Pulmonary Nodules & Masses - PDF Free Download

Pulmonary Nodules & Masses A Diagnostic Approach Heber MacMahon The University of Chicago Department of Radiology

Disclosure Information Consultant for Riverain Technology Minor equity in Hologic Royalties and licensing fees from multiple companies for CAD related software through University of Chicago (UCTech) Research support from Philips Healthcare Advisory Board for GE Medical Will not discuss investigational use.

What is a Pulmonary Nodule?

Pulmonary Nodule A rounded opacity, well or poorly defined, measuring up to 3 cm in diameter

28 year-old female with history of marijuana use and chronic cough.

Mucinous Adenocarcinoma

90% of peripheral cancers visible in retrospect (Muhm 1983)

Missed Lung Cancers : JHM Austin et al. Rad 1992;182:115-122 Size: 0.6 3.4 cm (mean 1.6) Location : Upper lobes 81% Conspicuity : Overlapping bones in 82%

74 y/o man with COPD and rales

Lung Carcinoma 74 y/o man with COPD and rales

Conventional CXR Dual energy soft tissue image

Bone Suppression Imaging Standard CXR BSI CXR DES CXR

69 y/o female with hx of multiple myeloma

69 y/o female with hx of multiple myeloma Standard CXR ST image

69 y/o female with hx of multiple myeloma Standard CXR Bone image

Standard Thoracic CT Protocol; University of Chicago 2016 Key 1mm 3mm 3mm Cor MIPs MINIPs Sag Source Scout Scout Dose Contrast

MIP 1mm thin section

MIP 1mm thin section Zoom

? Nodule

Axial Coronal Sagittal

Diagnostic Features of Nodules Size Morphology Growth rate Calcification

6mm metastasis

Percentage of Lung Cancers Detected by CXR According to Size 100 90 80 70 60 50 40 30 20 10 0 2-5mm 6-10mm 11-20mm 21-45mm Adapted from : Henschke et al. Lancet 1999;354 99-105

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%

Diagnostic Features of Nodules Size Morphology Growth rate Calcification Overall Shape Solid/Non-solid Edge features-spiculated -Lobulated -Smooth

Ground Glass Nodule Solid Nodule

Smooth

Smooth Lobulated

Smooth Lobulated Spiculated

Smooth Lobulated Spiculated Part-Solid

Diagnostic Features of Nodules Size Margins Growth rate Calcification

Growth rate of nodules Volume doubling time (VDT): 26% diameter increase = One volume doubling

Growth rate of nodules Volume doubling time (VDT): 26% diameter increase = One volume doubling Typical lung ca. VDT = 100 200 days Range = 30 400 + days

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 457 149

ARS #1 Incidental finding in a 58 year old former smoker

ARS #1 The MOST likely diagnosis is: (1) Indolent fungal infection. (2) Chronic organizing pneumonia (3) Atypical adenomatous hyperplasia (4) Nodular fibrosis (5) Invasive adenocarcinoma

Part-Solid and Non-Solid Nodules in a Screening Program Henschke et al. AJR 2002 ;178:1053-1057 Part-solid: 63% malignant Non-solid: 18% malignant Solid: 7% malignant

Persistent Non-Solid nodules 53 NS nodules in 49 pts Persisted or grew for > 1 month 75% were adenoca/ BAC 6% AAH 19% Nodular fibrosis/organizing pna Kim et al. Radiology 2007 245,1 p267

Lung Cancer: Major cell types Adenocarcinoma (50%)

Adenocarcinoma Up to 50% of lung cancers 55% present as peripheral nodule, often sub-solid May grow very slowly over years Some associated with pulmonary fibrosis

Lung Cancer: Major cell types Adenocarcinoma (50%) - Bronchioloalveolar (5%)

Lung Adenocarcinoma Classification AAH :Atypical Adenomatous Hyperplasia AIS : Adenoca in Situ MIA : Minimally Invasive Adenoca LPA : (Invasive) Lepidic Predominant Adenoca International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma. WD Travis et al. Journal of Thoracic Oncology Volume 6, Number 2, February 2011

Lung Adenocarcinoma Classification AAH :Atypical Adenomatous Hyperplasia AIS : Adenoca in Situ MIA : Minimally Invasive Adenoca LPA : (Invasive) Lepidic Predominant Adenoca Non-Mucinous Mucinous International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma. WD Travis et al. Journal of Thoracic Oncology Volume 6, Number 2, February 2011

Atypical Adenomatous Hyperplasia (AAH) Typically GGO <5mm Precursor of adenoca Found in 20% + of lobes resected for lung ca

Ground Glass Nodule 7-07 12-08 4-09

MIA

MIA -> Invasive lepidic predominant adenoca 1-09 1-10 12-10

Spectrum of Sub-solid Nodules GGO Part Solid Part Solid & Cystic

Mucinous Adenocarcinoma

Lung Cancer: Major cell types Adenocarcinoma (50%) Squamous cell (30%)

Squamous Cell Carcinoma 75% arise from segmental or larger bronchi 20% show central necrosis & cavitation 17% present with atelectasis

Small Cell Lung Cancer

Small-Cell Carcinoma 15-20% of lung cancers Early metastases, mediastinal adenopathy Strongest association with cigarette smoking Ectopic ACTH, inappropriate ADH

Lung Cancer: Major cell types Adenocarcinoma (50%) Squamous cell (30%) Small cell Undifferentiated (15%) Large cell Undifferentiated (5%)

Large Cell Undifferentiated Carcinoma 2-5%% of lung cancers 50% present as large peripheral mass May show very rapid growth Poor prognosis

Diagnostic Features of Nodules Size Margins Growth rate Calcification

Regarding calcification in lung nodules, which of the following statements is false: ARS #2 (1) Focal central calcification is reliable evidence of benignancy. (2) Eccentric calcification is highly suggestive of malignancy. (3) Popcorn calcification is associated with hamartomas. (4) Calcification is detectable by CT in about 6-10% of lung cancers. (5) Laminar calcification is associated with healed post infectious granulomas.

