Published Pulmonary Nodule Guidelines A Synthesis
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1 Published Pulmonary Nodule Guidelines A Synthesis Dr A Devaraj Royal Brompton Hospital London 4/28/2015 1
2 And very soon to be published Published ^ Pulmonary Nodule Guidelines A Synthesis Dr A Devaraj Royal Brompton Hospital London 4/28/2015 2
3 No Disclosures
4 OUTLINE OLD GUIDELINES A QUICK REVIEW BRITISH THORACIC SOCIET Y GUIDELINES THE KEY EVIDENCE PRACTICAL ASPECTS 4/28/2015 4
5 GUIDELINES FOR MANAGEMENT OF INCIDENTAL NODULES ON CT What did we do before the guidelines? Guideline Year Ost et al. NEJM 2003 ACCP Guidelines, Chest 2003 Fleischner Guidelines, Radiology 2005 ACCP Guidelines, Chest 2007 GRADUAL EVOLUTION ACCP Guidelines, Chest 2013 Fleischner Sub-solid Guidelines, Radiology 2013 BTS Guidelines, Thorax 2015 Fleischner Guidelines 2016?
6 Clinical conference in pulmonary disease 1971
7 Webb RW AJR 1990
8 Radiology 1999;212:
9 PULMONARY NODULE GUIDELINES 3 OPTIONS All guidelines provide 3 types of recommendations: When to IGNORE When to WATCH AND WAIT When to INTERVENE 4/28/2015 9
10 Early Guidelines IGNORE WATCH INTERVENE Ost et al. NEJM 2003 NONE <1cm: 6 CT scans 2 years >1cm ACCP Chest 2003 NONE Not for surgery: 4 CT scans 2 years All others 4/28/
11 2005 Fleischner Recommendations Ost et al. NEJM 2003 ACCP Chest 2003 IGNORE WATCH INTERVENE NONE NONE <1cm: 6 CT scans 2 years Not for surgery: 4 CT scans 2 years >1cm All others Fleischner Radiology 2005 <35 years <4mm never smokers <8mm: 3 CT scans 1-2 years >8mm 4/28/
12 : ACCP Guidelines Ost et al. NEJM 2003 ACCP Chest 2003 IGNORE WATCH INTERVENE NONE NONE <1cm: 6 CT scans 2 years Not for surgery: 4 CT scans 2 years >1cm All others Fleischner Radiology 2005 <35 years <4mm never smokers <8mm: 3 CT scans 1-2 years >8mm ACCP Chest <4mm never smokers <8mm or >8mm and low risk: 3-4 CT scans 1-2 Years >8mm and intermediate to high risk 4/28/
13 Fleischner Guidelines Some limitations From: ECR on demand /28/
14 NODULE SIZE SMALL MEDIUM LARGE DISCHARGE WATCH AND WAIT RISK STRATIFY AND PET DEFINITE STABILITY NEGLIGBLE GROWTH OR STABILITY UNCERTAIN SIGNIFICANT GROWTH INTERVENE DISCHARGE AT 1 YEAR LOW HIGH DISCHARGE AT 2 YEARS INTERVENE BTS SOLID NODULE GUIDELINES an adaptation 14
15 BTS Guidelines how are they different? IGNORE WATCH INTERVENE Ost et al. NEJM 2003 NONE <1cm: 6 CT scans 2 years >1cm ACCP Chest 2003 NONE Not for surgery: 4 CT scans 2 years All others Fleischner Radiology 2005 <35 years <4mm never smokers <8mm: 3 CT scans 1-2 years >8mm ACCP Chest 2007,2013 NONE <8mm or >8mm and low risk: 4 CTS 1-2 YEARS >8mm and intermediate to high risk BTS June 2015 <5mm or <80mm 3 5-8mm or mm 3 or >8mm/300mm 3 and low to medium risk >8mm/300mm 3 and medium to high risk 4/28/
16 NODULE SIZE SMALL MEDIUM LARGE DISCHARGE WATCH AND WAIT RISK STRATIFY AND PET DEFINITE STABILITY NEGLIGBLE GROWTH OR STABILITY UNCERTAIN SIGNIFICANT GROWTH INTERVENE DISCHARGE AT 1 YEAR LOW HIGH DISCHARGE AT 2 YEARS INTERVENE BTS SOLID NODULE GUIDELINES an adaptation 16
