Lung cancers associated with cystic airspaces: imaging features and therapy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHOU Xinrui , WANG Yuxuan , CUI Yuan , ZHAO Hanqing ,  TANG Xing

Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu, P. R. China;

Corresponding?author：

TANG Xing, Email: tangx81@163.com

Keywords：

Lung cancer; cystic airspaces; imaging features; pathology; aggressiveness; targeted therapy; chemotherapy; combined therapy

DOI：

10.7507/1007-4848.202505024

Video：

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Objective To explore the imaging characteristics of lung cancers associated with cystic airspaces (LCCA) and the effects of different treatment regimens. Methods A retrospective analysis was conducted on the clinical and radiological data of LCCA patients who underwent surgical resection and pathological confirmation at the Department of Thoracic Surgery, the First Affiliated Hospital of Soochow University from 2016 to 2023. The relationship between various radiological classifications and clinical pathology was studied. Based on the postoperative adjuvant treatment follow-up results, the effects of different treatment regimens were analyzed. Results A total of 147 patients were included, including 90 males and 57 females, with a median age of 63 (55, 70) years. There were 21 patients of imaging typeⅠ, 50 patients of typeⅡ, 57 patients of type Ⅲ, and 19 patients of type Ⅳ. The lobulation sign or burr sign of typeⅠcyst walls (P=0.004), and intracystic septa (P=0.030) were more commonly seen in the high-aggressiveness group. The components of the cyst walls or nodules of types Ⅰ-Ⅳ in the high-aggressiveness group were mostly solid or sub-solid (P<0.05). Multivariate logistic regression analysis indicated that subsolid cyst wall (OR=4.734, P=0.023), solid cyst wall (OR=97.972, P<0.001), and the lobulation sign or burr sign of the cyst wall (OR=13.215, P=0.024) were independent risk factors for aggressiveness. Fifty-eight patients received adjuvant therapy after surgery, including 22 in the chemotherapy group, 15 in the targeted therapy group, and 21 in the combined therapy group. The progression-free survival of the combined therapy group was better than the other two groups (P=0.045). Conclusion There is a correlation between the imaging features of LCCA and pathological aggressiveness. Compared to postoperative targeted therapy or chemotherapy alone, postoperative chemotherapy combined with targeted therapy can improve the progression-free survival of LCCA patients.

Citation： ZHOU Xinrui, WANG Yuxuan, CUI Yuan, ZHAO Hanqing, TANG Xing. Lung cancers associated with cystic airspaces: imaging features and therapy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(3): 383-389. doi: 10.7507/1007-4848.202505024 Copy

