PULMONARY NODULES AND MASSES : DIAGNOSTIC APPROACH AND NEW MANAGEMENT GUIDELINES.
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1 PULMONARY NODULES AND MASSES : DIAGNOSTIC APPROACH AND NEW MANAGEMENT GUIDELINES Heber MacMahon MB, BCh Department of Radiology The University of Chicago
2 Disclosures Consultant for Riverain Medical Minor stockholder in Hologic, Inc. Consultant for GE Healthcare Research Support from Philips Healthcare License and royalty fees from University of Chicago (UC Tech)
3 Pulmonary Nodules and Masses Diagnostic Approach and New Management Guidelines Examine the diagnostic features of lung nodules that determine cancer risk Review new evidence from screening trials Demonstrate the importance of using optimal CT technique Discuss the 2017 Fleischner Nodule Guidelines Illustrate newer techniques for nodule detection
4 69 y/o woman with facial weakness
5 Adenocarcinoma
6 Percentage of Lung Cancers Detected by CXR According to Size mm 2-5mm 6-10mm 11-20mm 21-45mm X Adapted from : Henschke et al. Lancet 1999;
7 Nodule Size and Probability of Malignancy Size ELCAP Mayo Nelson PanCan <3mm 0.1% 2-5mm <1% 0.4% <0.4% 4-7mm 0.7% 6-10mm 24% 8-20mm 18.7% 21-30mm 33.3% 21-45mm 80%
8 Missed Lung Cancers Size: cm (mean 1.6) Location : Upper lobes 80% + Conspicuity : Overlapping bones in 95% + Modified from Li et al. January 2008 Radiology, 246,
9 Missed Lung Cancers Size: cm (mean 1.6) Location : Upper lobes 80% + Conspicuity : Overlapping bones in 95% + Modified from Li et al. January 2008 Radiology, 246,
10 Dual Energy Chest Radiography
11 Standard CXR
12 Standard CXR Dual Energy CXR
13 Standard CXR Dual Energy CXR
14 Standard CXR Dual Energy CXR
15 What is a Pulmonary Nodule?
16 Pulmonary Nodule A rounded opacity, well or poorly defined, measuring up to 3 cm in diameter
17 Nodule Size and Probability of Malignancy Size ELCAP Mayo <3mm 0.1 % 2-5mm <1% 4-7mm 0.7 % 6-10mm 6% 8-20mm 19 % 21-30mm 33 % 21-45mm 80%
18 Diagnostic Features of Nodules Size Morphology Texture Solid, Part solid, Ground glass Calcification Shape Margins Location Growth rate
19 Spectrum of NoduleTexture GGO Part Solid Solid
20 CT Screening for Lung Cancer Frequency and Significance of Part-Solid and Nonsolid Nodules Part-solid: 63% malignant Non-solid: 18% malignant Solid: 7% malignant Henschke et al. AJR 2002 ;178:
21 Persistent Pulmonary Nodular Ground-Glass Opacity at Thin-Section CT: Histopathologic Comparisons Kim et al. Radiology ,1 p NS nodules in 49 pts Persisted or grew for > 1 month 75% were adenoca/ BAC 6% AAH 19% Nodular fibrosis/organizing pna
22 Atypical Adenomatous Hyperplasia (AAH) Typically GGO <5mm Precursor of adenoca Found in 20% + of lobes resected for lung ca
23 Ground Glass (Non-Solid) Nodule
24 Adenocarcinoma Progression
25 Adenocarcinoma Progression
26 Diagnostic Features of Nodules Size Morphology Texture Attenuation Solid, Part solid, Ground glass Calcium, Fat Shape Margins Location Growth rate
27 Benign Features Laminar Calc. Central Calc. Fat
28 Patterns of Calcification Central Laminated Eccentric Popcorn Diffuse Stippled
29 Calcified Lung Carcinoma Calcium detectable by CT in 10% Usually 2 dystrophic ca++ or engulfed granulomatous ca++ Most calcified carcinomas are 5cm.+ Diffuse, speckled or irregular
30 Diagnostic Features of Nodules Size Morphology Texture Attenuation Shape Margins Solid, Part solid, Ground glass Calcium, Fat Spherical, elliptical, linear Spiculated, lobulated, smooth Location Growth rate
31 Nodule Margins Smooth Lobulated Spiculated
32 Non Solid and Part Solid Nodules Benign Malignant Benign Malignant
