Lung Screening: Do s and Don t s

Transcription

1 18th Annual Interna3onal Symposium on Mul3detector-Row CT June HyaH Regency San Franciscio Wednesday June AM Lung Screening: Do s and Don t s Mathias Prokop, MD PhD Department of Radiology and Nuclear Medicine Radboud University Medical Center Nijmegen, The Netherlands

2 Disclosures Mathias Prokop Research support Toshiba Medical Systems Speaker bureau Bracco Toshiba Department Thirona (Spinoff; COPD analysis) Veolity (Screening CAD soxware; licensed by Invivo)

3 Lung Cancer How big is the problem? Epidemiology Leading cause of cancer death (28%) More than breast + prostate + colon + pancreas cancer Es3mated increase in cancer rates by 2030: % Survival 5-year survival: lung cancer 15% compare: breast 89%, prostate 99%, colon 65% Only 16 % is diagnosed at an early stage US Congress. Lung Cancer Mortality Reduc3on Act of 2011

4 Lung Cancer How big is the problem? S3gma3za3on by society Only cancer blamed on pa3ents but 20% have never smoked 60% are former smokers Economical impact Value of life lost > $433,000,000,000 / year by 2020 Early detec3on save >70,000 lives / year in the US US Congress. Lung Cancer Mortality Reduc3on Act of 2011

5 Na3onal Lung Screening Trial Less cancer deaths Death from lung cancer Less lung cancer deaths with LDCT than CXR NLST research team. N Engl J Med 2011;365:395

6 Lung Screening Semng up a Successful Program

7 Lung Screening What makes screening successful? Step 0: know what you re gemng into Long-term commitment (up to 20 years) Complex logis3cs Know what you want to screen for Lung cancer screening only? Calcium scoring? COPD? Osteoporosis?

8 Lung Cancer Screening LDCT for CAC Survival rates Any calcifica3on increases risk Agatston scores fit in same risk category Agatston scores > 400 increase risk by factor 12! Takx RAP et al. JCCT 2015;9.50

9 LDCT for Lung Cancer Screening Screen for other diseases? Osteoporosis Compare vertebral fracture and vertebral density in NELSON par3cipants that died during 6-year f/u and random survivors HR of fractures 2.04 HR per 10 HU reduc3on in vertebral density 1.08 Osteoporosis independent predictor of survival over age, gender, smoking status, pack years, emphysema coronary and aor3c calcium volume Buckens CF et al. Eur Radiol 2015;25(1):132

10 Lung Screening What makes screening successful? Step 1: form a team Administra3on and coordinators IT people Pa3ent informa3on officers Radiographers and radiologists Pulmonologists Radia3on oncologists, surgeons Cardiologists, others Good so)ware essen/al Expecta/on management Successful treatment

11 Lung Screening What makes screening successful? Step 2: get the procedures standardized Pa3ent selec3on Pa3ent expecta3on management Who does what? Scanning Evalua3on and data handling Work-up, treatment op3ons Step 3: train the people involved

12 Lung Screening What makes screening successful? Step 4: screen Schedule informa3on visits & pa3ent selec3on Schedule screening visits Scan (thin-sec3on) Evaluate (LungRADS) Use 4X

13 Lung Nodule Management Perifissural nodules = lymph nodes Lung Health Study Canada 234/837 (28%) nodules were perifissural à none turned out malignant NELSON trial 794/4026 (20%) baseline nodules à none turned out malignant PanCan and BCCA trial: 70/6989 (1%) and 501/5021 (10%) à none turned out malignant Ahn MI et al. Radiology, 2010 De Hoop B et al. Radiology, 2012 McWilliams A et al. NEJM, 2013 LungRADS: Nodules with features of PFN should be managed like all other nodules

14 Perifissural Nodules PFN may show malignant growth No follow-up None of the 919 PFN developed into malignancy despite malignant growth rates in 5-8% of PFN De Hoop B et al. Radiology. 2012;265(2):611

15 Do: Ignore perifissural Nodes Typical PFN Growing PFN 3 months f/u: Growth from 150 to 180 mm 3 VDT 270 days Malignant PFN Adenocarcinoma (irregular margins, flahened at only one side) De Hoop B et al. Radiology. 2012;265(2):611

16 Do: Use LungRADS 4X Discrimina3ng malignant / benign nodules All nodules Humans worse than Brock for (size-based) risk assessment Size-matched nodules Humans bener than Brock if size is excluded Van Riel et al.

17 Do: Use LungRADS 4X Discrimina3ng malignant / benign nodules All nodules Size-matched nodules Morphologic characteris/cs can (!!!) improve nodule characteriza/on Van Riel et al.

18 Do: Use LungRADS 4X Upper lobe loca3on increases risk More cancers R > L Upper lobe > lower lobe Periphery > central.. Horweg N et al. AJRCCM 2013; 187(8):848

19 Do: visual assessment of coronary calcium mild moderate severe Chiles C et al. Radiology 2015 (epub)

20 Do: visual assessment of coronary calcium Hazard ra3os AS o-cac s-cac AS = Agatston score > s-cac = summed segmental score Overall assessment of CAC and Agatston score yield similar risk o-cac = overall score 1. No calcium 2. mild 3. moderate 4. severe Chiles C et al. Radiology 2015 (epub)

21 Lung Screening What makes screening successful? Step 5: follow Automate scheduling Establish measures of growth (consider volumetry) Step 6: work up and treat Establish procedures for screen-detected nodules Consider markers prior to resec3on Form a team with trea3ng physicals Close feedback cycle

22 Lung Cancer Screening Treatment is key! Establish feedback cycle to screening radiologists! Early cancers treated by non-specialized surgeons Small nodules or GGNs cannot be palpated intraopera3vely May not be (fully) resected Histology axer VATS: Old infarc3on 3-year follow-up: T2N1 carcinoma 1-year follow-up VDT < 400 d

23 Lung Cancer Screening Treatment is key! Early cancers treated by non-specialized surgeons Small nodules or GGNs cannot be palpated intraopera3vely May not be (fully) resected Histology axer VATS: BOOP / COP

24 Lung Cancer Screening Establish team approach Early cancers treated by non-specialized surgeons Small nodules or GGNs cannot be palpated intraopera3vely May not be (fully) resected Case discussions and feedback are key! Preop Postop. control Final histology : Squamous cell carcinoma

25 Lung Screening Do s and Don ts

26 Lung Screening Do s Be prepared Know what you re gemng into Form a team Standardize procedures Get good soxware (pa3ent management/ evalua3on) Screen Manage expecta3ons Use LungRADS (4X!) [except for perifissural nodules] Build treatment alliances Establish feedback cycle

27 Lung Screening Don ts Underes3mate the effort Screening is not just radiology Underes3mate the IT part Surgery for small lesion requires knowledge Report Measure diameters without linking old & new Change soxware

28 Acknowledgements Nijmegen Bram van Ginneken Cornelia Schaefer-Prokop Eva van Rikxoort Ernst Scholten Colin Jacobs Sarah van Riel Kaman Chung Francesco Ciompi Arnaud Se3o Bremen Bianca Lassen Michael Schmidt Jan-Mar3n Kuhnigk Lübeck Jan Rühaak Stefan Heldmann Utrecht Pim de Jong Willem Mali Onno Mets Bartjan de Hoop Hester Gietema Copenhagen Asger Dirksen Jesper Pedersen Mathilde Winkler Seoul Jin Mo Goo New York David Naidich Boston Alex Bankier Vancouver John Mayo Stephen Lam Alex Ritchie Sukhinder Atkar-KhaHra

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