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2.	Mascalchi M, Attinà D, Bertelli E, et al. Lung cancer associated with cystic airspaces. J Comput Assist Tomogr, 2015, 39(1): 102-108.
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6.	Byrne D, English JC, Atkar-Khattra S, et al. Cystic primary lung cancer: evolution of computed tomography imaging morphology over time. J Thorac Imaging, 2021, 36(6): 373-381.
7.	Shi H, Liang B, Liu Y, et al. CT imaging in differentiating non-solid lung adenocarcinoma with cystic airspaces: a clinical and diagnostic study. BMC Pulm Med, 2025, 25(1): 292.
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14.	Liu C, Wang LC, Chen HS, et al. Outcomes of patients with different lepidic percentage and tumor size of stageⅠlung adenocarcinoma. Thorac Cancer, 2022, 13(14): 2005-2013.
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19.	Tan Y, Gao J, Wu C, et al. CT characteristics and pathologic basis of solitary cystic lung cancer. Radiology, 2019, 291(2): 495-501.
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21.	Wang L, Feng Y, Song S, et al. Lung cancer associated with cystic airspaces: current status and challenges. Front Oncol, 2025, 15: 1634835.
22.	Wang J, Dai J. Lung cancer associated with cystic airspaces: current progress and future perspectives. Oncol Rev, 2025, 19: 1615365.
23.	Ma Z, Wang S, Zhu H, et al. Comprehensive investigation of lung cancer associated with cystic airspaces: predictive value of morphology. Eur J Cardiothorac Surg, 2022, 62(5): ezac297.
24.	Miyauchi E, Morita S, Nakamura A, et al. Updated analysis of NEJ009: gefitinib-alone versus gefitinib plus chemotherapy for non-small-cell lung cancer with mutated EGFR. J Clin Oncol, 2022, 40(31): 3587-3592.
25.	Wu Q, Luo W, Li W, et al. First-generation EGFR-TKI plus chemotherapy versus EGFR-TKI alone as first-line treatment in advanced NSCLC with EGFR activating mutation: a systematic review and meta-analysis of randomized controlled trials. Front Oncol, 2021, 11: 598265.
26.	Noronha V, Patil VM, Joshi A, et al. Gefitinib versus gefitinib plus pemetrexed and carboplatin chemotherapy in EGFR-mutated lung cancer. J Clin Oncol, 2020, 38(2): 124-136.
27.	Zhang A, Miao K, Sun H, et al. Tumor heterogeneity reshapes the tumor microenvironment to influence drug resistance. Int J Biol Sci, 2022, 18(7): 3019-3033.
28.	Wen M, Xia J, Sun Y, et al. Combination of EGFR-TKIs with chemotherapy versus chemotherapy or EGFR-TKIs alone in advanced NSCLC patients with EGFR mutation. Biologics, 2018, 12: 183-190.
29.	Rebuzzi SE, Alfieri R, La Monica S, et al. Combination of EGFR-TKIs and chemotherapy in advanced EGFR mutated NSCLC: review of the literature and future perspectives. Crit Rev Oncol Hematol, 2020, 146: 102820.