33 Malignant (17) versus Benign (12) Non-solid (GGO) Nodules Margins Malignant Benign Rounded 85% 15% Straight 0 100% Li F, Sone S, Abe H, MacMahon H, Doi K: Radiology (3):233, November, 2004.Pages
34 Small Perifissural Solid Nodules De Hoop B, et al.pulmonary perifissural nodules on CT scans: rapid growth is not a predictor of malignancy. Radiology` 2012;265(2): Myeong I. Ahn MD et al. Perifissural Nodules Seen at CT Screening for Lung Cancer. Radiology: 2010; 254 (3):
35 Diagnostic Features of Nodules Size Morphology Texture Attenuation Shape Margins Location Solid, Part solid, Ground glass Calcium, Fat Spherical, elliptical, linear Spiculated, lobulated, smooth Perifissural, subpleural, upper lobe Growth rate
36 Growth Rate of Nodules Volume doubling time (VDT): 26% diameter increase = One volume doubling Typical lung ca. VDT = days Range = days
37 Growth rate of Small Cancers (Hasegawa BJR 2000) Parameter Mean VDT (Days) <10mm 536 >20mm 299 Smoker 292 Non-smoker 607 Adenoca 533 Squamous 129 Small cell 97 GGO 813 Mixed Solid
38
39 Fleischner Society Guidelines 2005 Nodule Size (mm) Low-Risk Patient High-Risk Patient 0-4 None 12 mos > mos 6-12, 18-24mos > , 18-24mos 3-6, 9-12, 24mos >8 Follow-up CT at around 3, 9, and 24mo, dynamic contrast-enhanced CT, PET, and/or bx
40
41 Fleischner Society Guidelines Solitary Subsolid Nodules (2013): Nodule type Management recommendations Solitary pure GGNs: <5mm >5mm No CT FU required 3 mos, then annual for at least 3 yrs Solitary part-solid nodules: 3 mos FU CT, then annual LDCT if solid part <5mm. If solid part >5mm then consider Bx or surg.
42 Incidental Nodules Exclusions: Patients with unexplained fever Patients with known or suspected metastases Patients < 35 years of age Lung Cancer Screening
43 Screening Detected vs Incidental Nodules Screen Detected Nodule Limited age range & high cancer risk Surgical candidate Understand risks and benefits Negative report > 12 month CT Incidental Nodule Wide age range Comorbid conditions Variable motivation & understanding Negative report > no follow up
44 New Evidence International Early Lung Cancer Action Program (ielcap) National Lung Cancer Screening Trial (NLST) Pan-Canadian Early Detection of Lung Cancer Study (PanCan) & British Columbia Cancer Agency Trial (BCCA) Nederlans-Leuvens Longkanker Screenings Onderzoek (NELSON) UKLS (UK), MILD (Italy), DANTE (Italy), DLCST (Denmark), LUSI (Germany), DEPISCAN (France)
45 Fleischner Guidelines 2017 : Threshold Size Nodule Size vs Cancer Risk in High Risk McWilliams A et al. N Engl J Med 2013;369: Size (mm) Cancer Risk (%) 3mm 0.1 4mm 0.2 5mm 0.4 6mm 0.7 7mm 1.5
46 Revised Guidelines 2017: Purpose Apply new evidence to determine optimal management strategy Reduce number of unnecessary CT scans Allow greater discretion to radiologists, clinicians and patients in management decisions - Consider morphology - Comorbid conditions - Patient preference
47 Fleischner Guidelines 2017 General recommendations: Contiguous thin section CT technique (1mm) Coronal & sagittal recons Low radiation technique for follow up scans
48 3mm 1mm Calcified granuloma
49 Revised Fleischner Guidelines 2017 General recommendations: Contiguous thin section CT technique (1mm) Coronal & sagittal recons Low radiation technique for follow up scans
50 ? Nodule
51 Axial Coronal Sagittal
52 Revised Fleischner Guidelines 2017 General recommendations: Contiguous thin section CT technique (1mm) Coronal & sagittal recons Low radiation technique for follow up scans
