Anomalies in the development of blood vessels and the bronchial tract also interfere with the visualization of small shadows in the image.

Signs of focal formations are often found on radiographs that were taken 1-2 years ago. Each X-ray department stores patient images for at least 3 years.

Such approaches were rational in the absence of computed tomography and PET/CT, which have high sensitivity and reliability in detecting pathology of the pulmonary parenchyma.

X-ray examination is rational in order to exclude pneumonia, chronic lung diseases, emphysema, and obstructive disease. Computed tomography helps to identify lesions 2-4 times more than radiography. Due to the high radiation exposure to the patient, it cannot be used for mass examination of people. Methods for reducing human radiation exposure during CT scans are being developed and undergoing clinical testing, but have not yet been widely implemented.

CT can detect more lesions in the pulmonary parenchyma than X-ray examination. If the solitary focal formation in the lung is less than 1 cm, the rationality of performing computed tomography increases significantly. A radiologist or attending physician can determine the indications for its use.

Computed tomography is not an absolute method for detecting a tumor. When the size of the formation is less than 5 mm, the sensitivity of the method is about 72%. The effectiveness of such screening for early lung cancer is poor. The low density of lesions on CT scans is caused by a specific feature called ground glass. Low-density formations are detected with a sensitivity of up to 65%. Clinical studies have shown that small focal formations in the lungs are detected on CT with a probability of 50%. Only when the lesion size exceeds 1 cm does the sensitivity increase to 95%.

To improve accuracy, some researchers have developed their own algorithms that work based on three-dimensional modeling of maximum irregularities, volumetric rendering.

Differential diagnosis of focal formations in the lungs

For differential diagnosis of formations, computed tomography or radiography is required. For correct verification, lesions should be analyzed based on the following indicators:

1. Dimensions;
2. Structure;
3. Contours;
4. Density;
5. Condition of surrounding tissues.

Individually, each described symptom has a probabilistic meaning, but together they reflect the nosological form. Despite this, even with the most careful analysis of the signs of a solitary formation, it is rarely possible to diagnose the nosological form. For example, adipose tissue has low intensity, clear contours (lipoma), but is also found in hamartoma, tuberculoma, and arteriovenous malformations. It creates low-intensity shadows in the image, which should be distinguished from “frosted glass”. With large lipomas, diagnosis is not difficult, but problems arise with small accumulations of lipocytes.

The location of the lesion in the pulmonary parenchyma is not of fundamental importance. According to researchers, coincidences or exceptions to standard radiographic rules occur in 70% of cases. A similar number of cancers are located in the upper lobes. In the right lung, localization is observed more often than in the left.

Tuberculosis infiltrates are characterized by a similar arrangement. Lung cancer in idiopathic pulmonary fibrosis is located in the lower lobe.

Tuberculous infiltrates are located more often at the apexes.

Structural characteristics of single lesions:

1. Uneven or even contours;
2. Clear, fuzzy edges;
3. Perifocal screenings, corolla radiata;
4. Different shape;
5. Excellent foci density.

In differential diagnosis, specialists pay attention to fuzzy, uneven contours of tumors and inflammatory infiltrates.

Some practical examinations have shown that tumor formations up to 1 cm have low-density contours, and radiance is not always visible on a computed tomogram.

Focal formations of the lungs on tomography in 97% of cases have a rim with uneven contours. Wavy borders with a lesion larger than 1 cm are a serious sign of cancer. Such tumors require morphological verification and careful additional examination using computed tomography, PET/CT.

Clear contours can be seen in the following diseases:

Squamous cell, small cell carcinoma;
Carcinoid.

One practical study in the literature indicates wavy contours of the lesion in malignant cancer in only 40% of cases. If these results are available, additional criteria should be introduced to allow differential diagnosis of single lesions in the lungs on a tomogram:

1. Solid structure (uniform);
2. Mixed knots;
3. Formation of the “frosted glass” type.

The formations that give rise to haze syndrome on a tomogram have a low density. The contours are represented by unchanged pulmonary interstitium. The formations characterize non-destructive inflammatory processes, atypical adenomatous hyperplasia. The morphological basis of the phenomenon is the thickening of the walls of the interalveolar septa in local areas with air alveoli.

The picture reflects inflammatory infiltration, fibrous cords. A similar picture with carcinoid is due to bronchoalveolar spread of the tumor. The “frosted glass” phenomenon is not visible on radiographs. It is also not visible on linear tomograms.

A solid, mixed node can be characterized by the presence of a dense area in the central part with a peripheral decrease in density in the form of dullness. The picture is formed around old foci, post-tuberculosis cavities. About 34% of non-solid lesions are formed by malignant tumors that are larger than 1.5 cm on radiographs.

The solitary formation is characterized by a typical structure:

Round shape;
Low density;
Excellent contours.

