LUNG NODULES: MODERN MANAGEMENT STRATEGIES

Transcription

1 Department of Radiology LUNG NODULES: MODERN MANAGEMENT STRATEGIES Christian J. Herold M.D. Department of Biomedical Imaging and Image-guided Therapy Medical University of Vienna Vienna, Austria

2 Pulmonary Nodules Pulmonary nodule defined as rounded or irregular opacity <3 cm Single or multiple Solid or sub-solid (part-solid, non-solid = ground-glass opacity) 90% of non-calcified nodules measure <10 mm, 70% <5 mm

3 Pulmonary Nodules Tasks and Challenges Establish diagnosis Detect malignancy Confirm benign disorder Avoid unnecessary thoracotomy Limit the number of follow-up CT exams (radiation)

4 Pulmonary Nodules Modern Management Methods and Strategies Categorization of clinical scenario Determination of individual pretest probability (individual risk situation) Evidence based guidelines integrating risk situation and imaging findings

5 Clinical Scenarios in which nodules may be detected Symptomatic patients Patients w known malignancy Lung cancer screening Incidentally found nodule SY Fever, cough, SOB Yes / no Asymptomatic Unrelated to nodule CT CT to detect/exclude CT to detect/exclude CT to detect/exclude CT for other reasons GL No guidelines No guidelines Guidelines Guidelines MA Case specific Personalized in TB Lung-RADS Fleischner / Gould

6 Nodules in Symptomatic Patients Influenza A virus pneumonia 24 year old diabetic outpatient (non-smoker) with cough and subfebrile temperatures

7 Nodules in Symptomatic Patients Cryptogenic organizing pneumonia 46 yo male, day 120 after BMT, low grade fevers, cough, CRP 6

8 Nodules in Symptomatic Patients Biopsy: eosinophilic lung disease Steroid treatment resulted in complete resolution of the lesion Part-solid lesion F/u after steroid Tx at 1 month Lab tests: Blood eosinophilia has 38% sensitivity, 97% specificity predicting transient nature of nodule and thus benign disease 1 INTEGRATED DIAGNOSIS CT & LAB 32 year old female patient with subfebrile temperatures and blood eosinophilia 1) Lee SM et al, Radiology 2010

9 Nodules in Symptomatic Patients Wide range of underlying entities (approximately 70) Infection, inflammatory, immunologic, and malignant disorders No systematic guidelines for use and interpretation of CT Case specific / personalized management

10 Clinical Scenarios in which nodules may be detected Symptomatic patients Patients w known malignancy Lung cancer screening Incidentally found nodule SY Fever, cough, SOB Yes / no Asymptomatic Unrelated to nodule CT CT to detect/exclude CT to detect/exclude CT to detect/exclude CT for other reasons GL No guidelines No guidelines Guidelines Guidelines MA Case specific Personalized in TB Lung-RADS Fleischner / Gould

11 77 year-old patient, heavy smoker, CT scan performed for elevated sedimentation rate shows transitional cell carcinoma Part-solid nodules in both lungs representing minimally invasive adenocarcinomas

12 Pulmonary Nodules in Patients with Known Malignancies - A pulmonary nodule in patients with a known malignancy may represent Metastasis Pseudoprogression of disease following or during immunotherapy Primary lung cancer (meta- or synchronous) Benign disease / infection

13 Clinical Scenarios in which nodules may be detected Symptomatic patients Patients w known malignancy Lung cancer screening Incidentally found nodule SY Fever, cough, SOB Yes / no Asymptomatic Unrelated to nodule CT CT to detect/exclude CT to detect/exclude CT to detect/exclude CT for other reasons GL No guidelines No guidelines Guidelines Guidelines MA Case specific Personalized in TB Lung-RADS Fleischner / Gould

14 Management Guidelines ACR Lung-RADS TM ACR Lung Imaging Reporting and Data System Quality assurance tool to standardize lung cancer screening interpretation, reporting and management (Medicare) Relates imaging findings to BI-RADS like numeric categories 1 Negative 2 Benign appearance or behavior 3 Probably benign 4a&b Suspicious

