screen discovered nodules: what next ?
DESCRIPTION
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 PresentationTRANSCRIPT
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
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