Patterns of Calcification Central Laminated Eccentric Popcorn Diffuse Stippled

Patterns of Calcification Benign Indeterminate Central Laminated Eccentric Popcorn Diffuse Stippled

Dystrophic Calcification in Lung Cancer

Calcified Lung Carcinoma Calcium detectable by CT in 10%

Calcified Lung Carcinoma Calcium detectable by CT in 10% Usually 2 dystrophic ca++ or

Calcified Lung Carcinoma Calcium detectable by CT in 10% Usually 2 dystrophic ca++ or engulfed granulomatous ca++

Calcified Lung Carcinoma Calcium detectable by CT in 10% Usually 2 dystrophic ca++ or engulfed granulomatous ca++ Most calcified carcinomas are 5cm.+

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

Granuloma

Granuloma Usually due to TB or Histo. in Midwest Typically diffuse, laminar or central calcs Typically smooth margins

Calcified Metastases- Osteosarcoma

Criteria for Benignancy Absence of growth over 2+ years* Benign pattern of Ca ++ * Does not apply to sub-solid nodules

ARS #3 60 y/o man who had a previous lobectomy for lung cancer.

ARS #3 60 y/o man who had a previous lobectomy for lung cancer. 8mm

ARS #3 Which of the following would be the most appropriate recommendation : Three to four month CT follow-up One year CT follow-up. PET scan Aspiration needle biopsy Immediate VATs resection 8mm

Recommendations for Follow-up and Management of Small Nodules 1 (Radiology NOV 2005) Nodule Low risk patient 3 High risk patient 4 Size 2 < 4 mm No follow-up needed 5 CT follow-up CT at 12 months; if unchanged, no further follow-up 6 >4-6 mm CT follow-up at 12 months; if unchanged, no further follow-up 6 >6-8 mm Initial CT follow-up at 6 to 12 months, then at 18 to 24 months if no change Initial CT follow-up at 6 to 12 months, then at 18-24 months if no change 6 Initial CT follow-up at 3 to 6 months, then at 12 and 24 months if no change. >8 mm One or more of the following: CT follow-up at 3, 9, 24 months/ Dynamic CT 7 / PET scan / Biopsy

Recommendation for Incidental Subsolid Nodules Adapted from Radiology Jan 2013. Naidich et al. Nodule Type Pure GGN < 5mm Pure GGN > 5mm Recommendations No CT follow-up CT at 3 mos then annually for 3 yrs Part-solid nodule: SC < 5mm Part-solid nodule: SC > 5mm Multiple GGNs < 5mm Multiple GGNs > 5mm without dominant lesion Dominant nodule(s) with solid component CT at 3 mos then annually for 3 yrs+ CT at 3 mos then bx or resection CT at 2 and 4 yrs CT at 3 mos then annually for 3 yrs CT at 3 mos* then bx or resection especially if SC >5mm GGN:Ground glass nodule SC: Solid component

27 y/o woman with lung mass

Carcinoid Tumor

Carcinoid Tumor Neuroendocrine tumors; carcinoid syndrome rare (1-3%)

Carcinoid Tumor Neuroendocrine tumors; carcinoid syndrome rare (1-3%) Majority (80%) in main or segmental bronchi; present with atelectasis/obstructive pneumonia

Carcinoid Tumor Neuroendocrine tumors; carcinoid syndrome rare (1-3%) Majority (80%) in main or segmental bronchi; present with atelectasis/obstructive pneumonia Calcification in 30%

Carcinoid Tumor Neuroendocrine tumors; carcinoid syndrome rare (1-3%) Majority (80%) in main or segmental bronchi; present with atelectasis/obstructive pneumonia Calcification in 30% Atypical carcinoids : 10%

Hamartoma

Hamartoma Most commonly resected benign tumor Peak incidence in sixth decade Endobronchial in 5% Fat and/or calcium on CT in 50%+ Well-defined, slow growing

Intrapulmonary Lymph Nodes Touching or within 5mm of pleural surface Typically triangular or oval Thin septal connection Usually in lower lungs

Incidental Nodule in 35 year old woman

Pulmonary AVM

AVM

Pulmonary AVM F:M=2:1, all ages Hemoptysis & dyspnea 35% multiple 40% - 65% have HHT (Osler-Weber-Rendu) Mostly lower lobe location

Conclusions Use routine thin sections and reformats to characterize small nodules Learn to recognize suspicious morphology Regard persistent non-solid nodules on CT with high suspicion, even if unchanged over long periods Always compare with earliest available scan to determine growth in subsolid nodules

Mucinous Adenocarcinoma

Adenocarcinoma