15 Recent evaluation suggest that Lung-RADS substantially reduces the false positive rate however, also the sensitivity! As a consequence, categories need to be revised!! Pinsky RR et al. Ann Int Med 2015

16 Screenshot of clinical decision support tool for the radiologist (Massachusetts General Hospital, Boston)

17 Software program integrated into PACS and Voice recognition application for structured reporting Guarantees consistent reporting by radiologists reading lung cancer screening CTs (Lung-RADS)

18 Clinical Scenarios in which nodules may be detected Symptomatic patients Patients w known malignancy Lung cancer screening Incidentally found nodule SY Fever, cough, SOB Yes / no Asymptomatic Unrelated to nodule CT CT to detect/exclude CT to detect/exclude CT to detect/exclude CT for other reasons GL No guidelines No guidelines Guidelines Guidelines MA Case specific Personalized in TB Lung-RADS Fleischner / Gould

19 Incidentally Detected Pulmonary Nodules Management Guidelines American College of Chest Physicians Guidelines (Gould) Fleischner Society Guidelines for Incidentally Detected Solid Nodules Fleischner Society Guidelines for Sub-solid Nodules

20 ACCP Guidelines - Clinical Management Interdisciplinary panel 25 recommendations a) New solitary nodules >8-10mm b) Multiple nodules Morphology less important Less practical to use for radiologists but important to understand Gould MK et al. Chest 2013

21 Incidentally Detected Solid Pulmonary Nodules: Management Evidence based For incidentally detected nodules Integrate individual risk factors, lesion size, growth rate Revision in preparation by Fleischner Society MacMahon H et al, Radiology 2005;237:

22 Incidentally Detected Solid Nodules Parameters & risk factors relevant for patient management Clinical pretest probabliity Smoking history Age Exposure to radon & asbestos Family cancer history History of malignancy Immune status Radiologic - Nodule Size Growth rate

23 Incidentally Detected Solid Nodules Clinical pretest probability The high risk patient The low risk patient Substantial smoking history (10 to 35 times increased risk) Age > 40 Cancer history in 1 st 0 relatives Minimal or absent smoking history Age < 40 Absence of any other known risk factor

24 Incidentally Detected Nodules Imaging factors (Size and growth rate) relevant for patient management 1. The likelihood of a nodule developing malignant characteristics increases with increasing size - Nodules < 4mm have a < 1% probability of representing malignancy, or turning into lethal cancers - Nodules > 8 mm range have a 25 % chance of representing malignancy 2. Malignant nodules in smokers grow faster than those in nonsmokers

25 Management Recommendations: Solid Nodules MacMahon H et al, Radiology 2005;237. Gould MK et al, Chest 2013 Nodule Size 1) <4 mm Low-Risk Patients Management Recommendations No follow-up needed 2) High-Risk Patients Management Recommendations Initial follow-up CT at 12 months; if unchanged, no further follow-up >4-6 mm >6-8 mm >8 mm Initial follow-up CT at 12 months; if unchanged, no further follow-up Initial follow-up CT at 6-12 months, then at months if no change Follow-up CTs at 3, 9, and 24 months, or dynamic contrast-enhanced CT, PET-CT, and/or biopsy Initial follow-up CT at 6-12 months, then at months if no change Initial follow-up CT at 3-6 months, then at 9-12 and 24 months if no change Dynamic contrast-enhanced CT, PET-CT, and/or biopsy 1) Average of length and width 2) The risk of malignancy in this category (< 1%) is substantially less than that in a baseline CT scan of an asymptomatic smoker

26 6mm nodule in a 60 y/o smoker Follow-up low dose CT at 6 months Adenocarcinoma, papillary type

27 Resolving pulmonary nodule (probably inflammatory) 6 mm nodule incidentally found in a smoker F/u at 6 months F/u at 12 months