The syndrome occurs in any pathological process.

The structure of a single formation is clearly visible on the tomogram:

Homogeneous low density structure;
Necrosis with air inclusions;
Fatty, high-density, fluid nodes.

The described characteristics are not characteristics of a specific pathological process. Only hamartomas are characterized by the inclusion of adipose tissue. Even calcification in foci occurs in different nosological forms.

The inclusion of air cavities and the identification of honeycomb cells are detected on CT 2 times more often than on a conventional x-ray.

Types of calcifications of a single focus:

"Popcorn";
Layered;
Diffuse - occupying the entire formation.

If calcification (calcium deposition) is detected, we can speak with a high degree of certainty about the benign structure of the disease, but there are exceptions. Metastases of ovarian cancer, intestinal cancer, and bone sarcomas may become calcified after chemotherapy.

Computed tomogram – single lesions in the sixth segment with vasculitis

In malignant formations there are pinpoint, amorphous inclusions of calcium salts that do not have clear contours.

There is practical evidence that in peripheral formations the frequency of calcification reaches 13%. For lesions smaller than 2 cm, the frequency is lower – about 2%.

The deposition of calcium salts is not a sensitive diagnostic sign. The pathognomy of the symptom is quite low.

Another interesting symptom in the differential diagnosis of a single lesion in the lungs is “air bronchography”. The porous or honeycomb structure is due to the inclusion of air, which can be traced in the malignant tumor. The probability of air in cancer is 30%, but in a benign node - 6%. The accumulation of air may mimic tissue breakdown, which also suggests a malignant nature of the lesion.

Focal secondary lung formations - growth rate assessment

Secondary pulmonary lesions on imaging should be monitored dynamically. Only in this way will differential diagnosis allow us to identify the maximum number of signs that allow us to optimally differentiate the nature of the lesion. Changes should be tracked using the available archival complex - radiographs, linear or computed tomograms, fluorograms. If the node does not enlarge for more than 2 years, this is a sign of a benign nature.

A significant portion of secondary lung formations are missed by the initial X-ray analysis. Archive analysis is a mandatory stage of differential diagnosis. The effectiveness of radiation examination in pathology is determined by the rate of change in the characteristics of the formation during malignant growth. The doubling time ranges from 40 to 720 days. Any node that appears in the image must be monitored throughout the month. If no changes are detected, dynamic monitoring should be carried out for 20 years.

There are exceptions to the above rule - ground-glass lesions detected on computed tomography represent bronchioloalveolar cancer. With this nosology, dynamic observation is excluded.

When determining low-density contours along the periphery of the lesion, it is necessary to send the patient for computed tomography!

Another factor that limits follow-up of patients is the retrospective analysis of lesions smaller than 1 cm in diameter. Doubling the volume of a lesion measuring 5 mm with subsequent computed tomography leads to an increase in diameter to 6.5 mm. Such changes are not visualized on an x-ray.

Many researchers argue that such a picture is beyond the resolution of not only radiography, but also CT.

Significant importance is attached to the computer evaluation of the three-dimensional helical computed tomography model that is capable of modeling. Some high-tech diagnostic algorithms can identify small nodes, but require practical confirmation.

The malignant nature of a secondary focal formation can be established based on an analysis of clinical and radiological signs, although some specialists underestimate this approach.

What signs indicate a malignant process:

1. Wall thickness more than 16 mm;
2. Hemoptysis;
3. Fuzzy, uneven contours;
4. History of operations on tumors;
5. The size of the lesion is from 20 to 30 mm;
6. Doubling time less than 465 days;
7. Age over 70 years;
8. Low intensity shadow in the photo;
9. History of smoking.

The density of the secondary lesion may vary and therefore does not have significant diagnostic value. You just need to take into account the large intrinsic vascular network of the tumor, which is revealed by angiography and PET/CT.

If the formations are devoid of a vascular network, this is a benign growth. With such a picture, the nature of the focus should be taken into account. With tuberculosis, caseation is observed, which has a different density on the x-ray. Specific melting of lung tissue develops gradually. Only with weak immunity are mycobacteria activated. Dynamic observation allows us to determine the progression of the tuberculosis focus. With cancer, the node grows much faster. Changes in the tumor are visualized when examining an x-ray after a month.

Filling with pus and exudate indicates a forming cyst or abscess. In this case, the dynamic tracking technique gives significant results. Tumors grow much faster than a tuberculous node.

Dynamic computed tomography allows one to clearly determine the nature of the lesion. When performing sections, contrasting is possible with the production of tomograms after 1,2,3,4 minutes.

Density measurement is carried out in ¾ of the slice volume. The amplification threshold allows one to differentiate between benign and malignant pathology. When detecting malignant tumors, a density of more than 15 HU indicates cancer with a confidence of more than 98%.