1. Fintelmann FJ, Brinkmann JK, Jeck WR, et al. Lung cancers associated with cystic airspaces: natural history, pathologic correlation, and mutational analysis. J Thorac Imaging, 2017, 32(3): 176-188.
2. Mascalchi M, Attinà D, Bertelli E, et al. Lung cancer associated with cystic airspaces. J Comput Assist Tomogr, 2015, 39(1): 102-108.
3. Zhang Y, Ding BW, Wang LN, et al. Using CT features of cystic airspace to predict lung adenocarcinoma invasiveness. Quant Imaging Med Surg, 2024, 14(10): 7265-7278.
4. Jung W, Cho S, Yum S, et al. Stepwise disease progression model of subsolid lung adenocarcinoma with cystic airspaces. Ann Surg Oncol, 2020, 27(11): 4394-4403.
5. Xu X, Zhang M, Guo J, et al. The impact of cystic lesions on the postoperative prognosis of non-small cell lung cancer: a comparative study. Clin Radiol, 2024, 79(11): 842-850.
6. Byrne D, English JC, Atkar-Khattra S, et al. Cystic primary lung cancer: evolution of computed tomography imaging morphology over time. J Thorac Imaging, 2021, 36(6): 373-381.
7. Shi H, Liang B, Liu Y, et al. CT imaging in differentiating non-solid lung adenocarcinoma with cystic airspaces: a clinical and diagnostic study. BMC Pulm Med, 2025, 25(1): 292.
8. Watanabe Y, Kusumoto M, Yoshida A, et al. Surgically resected solitary cavitary lung adenocarcinoma: association between clinical, pathologic, and radiologic findings and prognosis. Ann Thorac Surg, 2015, 99(3): 968-974.
9. Shen Y, Xu X, Zhang Y, et al. Lung cancers associated with cystic airspaces: CT features and pathologic correlation. Lung Cancer, 2019, 135: 110-115.
10. Rami-Porta R, Nishimura KK, Giroux DJ, et al. Members of the IASLC staging and prognostic factors committee and of the advisory boards, and participating institutions. The International Association for the Study of Lung Cancer lung cancer staging project: proposals for revision of the TNM stage groups in the forthcoming (ninth) edition of the TNM classification for lung cancer. J Thorac Oncol, 2024, 19(7): 1007-1027.
11. Choi SH, Jeong JY, Lee SY, et al. Clinical implication of minimal presence of solid or micropapillary subtype in early-stage lung adenocarcinoma. Thorac Cancer, 2021, 12(2): 235-244.
12. Watanabe Y, Kusumoto M, Yoshida A, et al. Cavity wall thickness in solitary cavitary lung adenocarcinomas is a prognostic indicator. Ann Thorac Surg, 2016, 102(6): 1863-1871.
13. Yotsukura M, Asamura H, Motoi N, et al. Long-term prognosis of patients with resected adenocarcinoma in situ and minimally invasive adenocarcinoma of the lung. J Thorac Oncol, 2021, 16(8): 1312-1320.
14. Liu C, Wang LC, Chen HS, et al. Outcomes of patients with different lepidic percentage and tumor size of stageⅠlung adenocarcinoma. Thorac Cancer, 2022, 13(14): 2005-2013.
15. Pan X, Wang H, Yu H, et al. Lung cancer associated with cystic airspaces: CT and pathological features. Transl Cancer Res, 2020, 9(6): 3960-3964.
16. Xue X, Wang P, Xue Q, et al. Comparative study of solitary thin-walled cavity lung cancer with computed tomography and pathological findings. Lung Cancer, 2012, 78(1): 45-50.
17. Chen C, Fu S, Ni Q, et al. Cavity formation is a prognostic indicator for pathologic stageⅠinvasive lung adenocarcinoma of ≥3 cm in size. Med Sci Monit, 2019, 25: 9003-9011.
18. Valsecchi C, Petrella F, Freguia S, et al. Lung cancers associated with cystic airspaces. Cancers (Basel), 2025, 17(2): 307.
19. Tan Y, Gao J, Wu C, et al. CT characteristics and pathologic basis of solitary cystic lung cancer. Radiology, 2019, 291(2): 495-501.
20. Tang X, Liu G, Tan X, et al. Solitary multicystic lesion lung cancer: two case reports and review of the literature. BMC Pulm Med, 2021, 21(1): 368.
21. Wang L, Feng Y, Song S, et al. Lung cancer associated with cystic airspaces: current status and challenges. Front Oncol, 2025, 15: 1634835.
22. Wang J, Dai J. Lung cancer associated with cystic airspaces: current progress and future perspectives. Oncol Rev, 2025, 19: 1615365.
23. Ma Z, Wang S, Zhu H, et al. Comprehensive investigation of lung cancer associated with cystic airspaces: predictive value of morphology. Eur J Cardiothorac Surg, 2022, 62(5): ezac297.
24. Miyauchi E, Morita S, Nakamura A, et al. Updated analysis of NEJ009: gefitinib-alone versus gefitinib plus chemotherapy for non-small-cell lung cancer with mutated EGFR. J Clin Oncol, 2022, 40(31): 3587-3592.
25. Wu Q, Luo W, Li W, et al. First-generation EGFR-TKI plus chemotherapy versus EGFR-TKI alone as first-line treatment in advanced NSCLC with EGFR activating mutation: a systematic review and meta-analysis of randomized controlled trials. Front Oncol, 2021, 11: 598265.
26. Noronha V, Patil VM, Joshi A, et al. Gefitinib versus gefitinib plus pemetrexed and carboplatin chemotherapy in EGFR-mutated lung cancer. J Clin Oncol, 2020, 38(2): 124-136.
27. Zhang A, Miao K, Sun H, et al. Tumor heterogeneity reshapes the tumor microenvironment to influence drug resistance. Int J Biol Sci, 2022, 18(7): 3019-3033.
28. Wen M, Xia J, Sun Y, et al. Combination of EGFR-TKIs with chemotherapy versus chemotherapy or EGFR-TKIs alone in advanced NSCLC patients with EGFR mutation. Biologics, 2018, 12: 183-190.
29. Rebuzzi SE, Alfieri R, La Monica S, et al. Combination of EGFR-TKIs and chemotherapy in advanced EGFR mutated NSCLC: review of the literature and future perspectives. Crit Rev Oncol Hematol, 2020, 146: 102820.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Lung cancers associated with cystic airspaces: imaging features and therapy

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