28 1cm nodule in a smoker Positive PET- CT Adenocarcinoma

29 Incidentally Detected Sub-solid Nodules Rounded or oval areas of increased attenuation, homogeneous or heterogeneous Found in screening studies (20% of non-calcified nodules), and incidentally on CT scans Non-solid lesions consist of ground-glass opacity (GGO) only Part-solid lesions contain solid (soft tissue) and ground-glass components Non-solid GGO Atypical adenomatous hyperplasia (AAH) Non-solid GGO Adenocarcinoma in situ (AIS) Part-solid lesion Minimally invasive adenocarcinoma (MIA) Courtesy J. Austin Godoy M, Naidich D. Radiology 2009

30 Sub-solid Nodules Persistent and Growing Lesions Persistent non-solid nodules commonly represent AAH (AIS) and focal fibrosis Growing non-solid nodules indicate malignancy and potential invasion (MIA) and, occasionally, lymphoproliferative disease Growing part-solid nodules point towards invasion (invasive adenocarcinoma) Courtesy J.A. Galvin M.D. Courtesy J.U.Schoepf M.D. AAH Invasive Adenocarcinoma 6 mo f/u

31 Sub-solid Nodules Persistent and Growing Lesions: Pathways of Evolution GGO <5mm Stable AAH or focal fibrosis GGO 5-10 mm Growth (and increase in density) Malignancy, invasion AIS MIA Growth and solid component invasive adenocarcinoma Time Adenoma-carcinoma sequence Modified from Fukui T et al. Surgery Today 2010, with permission

32 Methods and Tools to Identify Malignant Lesions CT Analysis and Surveillance Size Nodules <5mm are commonly AAHs (precursor lesions), but rarely also AIS 1 >15mm can be due to AIS, MIA and invasive adenocarcinomas The larger the lesion, the more likely it is to be malignant Lesion diameter >8mm is a predictor of malignancy 2 4mm GGO, AAH with atypical epithelial cells 14mm part-solid nodule MIA 1) Nakata M et al, Chest ) Lee HJ et al, Eur Radiol 2009

33 Methods and Tools to Identify Malignant Lesions CT Analysis and Surveillance Growth Associated with malignancy May affect ground-glass, solid components, or both The larger the solid component, the shorter the volume doubling time VDTs (days) GGNs 1832 (range: ) PSN< (range: ) PSN>5 759 (range: ) F/u at 24 months. AAH and AIS Young Sub Song et al, Radiology 2014

34 Methods and Tools to Identify Malignant Lesions CT Analysis and Surveillance Morphology predictors of malignancy: Lobulated border in pure GGOs 1 Air bronchograms and bubble-like lucencies 2 Development of solid portions in pure GGOs Spherical shape of small GGOs suggestive of AAH 1 All other features unreliable (polygonal shape in Noguchi C lesions 2, focal fibrosis 3 ) 1) Lee HJ et al, Eur Radiol ) Oda S et al, AJR ) Park JH et al, Korean J Radiol ) Kim HY et al, Radiology 2007

35 Sub-solid Nodules Management Guidelines Nodule Size Morphology Management <5 mm >5 mm Any size Multiple>5mm GGO GGO Part-solid GGO No follow-up needed Follow-up CT at 3-4 months; if unchanged, further yearly f/u (3-5 years minimum). If growing, surgery Initial follow-up CT at 3 months. If persistent or growing, consider surgical resection Follow-up CT at 3-4 months; if unchanged, further yearly f/u (3-5 years minimum). If growing, surgery Guidelines for Management of Sub-solid Pulm. Nodules Detected on CT Scans: A Statement from the Fleischner Society. Naidich D et al; Radiology 2013

36 Management of Pulmonary Nodules Summary Modern management strategies for pulmonary nodules are based on clinical scenarios, case specific (personalized) approaches, and evidence based guidelines Most strategies combine individual pretest probabilities (risk definition) with imaging parameters Guidelines for screening and assessment of incidental nodules are based on CT and require high resolution, low dose CT scans and consistency in CT technique Small solid lesions <4mm in low-risk individuals, and small sub-solid lesions <5mm do not need further action Existing guidelines are currently revised