The technique has disadvantages:

Small lesions up to 1 cm have low specificity on CT;
Technical errors due to artifacts;
The contrast agent creates small lesions in the tissue.

The described disadvantages are compensated by the use of multilayer spiral CT. The procedure evaluates the density of the lesion. There are many studies indicating that an excess of formation density by 25 HU and a rapid decrease by 10-30 HU indicates cancer.

The overall accuracy of multilayer tomography in detecting malignant neoplasms does not exceed 93%.

Solitary focal formation in the lungs on PET/CT

All of the above information is based on a macroscopic analysis of solitary lung formations. The introduction of positron emission tomography with short-lived isotopes made it possible to obtain the functional characteristics of the formation under study.

Metabolic characteristics are assessed using 18-fluorodeoxyglucose. Metabolism in the tumor is more intense, so the isotope accumulates strongly. The sensitivity of PET/CT is up to 96%.

To obtain a more complete picture, the metabolic and macroscopic characteristics of the pathological focus are combined. False-positive errors in the study arise due to the accumulation of the radioisotope in active tuberculous cavities, primary tumors with ground-glass macroscopic appearance, which are not characterized by an intensive blood supply. Neoplasms smaller than 7 mm also do not result in intensive accumulation.

PET/CT data should be compared with clinical results and other radiological methods. The decisive method for identifying a tumor is a biopsy. The method involves taking a section of material from an identified node. Subsequently, the cellular composition is studied using a microscope. Identification of atypical cells requires surgery.

In conclusion, it should be noted that there is an interesting technique for managing patients with different results from radiation methods in patients with single pulmonary formations.

If a lesion more than 1 cm in diameter with radiant, uneven contours, “ground glass” is detected, verification by biopsy is required.

The remaining patients are classified as intermediate and undetermined. In this category of patients, lesions more than 10 mm in diameter are found, with wavy, smooth contours without inclusions. After signs of malignancy are obtained through biopsy, PET/CT, and other methods, a wait-and-see approach is used. Dynamic tracking is the most rational approach.

Patients with lesions less than 10 mm and no calcium inclusions do not require dynamic monitoring if the node is less than 5 mm. The recommendation is a routine preventive examination throughout the year.

Lesion sizes from 5 to 10 mm require monitoring after 3 and 6, 12 and 24 months. If there is no dynamics, observation is stopped. In case of changes in formation, a biopsy is rational.

Differential diagnosis of focal formations in the lungs is a complex process that requires the professional skill of a radiologist. Rational knowledge of different methods of radiation diagnostics, schemes for using different algorithms helps to detect cancer at an early stage.

This is a large number of neoplasms, different in origin, histological structure, localization and characteristics of clinical manifestation. They can be asymptomatic or with clinical manifestations: cough, shortness of breath, hemoptysis. Diagnosed using X-ray methods, bronchoscopy, thoracoscopy. Treatment is almost always surgical. The extent of intervention depends on clinical and radiological data and ranges from tumor enucleation and economical resections to anatomical resections and pneumonectomy.

General information

Lung tumors constitute a large group of neoplasms characterized by excessive pathological proliferation of tissues of the lung, bronchi and pleura and consisting of qualitatively altered cells with impaired differentiation processes. Depending on the degree of cell differentiation, benign and malignant lung tumors are distinguished. There are also metastatic lung tumors (screenings of tumors that primarily arise in other organs), which are always malignant in type.

Benign lung tumors make up 7-10% of the total number of neoplasms in this location, developing with the same frequency in women and men. Benign neoplasms are usually registered in young patients under the age of 35 years.

Reasons

The reasons leading to the development of benign lung tumors are not fully understood. However, it is assumed that this process is facilitated by genetic predisposition, gene abnormalities (mutations), viruses, exposure to tobacco smoke and various chemical and radioactive substances that pollute soil, water, atmospheric air (formaldehyde, benzanthracene, vinyl chloride, radioactive isotopes, UV radiation and etc.). A risk factor for the development of benign lung tumors are bronchopulmonary processes that occur with a decrease in local and general immunity: COPD, bronchial asthma, chronic bronchitis, prolonged and frequent pneumonia, tuberculosis, etc.).

Pathanatomy

Benign lung tumors develop from highly differentiated cells, similar in structure and function to healthy cells. Benign lung tumors are characterized by relatively slow growth, do not infiltrate or destroy tissue, and do not metastasize. The tissues located around the tumor atrophy and form a connective tissue capsule (pseudocapsule) surrounding the tumor. A number of benign lung tumors have a tendency to malignancy.