17 BTS GL FOR SMALL AND MEDI UM SIZED NODULES THE EVIDENCE D I S C H A R G E N O D U L E S < 5 mm O R 8 0 m m 3 F U R T H E R I N V E S T I G AT I O N >8mm O R m m 3 STUDY NLST J Natl Cancer Inst 2014;106:11 NEJM 2013;368:21 NODULE SIZE <5mm 5-8mm >8mm LUNG CANCER RISK 0.15% (8/5435) 0.6% (22/3522) 9.3% (234/2509) 1 YEAR RISK NELSON Lancet Oncology 2014;15:1332 <5mm / <100mm 3 5-8mm / mm 3 0.6% (15/2300) 2.4% (27/1111) 2 YEAR RISK >8mm / >300mm % (104/617) 17
18 BTS GL FOR SMALL AND MEDI UM SIZED NODULES THE EVIDENCE D I S C H A R G E N O D U L E S < 5 mm O R 8 0 m m 3 F U R T H E R I N V E S T I G AT I O N >8mm O R m m 3 STUDY NODULE SIZE LUNG CANCER RISK NLST J Natl Cancer Inst 2014;106:11 NEJM 2013;368:21 NO NODULES <5mm 0.1% (14/14673) 0.15% (8/5435) NELSON Lancet Oncology 2014;15:1332 NO NODULES 0.4% (15/3946) <5mm / <100mm 3 0.6% (15/2300) 18
19 BTS GL FOR SMALL AND MEDI UM SIZED NODULES THE EVIDENCE D I S C H A R G E N O D U L E S < 5 mm O R 8 0 m m 3 F U R T H E R I N V E S T I G AT I O N >8mm O R m m 3 STUDY NODULE SIZE LUNG CANCER RISK NLST J Natl Cancer Inst 2014;106:11 NEJM 2013;368:21 No nodules <5mm 5-8mm >8mm 0.1% (14/14673) 1 YEAR RISK 0.15% (8/5435) 0.6% (22/3522) 9.3% (234/2509) NELSON Lancet Oncology 2014;15:1332 NO NODULES <5mm / <100mm 3 5-8mm / mm 3 >8mm / >300mm 3 0.4% (15/3946) 2 YEAR RISK 0.6% (15/2300) 2.4% (27/1111) 16.9% UKLS Submitted data 3-5mm/15-50mm 3 0.2% (1/479) 1 YEAR RISK 19
20 NODULE SIZE SMALL MEDIUM LARGE DISCHARGE WATCH AND WAIT RISK STRATIFY AND PET DEFINITE STABILITY NEGLIGBLE GROWTH OR STABILITY UNCERTAIN SIGNIFICANT GROWTH INTERVENE DISCHARGE AT 1 YEAR LOW HIGH DISCHARGE AT 2 YEARS INTERVENE BTS SOLID NODULE GUIDELINES an adaptation 20
21 Little guidance to date What is growth? What is significant growth?
22 STUDY OR GUIDELINE DEFINITION OF SIGNIFICANT GROWTH FLEISCHNER 2005 GUIDELINES ACCP accurate measurement of growth in sub-centimetre nodules is problematic Unequivocal increase in size
23 STUDY OR GUIDELINE DEFINITION OF SIGNIFICANT GROWTH FLEISCHNER 2005 GUIDELINES ACCP LUNGRADS NLST SCREENING TRIAL IELCAP SCREENING TRIAL ITALUNG SCREENING TRIAL NELSON/DLCST/UKLS/MILD Lung Cancer Screening Trials US National Comprehensive Cancer Network COSMOS SCREENING TRIAL accurate measurement of growth in sub-centimetre nodules is problematic Unequivocal increase in size >1.5mm increase in diameter 10% increase in diameter >30% increase in size >1mm increase in diameter >25% increase in volume and VDT <400 days >2mm increase in diameter <400 days calculated volume doubling time
24 STUDY OR GUIDELINE DEFINITION OF SIGNIFICANT GROWTH FLEISCHNER 2005 GUIDELINES ACCP accurate measurement of growth in sub-centimetre nodules is problematic Unequivocal increase in size LUNGRADS >1.5mm increase in diameter NLST SCREENING TRIAL IELCAP SCREENING TRIAL ITALUNG SCREENING TRIAL NELSON/DLCST/UKLS/MILD Lung Cancer Screening Trials US National Comprehensive Cancer Network COSMOS SCREENING TRIAL BRITISH THORACIC SOCIETY GUIDELINES 10% increase in diameter 30% increase in size >1mm increase in diameter 25% increase in volume >2mm increase in diameter <400 days calculated volume doubling time 25% increase in volume AND VDT<600 days or where there is clear evidence of marked growth
