The Virtual Lung Nodule Clinic Poster No.: C-1023 Congress: ECR 2016 Type: Educational Exhibit Authors: S. Higgins, F. C. Lyall, J. Taylor, J. goldman, S. Rolin, B. 1 2 1 2 2 3 2 2 3 Soar ; Torbay/UK, Torquay/UK, Plymouth/UK Keywords: Outcomes, Multidisciplinary cancer care, Cancer, Costeffectiveness, Computer Applications-Virtual imaging, Comparative studies, Teleradiology, CT-Quantitative, CT, Thorax, Respiratory system, Management DOI: 10.1594/ecr2016/C-1023 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18
Learning objectives Raise awareness of current British Thoracic Society guidelines for the management of pulmonary nodules (August 2015). Outline our early experience of instituting a novel Virtual Lung Nodule Clinic for the management of pulmonary nodules. Demonstrate a variety of cases that have been encountered in the Virtual Lung Nodule Clinic. Background The detection of pulmonary nodules is common. In populations undergoing CT screening and at high risk of lung cancer nodules are detected in 20-50% of individuals. The vast majority of these are benign but they require ongoing surveillance to detect early lung cancers [1]. Management and follow up frequently varies particularly when the patient is not being looked after by a chest physician. Lung nodules do not cause symptoms or abnormal physical signs and as such the value of clinical assessment is limited. The aim of the virtual lung nodule clinic (VLNC) is to assess the imaging of these patients in a structured manner and advise on further management without the patient being present. This will save a significant amount of outpatient appointments and MDT time and is also likely to reduce the number of CT examinations requested. Anecdotally, there are several centres which run virtual lung nodule clinics (VLNC), although a literature search revealed only one published audit of 58 patients [2]. They estimated they saved 157 outpatient appointments equating to 11,471 over 2 years. Here, we share our experience. Findings and procedure details Page 2 of 18
A new service for the specialist evaluation and follow up of lung nodules was introduced at South Devon Healthcare NHS Foundation Trust (Torbay, UK) in November 2014. Nodules identified during the reporting of radiological investigations are highlighted to the referring clinician via a short code to which all radiologists at our institution have been made aware. A proforma is sent to the referring clinician (Hospital consultant or General Practitioner) for completion. This proforma is returned to the Virtual Lung Nodule Clinic (VLNC) for assessment of suitability. The VLNC is held weekly and run by a consultant respiratory physician and consultant chest radiologist. The physician reviews the clinical details on the proforma and the patient's hospital notes. The radiologist reviews relevant imaging. There is no need for the patient to be present as the value of clinical assessment in patients with (normally) asymptomatic lung nodules is limited. Ten cases are usually reviewed over a one to two hour period. Broad guidelines that mandate referral to the VLNC are: Anyone with a lung nodule fitting the size criteria (5mm - 15mm) which may have resulted in an unnecessary respiratory clinic referral in the past. Anyone with a lung nodule fitting the size criteria (5mm - 15mm) where there is uncertainty about what management plan needs to be followed for a small lung nodule or nodules. Groups who do not need referral include: Patients with known cancer who are already on follow up for their primary cancer and being looked after in an MDT setting. Where the radiologist is happy they have sufficient information to recommend the appropriate follow up or management plan. The radiological assessment of lung nodules is now based on new British Thoracic Society guidelines published in August 2015. Review of previous imaging and comparison with nodule size, morphology and volume measurements are performed. Nodules are managed according to recent BTS guidelines. Algorithms are presented opposite (Figs 1-3). Page 3 of 18
Risk for malignancy calculators are used which are freely available on the BTS website. Possible outcomes include: Reassure and discharge Repeat CT scan in accordance with the BTS guidelines and review in nodule clinic. Advise clinical assessment. Request PET-CT scan. Referral to an MDT A detailed non-medical letter is dictated to the patient with a copy sent to the GP and referring hospital clinician if appropriate explaining the imaging findings and management plan. The patient is also given a contact number if they want to phone and speak to one of the respiratory team. In addition they are sent a detailed patient information leaflet about incidental lung nodules. Outcomes The VLNC has been run for 14 months at the time of writing (starting in November 2014). As at December 2014 94 separate patients have been discussed with a total of 109 'attendances'. Of these, 29 patients