Based on location, they distinguish between central, peripheral and mixed benign lung tumors. Tumors with central growth originate from large (segmental, lobar, main) bronchi. Their growth in relation to the bronchial lumen can be endobronchial (exophytic, inside the bronchus) and peribronchial (into the surrounding lung tissue). Peripheral lung tumors originate from the walls of small bronchi or surrounding tissues. Peripheral tumors can grow subpleurally (superficially) or intrapulmonarily (deeply).

Benign lung tumors of peripheral localization are more common than central ones. In the right and left lungs, peripheral tumors are observed with equal frequency. Central benign tumors are most often located in the right lung. Benign lung tumors often develop from the lobar and main bronchi, rather than from segmental bronchi, like lung cancer.

Classification

Benign lung tumors can develop from:

• epithelial tissue of the bronchi (polyps, adenomas, papillomas, carcinoids, cylindromas);
• neuroectodermal structures (neurinomas (schwannomas), neurofibromas);
• mesodermal tissues (chondromas, fibromas, hemangiomas, leiomyomas, lymphangiomas);
• from germinal tissues (teratoma, hamartoma - congenital lung tumors).

Among benign lung tumors, hamartomas and bronchial adenomas are more common (in 70% of cases).

1. Bronchial adenoma– glandular tumor developing from the epithelium of the bronchial mucosa. In 80-90% it has central exophytic growth, localized in large bronchi and disrupting bronchial patency. Typically, the size of the adenoma is up to 2-3 cm. The growth of the adenoma over time causes atrophy and sometimes ulceration of the bronchial mucosa. Adenomas have a tendency to malignancy. Histologically, the following types of bronchial adenomas are distinguished: carcinoid, carcinoma, cylindroma, adenoid. The most common type among bronchial adenomas is carcinoid (81-86%): highly differentiated, moderately differentiated and poorly differentiated. 5-10% of patients develop carcinoid malignancy. Adenomas of other types are less common.
2. Hamartoma- (chonroadenoma, chondroma, hamartochondroma, lipochondroadenoma) – a neoplasm of embryonic origin, consisting of elements of embryonic tissue (cartilage, layers of fat, connective tissue, glands, thin-walled vessels, smooth muscle fibers, accumulation of lymphoid tissue). Hamartomas are the most common peripheral benign lung tumors (60-65%) localized in the anterior segments. Hamartomas grow either intrapulmonarily (into the thickness of the lung tissue) or subpleurally, superficially. Typically, hamartomas have a round shape with a smooth surface, clearly demarcated from surrounding tissues, and do not have a capsule. Hamartomas are characterized by slow growth and asymptomatic course, extremely rarely degenerating into a malignant neoplasm - hamartoblastoma.
3. Papilloma(or fibroepithelioma) is a tumor consisting of connective tissue stroma with multiple papillary processes, externally covered with metaplastic or cuboidal epithelium. Papillomas develop predominantly in large bronchi, grow endobronchially, sometimes obstructing the entire bronchial lumen. Often, bronchial papillomas occur together with papillomas of the larynx and trachea and can undergo malignancy. The appearance of papilloma resembles cauliflower, cockscomb or raspberry. Macroscopically, papilloma is a formation on a broad base or stalk, with a lobulated surface, pink or dark red color, soft-elastic, less often hard-elastic consistency.
4. Pulmonary fibroma– tumor d – 2-3 cm, arising from the connective tissue. Represents from 1 to 7.5% of benign lung tumors. Pulmonary fibroids equally often affect both lungs and can reach a gigantic size of half the chest. Fibroids can be localized centrally (in large bronchi) and in peripheral areas of the lung. Macroscopically, the fibromatous node is dense, with a smooth whitish or reddish surface and a well-formed capsule. Lung fibroids are not prone to malignancy.
5. Lipoma- a neoplasm consisting of adipose tissue. In the lungs, lipomas are detected quite rarely and are random radiological findings. They are localized mainly in the main or lobar bronchi, less often in the periphery. Lipomas arising from the mediastinum (abdomino-mediastinal lipomas) are more common. Tumor growth is slow, malignancy is not typical. Macroscopically, the lipoma is round in shape, densely elastic in consistency, with a clearly defined capsule, yellowish in color. Microscopically, the tumor consists of fat cells separated by connective tissue septa.
6. Leiomyoma is a rare benign tumor of the lungs that develops from the smooth muscle fibers of blood vessels or the walls of the bronchi. More often observed in women. Leiomyomas are of central and peripheral localization in the form of polyps on the base or stalk, or multiple nodules. Leiomyoma grows slowly, sometimes reaching gigantic sizes, has a soft consistency and a well-defined capsule.
7. Vascular lung tumors(hemangioendothelioma, hemangiopericytoma, capillary and cavernous pulmonary hemangiomas, lymphangioma) account for 2.5-3.5% of all benign formations of this localization. Vascular tumors of the lungs can have peripheral or central localization. All of them are macroscopically round in shape, dense or densely elastic in consistency, surrounded by a connective tissue capsule. The color of the tumor varies from pinkish to dark red, size - from a few millimeters to 20 centimeters or more. Localization of vascular tumors in large bronchi causes hemoptysis or pulmonary hemorrhage.
8. Hemangiopericytoma and hemangioendothelioma are considered conditionally benign lung tumors, since they have a tendency to rapid, infiltrative growth and malignancy. On the contrary, cavernous and capillary hemangiomas grow slowly and are separated from surrounding tissues and do not become malignant.
9. Dermoid cyst(teratoma, dermoid, embryoma, complex tumor) - a disembryonic tumor-like or cystic neoplasm consisting of different types of tissue (sebaceous masses, hair, teeth, bones, cartilage, sweat glands, etc.). Macroscopically it looks like a dense tumor or cyst with a clear capsule. It accounts for 1.5–2.5% of benign lung tumors, mainly occurring at a young age. The growth of teratomas is slow, suppuration of the cystic cavity or malignancy of the tumor (teratoblastoma) is possible. When the cyst contents break into the pleural cavity or bronchial lumen, a picture of an abscess or pleural empyema develops. The localization of teratomas is always peripheral, most often in the upper lobe of the left lung.
10. Neurogenic lung tumors(neurinomas (schwannomas), neurofibromas, chemodectomas) develop from nerve tissue and make up about 2% of benign lung blastomas. More often, lung tumors of neurogenic origin are located peripherally and can be found in both lungs at once. Macroscopically they look like rounded dense nodes with a clear capsule, grayish-yellow in color. The issue of malignancy of lung tumors of neurogenic origin is controversial.

