What to Do with Small Lung Nodules Hanh Vu Nghiem, MD William Beaumont Hospital Royal Oak, Michigan

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1 What to Do with Small Lung Nodules Hanh Vu Nghiem, MD William Beaumont Hospital Royal Oak, Michigan

2 Small Lung Nodules What to do with small lung nodules? We biopsy them when requested What are our accuracy and safety? We conducted a retrospective study to evaluate the accuracy and safety of CT guided biopsy of small lung nodules.

3 Our Study of CT Guided Bx of Small Lung Nodules Retrospective study from to Total of 312 CT guided lung mass biopsies during this period Of these, 34 biopsies had average lesion size of 11 mm or less and were included in the study group 34 lung nodule biopsies in 30 patients (age average 67 years) 2 patients with 2 Bx of 2 different nodules and 2 patients with repeat Bx of same nodule 8 different radiologists performing lung biopsies

4 Materials and Methods Nodule size: retrospectively measured and calculated mean of 2 greatest diameters 34 lung nodules with mean diameter of 11 mm or less size range: 6.5 to 11 mm average size: 9.4 mm

5 Materials and Methods 34 nodules Location and morphology: 18 upper lobes, 12 lower lobes, 4 middle lobes 20 parenchyma, 12 sub-pleural ( within 2cm of pleura, none abutting pleura), 2 sub-pleural and para-diaphragmatic 32 solid and 2 ground-glass 22 cases with multiple lesions and 13 cases with single lesions CT-PET 6/34 nodules without CT-PET 28/34 nodules with CT-PET SUV range from no uptake to 13.6 Average SUV uptake 4.08

6 Materials and Methods 34 lung nodule biopsies 30 core, 4 FNA 29 core biopsies: 19 G introducer /20 G core 26/29 20 G core only 3/29 both 20 G core and 23 G FNA 1 core biopsy: 17 G introducer/ 18 G core 4 FNA : 20 G introducer and 23 G FNA

7 Materials and Methods Definitions: Successful biopsies: Diagnostic biopsies yielding true benign or malignant diagnoses which are concordant with clinical, imaging, surgical pathologic follow up or additional procedure results Unsuccessful biopsies: Non-diagnostic biopsies due to insufficient tissue and yielding no diagnosis

8 Materials and Methods True positive: Successful biopsies positive for malignancy in true malignant cases True negative: Successful biopsies negative for malignancy, and positive for a benign diagnosis in true benign cases False positive: Non-diagnostic biopsies in true benign cases False negative: Non-diagnostic biopsies in true malignant cases

9 Results 34 lung nodules 22 True malignant cases ( sarcomas, SCC, Adeno CA, Melanoma, Breast, H and N CA, Colon CA in 19 cases and BAC in 3 cases) 12 True benign cases (10 cases including Histoplasmosis, granuloma, eosinophylic granuloma, anthracosis, and BOOP, 1 nodule resolved in follow up studies and 1 nodule stable over 1 yr f/u in a patient without hx of malignancy)

10 Results 34 biopsies 24 successful biopsies 16 true positive, 8 true negative 10 unsuccessful biopsies 6 false negative and 4 false positive Sensitivity: 72.7% Accuracy: 70.6% P value= ( Fisher Exact Test)

11 Results CT-PET value Using SUV of > 2.5 as a cut off for malignancy 34 biopsies: 28/34 cases had CT-PET prior to bx True positive for malignancy: 13/28 True negative for malignancy: 6/28 False positive for malignancy: 4/28 False negative for malignancy: 5/28 Sensitivity: 72% Accuracy: 68%

12 CT Guided Lung Bx: : Published Literature Li et al: AJR 167: , 1996 Accuracy and sensitivity for CT guided bx of nodules <15mm: 74% and 72% Hur et al: AJR 192: , 2009 Accuracy and sensitivity for CT guided bx of nodules < 10mm: 80% and 67%

13 Results Locations of 10 unsuccessful biopsies 5 upper lobe 5 lower lobe 3 parenchymal 6 subpleural 1 subpleural and paradiaphragmatic

14 Results Complications: 22/34 (65%) minor parenchymal hem. or no complication 12 (35%) pneumothorax ( Up to 42% reported rate in published literature) 3/12 PTX were FNA ( total 4 FNA bx in the study) 9/12 PTX were Core ( total 30 core bx in the study) 5 PTX (15%) requiring chest tube and admission 7 PTX did not require chest tube, other treatments or admission

15 Conclusion CT guided biopsy is a useful diagnostic technique for small (< 11mm) lung nodules with a sensitivity of 72.7% and an accuracy of 70.6% in the diagnosis of malignancy CT-PET yields a sensitivity of 72% and accuracy of 68% Despite small lesions (< 11mm), CT guided biopsy yields are still acceptable with comparable accuracy to CT-PET which also suffers due to small lesion size

16 Conclusion of Our Study Complication rate of CT guided biopsy of small lung nodules, mostly pneumothorax, is acceptable (35%) Unsuccessful biopsies are observed more often in nodules in sub-pleural location