53 Fleischner Guidelines 2005 vs 2017 Nodule Size (mm) * Low-Risk Patient High-Risk Patient 0-<4 None 12 mos < 6 None + 12 mos > mos 6-12, 18-24mos > , 18-24mos 3-6, 9-12, 24mos , mos 6-12, 18-24mos >8 Follow-up CT at around 3, 9, and 24mo, dynamic contrast-enhanced CT, PET, and/or bx >8 Consider 3 mos CT, PET/CT or bx *Measure average diameter to nearest millimeter
54 Fleischner Guidelines 2005 vs 2017 Nodule Size (mm) * Low-Risk Patient High-Risk Patient 0-<4 None 12 mos < 6 1 mm change None + 12 mos Less FU > mos 6-12, 18-24mos > , 18-24mos 3-6, 9-12, 24mos 6-8 Only 3 groups 6-12, mos 6-12, 18-24mos >8 Follow-up CT at around 3, 9, and 24mo, dynamic contrast-enhanced CT, PET, and/or bx >8 Consider 3 mos CT, PET/CT or bx *Measure average diameter to nearest millimeter
55 Fleischner Subsolid Guidelines 2013 vs 2017 Nodule Size (mm) * Management recommendations GGN < 5mm No FU < 6mm No FU >5mm 3 mos CT then annual for3 yrs > 6mm 6-12 mos CT then every 2 yrs until 5 yrs PSN < 5mm No FU < 6mm No FU > 5mm 3 mos then annual for 3 yrs > 6mm 3-6 mos CT then annual x 5 yrs
56 Fleischner Subsolid Guidelines 2013 vs 2017 Nodule Size (mm) * Management recommendations GGN < 5mm No FU < 6mm No FU >5mm 3 mos CT then annual for3 yrs > 6mm 6-12 mos CT then every 2 yrs until 5 yrs Same size threshold: < 5mm= <6 PSN when rounding < 5mm No FU < 6mm No FU > 5mm 3 mos then annual for 3 yrs > 6mm 3-6 mos CT then annual x 5 yrs
57 Fleischner Subsolid Guidelines 2013 vs 2017 Multiple Subsolid Nodules Nodule type Pure GGNs: <5mm >5mm <6mm Management recommendations No CT FU required 3 mos, then annual for at least 3 yrs 3-6 mos, then +2 and 4 yr CT FU Dominant Nodules with Part-Solid/Solid Component: 3 mos FU CT, then bx or surgery, especially if solid part <5mm. >6mm 3-6 mos CT, then based on most suspicious nodule
58 Fleischner Subsolid Guidelines 2013 vs 2017 Multiple Subsolid Nodules Nodule type Pure GGNs: <5mm >5mm <6mm Management recommendations No CT FU required 3 mos, then annual for at least 3 yrs 3-6 mos, then +2 and 4 yr CT FU Dominant Nodules with Part-Solid/Solid Component: 3 mos FU CT, then bx or surgery, especially if solid part <5mm. Multiple Subsolid Nodules 3-6 mos CT, then based on most suspicious nodule. If stable, consider 2 and 4 yr CT Optional later first FU, then longer FU
59 Fleischner Subsolid Guidelines 2013 vs 2017 Multiple Subsolid Nodules Nodule type Pure GGNs: <5mm >5mm Dominant Nodules with Part-Solid/Solid Component: Multiple Subsolid Nodules <6mm >6mm Management recommendations No CT FU required 3 mos, then annual for at least 3 yrs 3 mos FU CT, then bx or surgery, especially if solid part <5mm. 3-6 mos CT. If stable, consider 2 and 4 yr CT. 3-6 mos CT. Subsequent management based on the most suspicious nodule.
60 Fleischner Subsolid Guidelines 2013 vs 2017 Multiple Subsolid Nodules Nodule type Pure GGNs: <5mm >5mm Dominant Nodules with Part-Solid/Solid Component: Multiple Subsolid Nodules <6mm >6mm Management recommendations No CT FU required 3 mos, then annual for at least 3 yrs 3 mos FU CT, then bx or surgery, especially if solid part <5mm. 3-6 mos CT. If stable, consider 2 and 4 yr CT. 3-6 mos CT. Subsequent management based on the most suspicious nodule. Same size threshold as before Consider longer FU for some with multiple small subsolids
61 Revised Fleischner Guidelines 2017
62 Take Home Points Optimize CT technique, including thin sections, coronal & sagittal recons Consider nodule morphology, individual risk factors and patient preference, if possible Use new guidelines: o o o Less routine follow-up for very small nodules More flexibility for follow up timing Longer follow up for suspicious sub-solid nodules
63
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