SCBT-MR 2015 LungRADS : Basics

Transcription

1 SCBT-MR 2015 LungRADS : Basics Reginald F. Munden MD, DMD, MBA I have no conflicts of interest to report

2 National Lung Cancer Screening Trial 20% lung cancer mortality reduction 6.9% all cause mortality reduction 320 individuals to save 1 from lung cancer death

3 NLST 24% of all screens - called positive study T0-27%, T1-28%, T2-17% 96% of positive studies - false positive At least one positive study in participant: CT 39%; CXR 16% Complications: 0.4% CT; 1.6% CXR 16 deaths (within 60 days) of CT (10 lung cancer) False negative - missed rate? NLST Research Team. NEJM, 2011

4 Lung Cancer Screening: Standardized lung nodule identification ACR LungRADS

5 ACR LungRADS Category Descriptor Category Descriptor Primary Category Incomplete - 0 Negative No nodules & definitely benign nodules 1 Management Additional lung cancer screening CT images and/or comparison to prior chest CT examinations is needed Benign Appearance or Behavior Nodules with a very low likelihood of becoming a clinically active cancer due to size or lack of growth 2 Continue annual screening with LDCT in 12 months Probably Benign Probably benign finding(s) - short term follow up suggested; includes nodules with a low likelihood of becoming a clinically active cancer 3 6 month LDCT 4A 3 month LDCT; PET/CT may be used when there is a 8 mm solid component Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4B Chest CT, PET/CT and/or biopsy-depending on *probability of malignancy and comorbidities.

6 ACR LUNG-RADS Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Negative No nodules and definitely benign nodules 1 no lung nodules nodule(s) with specific calcifications: complete, central, popcorn, concentric rings and fat containing nodules Benign Appearance or Behavior Nodules with a very low likelihood of becoming a clinically active cancer due to size or lack of growth 2 solid nodule(s): < 6 mm new < 4 mm part solid nodule(s): < 6 mm total diameter on baseline screening non solid nodule(s) (GGN): < 20 mm OR 20 mm and unchanged or slowly growing Continue annual screening with LDCT in 12 months < 1% 90% category 3 or 4 nodules unchanged for 3 months Probably Benign Probably benign finding(s) - short term follow up suggested; includes nodules with a low likelihood of becoming a clinically active cancer 3 solid nodule(s): 6 to < 8 mm at baseline OR new 4 mm to < 6 mm part solid nodule(s): 6 mm total diameter with solid component < 6 mm OR new < 6 mm total diameter non solid nodule(s) (GGN) 20 mm on baseline CT or new 6 month LDCT 1-2% 5%

7 ACR LungRADS Category 4 Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Solid nodule(s): 8 to < 15 mm at baseline OR growing < 8 mm OR new 6 to < 8 mm 3 month LDCT; 4A Part solid nodule(s): 6 mm with solid component 6 mm to < 8 mm OR PET/CT may be used when there is a 8 mm solid component 5-15% 2% Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4B 4X with a new or growing < 4 mm solid component Endobronchial nodule Solid nodule(s) 15 mm OR new or growing, and 8 mm Part solid nodule(s) with: a solid component 8 mm OR a new or growing 4 mm solid component Category 3 or 4 nodules with additional features or imaging findings that increases the suspicion of malignancy Chest CT with or without contrast; PET/CT and/or tissue sampling depending on the *probability of malignancy and comorbidities; PET/CT may be used when there is a 8 mm solid component. > 15% 2%

8 Baseline 3 months follow-up 4A Management

9 4A - Solid Nodule Findings > 8 to < 15mm at baseline Growing < 8mm or New 6 to < 8mm Endobronchial nodule Management: 3 month LDCT PET/CT if solid component is > 8mm

10 Follow up 3 months PET/CT 4A Solid > 8mm to < 15mm at baselline

11 4A: Growing < 8m One year

12 4A Endobronchial

13 Category 4A Part-solid Nodule Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4A Part solid nodule(s): 6 mm with solid component 6mm to < 8 mm OR with a new or growing < 4 mm solid component 3 month LDCT; PET/CT may be used when there is a 8 mm solid component 5-15% 2%

14 Findings: > 6 mm with solid component > 6mm to < 8mm or with a new or growing < 4mm solid component Management: 3 month LDCT PET/CT if solid component is > 8mm 4A Part Solid Nodule

15 New < 4mm Solid Component 4A Part Solid Nodule

16 Category 4B Solid Nodule Category Category Descriptor Category Findings Management Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4B Solid nodule(s) 15 mm OR new or growing, and 8 mm Chest CT with or without contrast; PET/CT and/or tissue sampling depending on the *probability of malignancy and comorbidities; PET/CT may be used when there is a 8 mm solid component. Probability of Malignancy Estimated Population Prevalence > 15% 2%

17 4B Solid Nodule Findings > 15mm at baseline or New or growing, and > 8mm Management Chest CT w/ or w/o contrast PET/CT and/or tissue sampling depending on probability of malignancy

18 4B - Growing and > 8mm

19 Category 4B Part-Solid Nodule Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4B Part solid nodule(s) with: a solid component 8 mm OR a new or growing 4 mm solid component Chest CT with or without contrast; PET/CT and/or tissue sampling depending on the *probability of malignancy and comorbidities; PET/CT may be used when there is a 8 mm solid component. > 15% 2%

20 4B New > 8mm solid

21 4B Growing Solid Component

22 4x Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Chest CT with or without contrast; Suspicious Findings for which additional diagnostic testing and/or tissue sampling is recommended 4X Category 3 or 4 nodules with additional features or imaging findings that increases the suspicion of malignancy PET/CT and/or tissue sampling depending on the *probability of malignancy and comorbidities; PET/CT may be used when there is a 8 mm solid component. > 15% 2% Increases the suspicion of malignancy: Spiculations, edge contours Hilar/central mass small cell cancer GGN doubles in size in 1 year Calcification

23 Findings Additional imaging features that increase the suspicion of malignancy: Spiculations, hilar/central mass, GGN doubles in size in 1 year Management Chest CT w/w/o contrast PET/CT and/or tissue sampling depending on probability of malignancy 4x - Other Stuff

24 4x Other suspicious

25 4B Management Factors Patient preference Probability of malignancy based on patient evaluation McWilliams Lung Cancer Risk Calculator

26 McWilliams Lung Cancer Risk Calculator

27 Category S and C Category Category Descriptor Category Findings Management Probability of Malignancy Estimated Population Prevalence Other Clinically Significant or Potentially Significant Findings (non-lung cancer) S Modifier - may add on to category 0 4 coding As appropriate to the specific findings n/a 10% Prior Lung Cancer Modifier for patients with a prior diagnosis of lung cancer who return to screening C Modifier may add on to category 0 4 coding

28 Coronary Artery Calcification as a Predictor of Morality in the NLST 1575 NLST CTs graded for CAC 210 CHD deaths, 315 all cause deaths, 1050 alive Agatston score, qualitative vessel, overall visual CAC classification HR overall assessment HR vessel-specific segments HR Agatston score None/0/ Mild/1-5/ Moderate/6-11/101-1, Heavy/12-30/>1, Chiles, et al. Radiology2014

29 Thank You Reginald F. Munden MD, DMD, MBA