Rare benign lung tumors include fibrous histiocytoma (a tumor of inflammatory origin), xanthomas (connective tissue or epithelial formations containing neutral fats, cholesterol esters, iron-containing pigments), plasmacytoma (plasmocytic granuloma, a tumor resulting from a disorder of protein metabolism). Among benign lung tumors, there are also tuberculomas - formations that are the clinical form of pulmonary tuberculosis and are formed by caseous masses, elements of inflammation and areas of fibrosis.

Symptoms

Clinical manifestations of benign lung tumors depend on the location of the tumor, its size, direction of growth, hormonal activity, degree of bronchial obstruction, and complications caused. Benign (especially peripheral) lung tumors may not produce any symptoms for a long time. In the development of benign lung tumors, the following are distinguished:

• asymptomatic (or preclinical) stage
• stage of initial clinical symptoms
• stage of severe clinical symptoms caused by complications (bleeding, atelectasis, pneumosclerosis, abscess pneumonia, malignancy and metastasis).

Peripheral lung tumors

With peripheral localization in the asymptomatic stage, benign lung tumors do not manifest themselves in any way. In the stage of initial and severe clinical symptoms, the picture depends on the size of the tumor, the depth of its location in the lung tissue, and its relationship to the adjacent bronchi, vessels, nerves, and organs. Large lung tumors can reach the diaphragm or chest wall, causing pain in the chest or heart area, and shortness of breath. In case of vascular erosion by a tumor, hemoptysis and pulmonary hemorrhage are observed. Compression of large bronchi by the tumor causes bronchial obstruction.

Central lung tumors

Clinical manifestations of benign lung tumors of central localization are determined by the severity of bronchial obstruction, which is classified as grade III. In accordance with each degree of bronchial obstruction, the clinical periods of the disease differ.

• I degree - partial bronchial stenosis

In the first clinical period, corresponding to partial bronchial stenosis, the bronchial lumen is narrowed slightly, so its course is often asymptomatic. Sometimes there is a cough, with a small amount of sputum, less often with blood. General health does not suffer. Radiologically, a lung tumor is not detected during this period, but can be detected by bronchography, bronchoscopy, linear or computed tomography.

• II degree - valvular or valve bronchial stenosis

In the 2nd clinical period, valvular or valve bronchial stenosis develops, associated with tumor obstruction of most of the bronchial lumen. With ventral stenosis, the lumen of the bronchus partially opens on inspiration and closes on exhalation. In the part of the lung ventilated by the narrowed bronchus, expiratory emphysema develops. Complete closure of the bronchus may occur due to swelling, accumulation of blood and sputum. An inflammatory reaction develops in the lung tissue located at the periphery of the tumor: the patient’s body temperature rises, cough with sputum, shortness of breath, sometimes hemoptysis, chest pain, fatigue and weakness. Clinical manifestations of central lung tumors in the 2nd period are intermittent. Anti-inflammatory therapy relieves swelling and inflammation, leads to the restoration of pulmonary ventilation and the disappearance of symptoms for a certain period.

