screen discovered nodules: what next ?

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Screen discovered nodules: What next ?. 18 th Annual Perspectives in Thoracic Oncology. Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical Center. Disclosures. Research Funding NIH, DOD - PowerPoint PPT Presentation

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Screen discovered nodules: What next?

Anil Vachani, MD, MSAssistant Professor of MedicineDirector, Lung Nodule Program

University of Pennsylvania Medical Center

18th Annual Perspectives in Thoracic Oncology

Disclosures

• Research Funding– NIH, DOD– Integrated Diagnostics, Allegro Diagnostics,

• Scientific Advisory Board– Allegro Diagnostics

Nodule, Biopsy and Benign Disease RatesPe

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Ost & Gould, AJRCCM 2011

Assessing the Probability of Cancer

• Most Important Factors to consider:– Nodule size and characteristics– Smoking history– Age– Family history of lung cancer– Emphysema

http://www.brocku.ca/lung-cancer-risk-calculator

http://www.brocku.ca/lung-cancer-risk-calculator

Importance of Nodule Size

Nodule Size Confirmed Lung Cancer PPV (%)Yes No

4-7 mm 18 (7%) 3642 (53%) 0.5

7-10 mm 35 (13%) 2079 (30%) 1.7

11-20 mm 111 (41%) 821 (12%) 11.9

21-30 mm 58 (22%) 137 (2%) 29.7

> 30 mm 45 (17%) 64 (1%) 41.3

NLST Investigators. NEJM 2013

Guidelines

Fleischner Society Guidelines

Nodule Size Low Risk High Risk

≤ 4 mm No follow-up needed 12 mo

> 4-6 mm 12 mo 6-12 mo

> 6-8 mm 6-12 mo 3-6 mo

> 8 mm 3 mo, PET, and/or biopsy

McMahon, et al. Radiology 2005; 237:395-400

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

Thick vs. Thin Sections for Small Nodules

Naidich D P et al. Radiology 2013;266:304-317

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 years

Pure GGN larger than 5mm

• Lesions are frequently due to preinvasive AAH or AIS

• Up to 20% of persistent GGOs are benign• Growth of a GGO can suggest presence of an

invasive adenocarcinoma

Serial Imaging to Assess Growth (1mm cuts)

Naidich D P et al. Radiology 2013;266:304-317

Rapid Enlargement of a GGO

Naidich D P et al. Radiology 2013;266:304-317

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 yrs

Solitary part-solid Initial CT at 3 months; if persistent and solid component < 5mm, then yearly CT for min of 3 yrs. If persistent and solid component > 5mm, then biopsy or surgery

Rationale

• Part solid nodules have a high likelihood of malignancy

• Development of a solid component within a pure GGO

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 yrs

Solitary part-solid Initial CT at 3 months; if persistent and solid component < 5mm, then yearly CT for min of 3 yrs. If persistent and solid component > 5mm, then biopsy or surgery

Multiple subsolid nodules

Pure GGNs < 5 mm Obtain follow-up CT at 2 and 4 years

Pure GGNs > 5mm without a dominant lesion

Initial CT at 3 months; then annual surveillance for a minimum of 3 yrs

Dominant nodule with part solid or solid component

Initial CT at 3 months; If persistent, biopsy or surgical resection, especially for lesions with > 5mm solid component

Multiple subsolid lesions with single dominant focus.

Naidich D P et al. Radiology 2013;266:304-317

PET Scans

Erasmus, et al. Clinics in Chest Medicine 2008

PET Scans

• Sensitivity ~ 85% • Specificity ~ 80%• Less accurate for:– Smaller lesions– Subsolid nodlues

Establishing a Tissue Diagnosis

• Bronchoscopy vs. CT guided TTNA

Modality Sensitivity Traditional bronchoscopy (screen detected) 15%

Navigational bronchoscopy 70%

CT guided TTNA 90%

Establishing a Tissue Diagnosis

• Bronchoscopy vs. CT guided TTNA

• Data based on case series• Risks of CT guided TTNA– Pneumothorax 15-27%

Modality Sensitivity Traditional bronchoscopy (screen detected) 15%

Navigational bronchoscopy 70%

CT guided TTNA 90%

Conclusions• Lung nodules are increasingly common • Important to elicit patient preferences• Management should include– Estimation of cancer risk

• Nodules ≤ 8mm are infrequently malignant– CT scan surveillance is best option in most cases

• If high likelihood of malignancy and low surgical risk, consider surgical evaluation

• Emergence of peripheral blood biomarkers

THANK YOU

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