have so far been discharged from the VLNC (30%). Twenty-four of these patients (83%) were discharged after one review at the VLNC. Of patients discharged, intrapulmonary lymph nodes and granulomata were the most common findings. The majority of patients (n=51) had pulmonary nodules which required or will require follow-up with CT. Eight patients were referred for further investigation with PET-CT and six patients required formal review in respiratory clinic for suspicious nodules. Non chest hospital consultants and GPs are enthusiastic about the service as it gives them easy access to an expert chest opinion regarding the management of pulmonary nodules. We are in the process of getting feedback from patients. To date none have requested phone or face to face communication. Indicative Cases Case 1 Page 4 of 18
A 68 year old male had a CT thorax abdomen and pelvis due to suspicion of malignancy following an unprovoked DVT. This demonstrated a 7mm nodule within the left lower lobe which was classed as indeterminate by the reporting radiologist (Fig 4). The case was reviewed at the VLNC and the nodule was thought to have the hallmarks of an intrapulmonary lymph node (Figs 4&5). The referring clinician and patient were informed and no further follow up was required. Case 2 A 55 year old female had an incidentally discovered lung nodule on CT in December 2013 (Fig 6). This was followed up with CT chest twice at 6 monthly intervals during which time the nodule increased in volume measurement (Figs 7&8). A PET-CT was therefore performed which did not show increased metabolic activity (Fig 9). MDT opinion was that the nodule was most likely benign, but a further CT chest is planned for January 2016 to ensure no further increase in size. Case 3 A 69 year old male smoker had a CT chest and abdomen following a possible nodule discovered on chest radiograph performed for cough. CT demonstrated a 19mm nodule within the left lower lobe (Fig 10) which was referred to the VLNC. The Brock score was 18.8% and therefore a PET-CT was performed. This showed the lung nodule was of increased metabolic activity in keeping with malignancy (Fig 11). There was no regional or distant disease and the patient is scheduled for surgical treatment. Case 4 A 54 year old female with a previous history of breast cancer had a 13mm lung nodule discovered during a CT performed for right upper quadrant pain (Fig 12). This was reviewed at the VLNC and a Brock score of 10.2% was calculated. A PET-CT was performed which demonstrated increased metabolic acitivty within the lung nodule (Fig 13) as well as mediastinal lymph nodes and bones (not visible on CT) consistent with metastatic spread of breast cancer. Images for this section: Page 5 of 18
Fig. 1: Initial approach to solid pulmonary nodules British Thoracic Society Page 6 of 18
Fig. 2: Solid pulmonary nodule surveillance algorithm. VDT = volume doubling time. British Thoracic Society Page 7 of 18
Fig. 3: Sub-solid pulmonary nodules algorithm. PSNs, part solid nodules; SSN, sub-solid nodules. British Thoracic Society Page 8 of 18
Fig. 4: Small intrapulmonary lymph node within the left lower lobe abutting the diaphragm. Page 9 of 18
Fig. 5: Volume measurement at the VLNC Page 10 of 18
Fig. 6: Incidental left lower lobe nodule Page 11 of 18
Fig. 7: Volume measurement 1 Page 12 of 18
Fig. 8: Volume measurement 2 six months later shows a slight increase in nodule volume Page 13 of 18
Fig. 9: Subsequent PET-CT does not demonstrate increased metabolic activity within the nodule, which is likely to be benign Page 14 of 18
Fig. 10: Left lower lobe nodule in smoker Page 15 of 18
Fig. 11: Increased avidity on PET-CT in keeping with malignancy (most likely bronchogenic following discussion at multidisciplinary team meeting). Patient scheduled for surgery. Fig. 12: Incidentally discovered left lower lobe nodule in patient with known breast cancer. Page 16 of 18
Fig. 13: PET-CT performed due to risk of malignancy shows increased metabolic activity in keeping with malignancy. Most likely metastatic due to history of breast cancer and associated mediastinal adenopathy and bone lesions. Page 17 of 18
Conclusion The virtual lung nodule clinic is one of the first of its kind in the UK. It provides an easily accessed and effective way of assessing patients who present with a chance finding of a lung nodule on CT scans performed for other purposes. It is timely, cost effective and ensures patients are managed systematically in line with current guidelines. Personal information References 1. 2. BTS Guidelines for the investigation and management of pulmonary nodules. British Thoracic Society Pulmonary Nodule Guideline Development Group. Thorax. BMJ. August 2015; 70(2). Sutton B, Bowles K, Richardson A, Raj V, Balaj A, Maskell T, Agrawal S, Bennett J, Free C. A pilot trial of a solitary pulmonary nodule virtual clinic (Poster). 10th Annual British Thoracic Oncology Group Conference 2012. Page 18 of 18