• III degree - bronchial occlusion

The course of the 3rd clinical period is associated with the phenomena of complete occlusion of the bronchus by the tumor, suppuration of the atelectasis zone, irreversible changes in the area of ​​lung tissue and its death. The severity of symptoms is determined by the caliber of the bronchus obstructed by the tumor and the volume of the affected area of ​​the lung tissue. There is a persistent increase in temperature, severe chest pain, weakness, shortness of breath (sometimes attacks of suffocation), poor health, cough with purulent sputum and blood, and sometimes pulmonary hemorrhage. X-ray picture of partial or complete atelectasis of a segment, lobe or the entire lung, inflammatory and destructive changes. Linear tomography reveals a characteristic pattern, the so-called “bronchial stump” - a break in the bronchial pattern below the obstruction zone.

The speed and severity of bronchial obstruction depends on the nature and intensity of lung tumor growth. With peribronchial growth of benign lung tumors, clinical manifestations are less pronounced, and complete bronchial occlusion rarely develops.

Complications

With a complicated course of benign lung tumors, pneumofibrosis, atelectasis, abscess pneumonia, bronchiectasis, pulmonary hemorrhage, compression syndrome of organs and blood vessels, and malignancy of the tumor may develop. With carcinoma, which is a hormonally active tumor of the lungs, 2–4% of patients develop carcinoid syndrome, manifested by periodic attacks of fever, hot flashes in the upper half of the body, bronchospasm, dermatosis, diarrhea, and mental disorders due to a sharp increase in the blood level of serotonin and its metabolites.

Diagnostics

At the stage of clinical symptoms, dullness of percussion sound over the area of ​​atelectasis (abscess, pneumonia), weakening or absence of vocal tremor and breathing, dry or moist rales are physically determined. In patients with obstruction of the main bronchus, the chest is asymmetrical, the intercostal spaces are smoothed, and the corresponding half of the chest lags behind during respiratory movements. Necessary instrumental studies:

1. Radiography. Often, benign lung tumors are incidental radiological findings detected by fluorography. When X-raying the lungs, benign lung tumors are defined as round shadows with clear contours of varying sizes. Their structure is often homogeneous, sometimes, however, with dense inclusions: lumpy calcifications (hamartomas, tuberculomas), bone fragments (teratomas). Vascular tumors of the lungs are diagnosed using angiopulmonography.
2. Computed tomography. Computed tomography (CT of the lungs) allows a detailed assessment of the structure of benign lung tumors, which determines not only dense inclusions, but also the presence of adipose tissue characteristic of lipomas, fluid - in tumors of vascular origin, dermoid cysts. The contrast bolus-enhanced computed tomography method makes it possible to differentiate benign lung tumors from tuberculomas, peripheral cancer, metastases, etc.
3. Bronchial endoscopy. In the diagnosis of lung tumors, bronchoscopy is used, which allows not only to examine the tumor, but also to perform a biopsy (for central tumors) and obtain material for cytological examination. With a peripheral location of the lung tumor, bronchoscopy allows us to identify indirect signs of the blastomatous process: compression of the bronchus from the outside and narrowing of its lumen, displacement of the branches of the bronchial tree and changes in their angle.
4. Biopsy. For peripheral lung tumors, a transthoracic aspiration or puncture biopsy of the lung is performed under X-ray or ultrasound control. If there is a lack of diagnostic data from special research methods, they resort to thoracoscopy or thoracotomy with biopsy.

Treatment

All benign lung tumors, regardless of the risk of their malignancy, are subject to surgical removal (in the absence of contraindications to surgical treatment). The operations are performed by thoracic surgeons. The earlier a lung tumor is diagnosed and removed, the less volume and trauma from surgery, the risk of complications and the development of irreversible processes in the lungs, including malignancy of the tumor and its metastasis. The following types of surgical interventions are used:

1. Bronchial resection. Central lung tumors are usually removed using sparing (without lung tissue) bronchial resection. Tumors with a narrow base are removed by fenestrated resection of the bronchial wall followed by suturing the defect or bronchotomy. Broad-based lung tumors are removed by circular resection of the bronchus and interbronchial anastomosis.
2. Lung resection. If complications in the lung have already developed (bronchiectasis, abscesses, fibrosis), they resort to removing one or two lobes of the lung (lobectomy or bilobectomy). If irreversible changes develop in the entire lung, it is removed - pneumonectomy. Peripheral lung tumors located in the lung tissue are removed by enucleation (enucleation), segmental or marginal lung resection; in case of large tumor sizes or complicated course, lobectomy is used.

Surgical treatment of benign lung tumors is usually performed by thoracoscopy or thoracotomy. Benign central lung tumors growing on a thin stalk can be removed endoscopically. However, this method is associated with the risk of bleeding, insufficiently radical removal, and the need for repeated bronchological monitoring and a biopsy of the bronchial wall at the location of the tumor stalk.