25 BTS A more precise definition of significant growth NELSON screening study, Volume Doubling Time Lung Cancer Risk VDT<400 days 9.7% VDT days 4.1% VDT>600 days 0.8% Horeweg et al Lancet Oncology 2014;15:
26 Example Is there growth? Is it significant? BASELINE 12 MONTHS FOLLOW UP 4/28/
27 Example Is there growth? Is it significant? 4/28/
28 Example Is there growth? Is it significant? Vol= 127mls Vol= 415mls VDT = 214 days definitive workup 4/28/
29 NODULE SIZE SMALL MEDIUM LARGE DISCHARGE WATCH AND WAIT RISK STRATIFY AND PET DEFINITE STABILITY NEGLIGBLE GROWTH OR STABILITY UNCERTAIN SIGNIFICANT GROWTH INTERVENE DISCHARGE AT 1 YEAR LOW HIGH DISCHARGE AT 2 YEARS INTERVENE BTS SOLID NODULE GUIDELINES an adaptation 29
30 BTS GL FOR LARGE NODULES THE EVIDENCE RESECTION O R B IOPSY O R SURV EILLANCE? STEP 1 USE THE BROCK RISK CALCULATOR Test set 7008 nodules / Validation set 5021 nodules AUC Predictor s of cancer Radiological Nodule size Emphysema Upper lobe location Nodule density Nodule number Spiculation Clinical Age Sex Family History Mcwilliams et al. New England Journal of Medicine 2013;369:10 30
31 BTS GL FOR LARGE NODULES RESECTION VS BIOPSY VS SURVEILLANCE STEP 1 USE THE BROCK RISK CALCULATOR 4/28/
32 BTS GL FOR LARGE NODULES RESECTION VS BIOPSY VS SURVEILLANCE STEP 1 USE THE BROCK RISK CALCULATOR STEP 2 - IF RISK <10% FOR SURVEILLANCE IF RISK >10% FOR PET/CT AND HERDER SCORE Herder GJ et al. Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography. Chest 2005;128:
33 Large nodules Example 1 60 year old male with non-spiculated 12mm nodule in right middle lobe, with no emphysema or family history of lung cancer Brock score= 4.7% CT Surveillance
34 Large nodules Example 2 60 year old male patient with spiculated 14mm nodules in right upper lobe, with emphysema but no family history of lung cancer Brock score= 28.7% PET/CT
35 Large nodules Example 2 60 year old male patient with spiculated 14mm nodules in right upper lobe, with emphysema but no family history of lung cancer Herder Score = 85.8% Consider Resection
36 NODULE SIZE SMALL MEDIUM LARGE DISCHARGE WATCH AND WAIT RISK STRATIFY AND PET DEFINITE STABILITY NEGLIGBLE GROWTH OR STABILITY UNCERTAIN SIGNIFICANT GROWTH INTERVENE DISCHARGE AT 1 YEAR LOW HIGH DISCHARGE AT 2 YEARS INTERVENE BTS SOLID NODULE GUIDELINES an adaptation 36
37 Potential benefits of BTS guidelines? Scenario Impact of change Ignore very small nodules +++
38 Potential benefits of BTS guidelines? Scenario Impact of change Ignore very small nodules +++ Better identify subtle but significant growth using VDT +
39 Potential benefits of BTS guidelines? Scenario Impact of change Ignore very small nodules +++ Better identify subtle but significant growth using VDT Avoid 2 years follow-up for stable nodules (5-8mm) using volumetry + ++
40 Potential benefits of BTS guidelines? Scenario Impact of change Ignore very small nodules +++ Better identify subtle but significant growth using VDT Avoid 2 years follow-up for stable nodules (5-8mm) using volumetry More consistent management of 8-15mm nodules using Brock and Herder Scores Others: E.g. Precise definitions of intrapulmonary lymph nodes
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