If a malignant lung tumor is suspected, during the operation an urgent histological examination of the tumor tissue is performed. If the malignancy of the tumor is morphologically confirmed, the scope of surgical intervention is performed as for lung cancer.

Prognosis and prevention

With timely treatment and diagnostic measures, long-term results are favorable. Relapses following radical removal of benign lung tumors are rare. The prognosis for lung carcinoids is less favorable. Taking into account the morphological structure of the carcinoid, the five-year survival rate for the highly differentiated type of carcinoid is 100%, for the moderately differentiated type – 90%, for the poorly differentiated type – 37.9%. Specific prevention has not been developed. Timely treatment of infectious and inflammatory lung diseases, avoidance of smoking and contact with harmful pollutants can minimize the risk of neoplasms.

Lesions in the lungs are an independent clinical diagnosis. This disease does not make itself felt and in the vast majority of cases does not manifest itself in any way. Foci in the lung tissue are most often detected accidentally during standard preventive procedures and x-ray examination.

A single lesion in the lungs is a localized area of ​​​​increased density, which has a round or oval shape and reaches 30 millimeters in diameter. The reasons for the occurrence of such seals can be different, and to determine them, an examination by a doctor and an x-ray are not enough. In order to make an accurate, reliable diagnosis, a number of important studies will have to be carried out (biochemical analysis of blood, sputum, as well as puncture of lung tissue).

There is a widespread belief that the factor provoking the occurrence of lesions in the lungs is exclusively tuberculosis, but this is not true.

Most often, lesions in the lung tissue are a symptom of the following conditions:

• malignant neoplasms;
• impaired fluid exchange in the respiratory system;
• prolonged pneumonia.

That is why, when making a diagnosis, it is necessary to use the results of laboratory tests of blood and sputum. Even if the doctor is sure that the patient is suffering from focal pneumonia, the test results will help identify the causative agent of the disease and eliminate it using an individually selected treatment regimen.

Sometimes people are in no hurry to take diagnostic tests due to the distance of the laboratory from their place of residence. It is extremely undesirable to neglect laboratory tests, since without treatment the lesion in the lungs begins to be secondary.

Anatomically, single pulmonary lesions are altered areas of lung tissue or the pathological presence of fluid (blood or sputum) in it.

It should be noted that the criteria in the international and domestic classification of pulmonary lesions differ. Foreign medicine recognizes formations reaching 3 centimeters in size as single lesions in the lungs. In the Russian Federation, lesions in the lung tissue are diagnosed if they do not exceed 10 millimeters in diameter. Anything that is large in size refers to infiltrates or tuberculomas.

The problem of reliable diagnosis and classification of lesions in the lungs is one of the most important in medicine.

According to statistical data, from 60 to 70 percent of single lesions in the lung tissue that reappear after treatment are malignant. That is why great attention is paid to the development of new diagnostic methods in this area.

Today the following diagnostic procedures are widely used:

1. Computer examination, including tomography, which allows you to determine the size of lesions in the lungs with great accuracy.
2. Radiography.
3. Magnetic resonance imaging.
4. Laboratory examination of blood and sputum, as well as lung tissue.

Despite the reliability of the results of the listed studies, there is still no uniform algorithm for making a diagnosis when lesions are detected in the lung tissues. Each case of the disease is individual and must be considered separately from general practice.

Single lesions in the lungs: possibilities of radiodiagnosis

Correct diagnosis and making the correct diagnosis is very important when single lesions are detected in the lungs. Radiation diagnostics in these cases provides assistance that is difficult to overestimate.

The main tasks of radiological diagnosis of lesions in the lungs:

1. Using these methods, it is possible to identify the nature of the origin of lesions in the lungs and determine whether they are malignant or benign.
2. Radiation diagnostics allows you to reliably determine the form of tuberculosis when it is detected.

Currently, lesions in the lungs are primarily detected using simple radiography or fluorography (in the vast majority of cases). This pathology is found in 0.7-1% of all chest examinations.

However, using radiography and fluorography, it is extremely difficult to see single formations whose diameter is less than 1 cm. In addition, due to the different structures that are anatomically located in the sternum, it is sometimes impossible to distinguish large-scale lesions in the lungs. Therefore, when diagnosing, greater preference is given to computed tomography. It makes it possible to examine the lung tissue from different angles and even in cross-section. This eliminates the possibility that single formations will be indistinguishable behind the heart muscle, ribs or root of the lung.

Computed tomography is a unique diagnostic method that can detect not only lesions, but also pneumonia, emphysema and other pathological conditions of the lungs. But it must be remembered that even this diagnostic method has its drawbacks. Thus, in approximately 50% of cases of primary examination, neoplasms with a diameter of less than 5 millimeters are not detected in the photo. This is explained by such difficulties as the location of lesions in the center of the lung, the small size of the formations or their too low density.

If the formation exceeds 1 centimeter in diameter, then the diagnostic accuracy of computed tomography reaches 95 percent.

Tuberculosis remains a very common disease, despite the fact that huge amounts of money are allocated annually to combat it and large-scale research is carried out.

The most interesting facts about tuberculosis:

1. The causative agent of the disease is Koch's bacillus or mycobacterium, which is quickly transmitted by coughing or sneezing, that is, by airborne droplets.
2. With sputum into the air, one patient with tuberculosis releases from 15,000,000 to 7,000,000,000 mycobacteria. They spread within a radius of 1-7 meters.
3. Koch's bacillus can survive even at subzero temperatures (up to -269 degrees Celsius). When dried in the external environment, the mycobacterium remains viable for up to four months. In dairy products, the rod lives up to one year, and in books - six months.
4. Mycobacterium adapts very quickly to antibiotics. In almost every state, a type of tuberculin bacillus has been identified that is not sensitive to existing medications.
5. 1/3 of the world's population are carriers of the tuberculosis bacillus, but only 10 percent of them have suffered an active form of the disease.

It is important to remember that having had tuberculosis once, a person does not acquire lifelong immunity and can contract the disease again.

Are medical masks useful?

Scientists from Australia have conducted a number of scientific studies and have reliably established that medical masks practically do not protect against viruses and bacteria that are transmitted by airborne droplets. Moreover, they absolutely cannot be used in conditions where the risk of infection is high (constant work in the intensive care unit, tuberculosis).

A medical mask is only useful when it is worn by an already sick person. The fabric of the mask can reduce the risk of spreading infection.

Reasons for the ineffectiveness of masks:

• the distance between the fibers in a fabric medical mask is tens of microns, and viruses and bacteria are much smaller;
• viruses easily penetrate the side holes that form between the mask and the face.

In developed countries, hospital staff use special respirators that effectively trap air particles containing viruses and bacteria.

Using computed tomography, lesions in the lungs are classified. It can also be used to identify whether a single or multiple lesions have affected the lung, and also to suggest the most adequate treatment. This diagnostic procedure is one of the most reliable today. Its principle is that the tissues of the human body are exposed to X-rays, and then a conclusion is given based on this study.

If there is a suspicion of any lung disease, the doctor refers the patient to a CT scan of the chest organs. All segments of this part of the body are clearly visible on it.

Depending on their location, outbreaks are divided into two categories:

1. Subpleural lesions in the lungs, located under the pleura - the thin membrane that encloses the lungs. This localization is characteristic of the manifestation of tuberculosis or malignant tumors.
2. Pleural lesions.

Using computed tomography, the apical lesion in any segment of the lung is clearly visible. This type of lesion represents the proliferation of fibrous tissue and the replacement of healthy cells with it. The perivascular fibrous lesion is located near the blood vessels that provide its nutrition and growth.

Lesions in the lungs on CT: classification of formations

For an accurate diagnosis, it is very important to study lesions in the lungs using CT. Classification of formations allows us to understand how they should be treated.

Depending on the size of the formations in the lungs they are divided into:

• small (from 0.1 to 0.2 cm);
• medium size (0.3-0.5 cm);
• large lesions (up to 1 centimeter).

Based on density:

• not dense;
• medium-dense;
• dense.

By number:

• polymorphic lesions in the lungs - multiple formations having different densities and different sizes. Polymorphism of foci is characteristic of tuberculosis or pneumonia;
• single outbreaks.

If the lesions are located in the pleura, then they are called pleural; the subpleural lesion is located near it.

A subpleural lesion may not be visible to x-ray or fluorography, so CT is preferable for its diagnosis.

Thus, the answer to the question of focal lung damage and what it is has been received. It must be remembered that in order to exclude any diseases in the lungs, such a simple procedure as annual fluorography should not be neglected. It takes a matter of minutes and is capable of identifying any pathologies in the lungs in the early stages.

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• Congratulations! The likelihood that you will develop tuberculosis is close to zero.

  But don’t forget to also take care of your body and undergo regular medical examinations and you won’t be afraid of any disease!
  We also recommend that you read the article on.

• There is reason to think.

  It is impossible to say with certainty that you have tuberculosis, but there is such a possibility; if this is not the case, then there is clearly something wrong with your health. We recommend that you undergo a medical examination immediately. We also recommend that you read the article on.

• Contact a specialist urgently!

  The likelihood that you are affected is very high, but it is not possible to make a diagnosis remotely. You should immediately contact a qualified specialist and undergo a medical examination! We also strongly recommend that you read the article on.

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   1 .

   Does your lifestyle involve heavy physical activity?

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   Do you take care of your immunity?

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