Organ Imaging : September 25 2015 OBJECTIVES Case Based Discussion: State of the Art Management of Lung Nodules Dr. Elsie T. Nguyen Dr. Kazuhiro Yasufuku 1. To review guidelines for follow up and management of solid and sub solid nodules 2. To review low dose CT chest technique 3. To highlight some pitfalls when reporting the chest CT 4. To describe various options for surgical management of nodules Case 1 64 year old woman with chronic cough, CT chest completed to rule out bronchiectasis as a cause 35 pack year history of smoking, quit 5 years ago No constitutional symptoms No SOB, chest pain, or hemoptysis No other significant medical history Solitary Solid Spiculated Nodule No adenopathy Moderate emphysema No other findings What would you do next? Algorithm for initial detection of Solitary Pulmonary Nodule A) Follow up chest CT in 3 months B) Let it go C) CT guided biopsy D) Bronchoscopy E) PET CT Chest. 2013;143(3):840 846. 1
Algorithm for evaluation of solid nodules SOLITARY PULMONARY NODULE Recommendations for Follow up and Management of Nodules Detected Incidentally at Non screening CT McMahon et al. Radiology 237, November 2005; 395 400. Lobectomy is the Standard Anatomical lobectomy with systematic hilar lymph node dissection is the standard of surgical treatment for lung cancer Different Approaches Thoracotomy VATS Ann Thorac Surg 1995; 60(3): 615-622 9 10 Minimally Invasive (VATS) Lobectomy VATS Lobectomy Technique VATS Instruments Endoscopic Staplers J Thorac Cardiovasc Surg 2010;139:366-78 Same work on the inside Different incision on the outside 11 12 2
VATS Lobectomy Oncologic Outcome There are no studies that report or suggest a difference in ability to achieve complete resection in patients with stage I or II NSCLC da Vinci Robotic Lobectomy There is evidence that there is equivalence in selected patients with stage IIIA after induction therapy 13 14 Robotic Lobectomy Robotic Lobectomy Oncologic results Multi institutional retrospective review (n=325) Majority clinical stage I (IA, 247; IB, 63) Conversion rate: 8% (27/325) Morbidity 25.2% (82/325) Mortality 0.3% (1/325) Major complication rate 3.7% (12/325) p stage: IA, 54%, IB, 22%, IIA, 13%, IIB, 5%, IIIA, 6% Overall 5 year survival 80% (CI 73 88) IA 91%, IB 88%, II 49% Park. J Thorac Cardiovasc Surg 2012;143:383-9 15 16 CALGB 140503 Phase III Randomized Trial of Lobectomy vs Sublobar Resection for Small (<2cm) Peripheral NSCLC Surgery Confirmation of NSCLC on Path N0 status on frozen section (4R, 7, 10R on right) (5or6, 7, 10L on left) VATS Segmental Resection Lobectomy Randomization Limited Resection Extensive central lobular emphysema (upper lobe predominant) 18x14mm peripheral ill defined nodule Stage IA, NSCLC 17 18 3
Case 2 59 year old woman investigated with CT chest for? Interstitial lung disease in 2009 History of mixed connective tissue disease Due to a finding in the RUL, follow up CT chest examinations were completed Asymptomatic Normal PFTs Case 2 Low Dose CT chest Technique: 135 kv, 50 ma, dose usually 1 2 msv No contrast Helical acquisition 3mm reconstruction FOV 35 40 cm Case 2 59F RUL abnormality Case 2 2009 2012 2015 Always compare with most recent previous as well as baseline examination to detect small changes in density or overall size for sub solid nodules (GGO), new solid component Changes occur very slowly as they are slow growing lesions Make sure you are comparing similar slice reconstructions (3mm versus 5mm) Can Texture Analysis Help? Texture and Volumetric Analysis Differentiation of AAH/AIS/min invasive vs invasive adenocarcinoma Better assessment of change over time Pure GGO Sub Solid 4
What would you do next? A) Follow up chest CT in 3 months B) Lobectomy C) CT guided FNA biopsy D) Microcoil localization prior to VATS E) PET CT Case 2 RUL Growing Sub Solid Nodule Next step may vary depending on institution and availability/expertise locally in radiology and thoracic surgery Sub solid nodules have higher risk of malignancy than solid nodules Growing sub solid nodules especially with enlarging solid component should be resected Algorithm for evaluation of sub-solid nodules Subsolid nodules differential diagnosis 30 70% of subsolid nodules resolve on short term follow up If they do persist: high probability of being malignant V.Patel et al. Chest. 2013;143(3):840-846. GGO Resolution in 3 months Definitions of Sub solid Nodules Pure ground glass nodule (GGN): A focal area of increased lung attenuation that does not completely obscure the lung parenchyma The margins of normal structures such as vessels remain outlined, and there are no areas of soft tissue density 5
Definitions of subsolid nodules Sub solid nodule: A focal opacity containing both solid and ground glass components Areas of parenchymal architecture are obscured within Malignancy Risk in Sub Solid Nodules Early Lung Cancer Action Project (ELCAP) 34% of subsolid nodules were malignant vs. 7% solid nodules Sub solid (part solid) Nodules: 63% malignant Ground Glass Nodules: 18 % malignant Noguchi M et al Cancer 1995 June 15; 75 (12): 2844 52 Henschke et al Am J Roentgenol. 2002 May; 178(5): 1053 7 PREINVASIVE LESIONS Atypical adenomatous hyperplasia Considered precursor to adenocarcinoma Proliferation of Type II Pneumocytes or Clara Cell like cells with mild to moderate cellular atypia Usually <5 mm PREINVASIVE LESIONS Adenocarcinoma in situ (formerly BAC) Adenocarcinoma in situ (AIS) Pre invasive lesions <3cm Pure lepidic growth No stromal, vascular, lymphatic or pleural invasion Need complete histologic sampling for diagnosis Usually non mucinous MINIMALLY INVASIVE LESIONS Minimally invasive adenocarcinoma 6
Minimally invasive adenocarcinoma (MIA) Invasive lesions Lepidic predominant <5 mm stromal invasion No lymphatic, vascular or pleural invasion Need complete histologic sampling for diagnosis Lepidic predominance Papillary predominance Acinar predominance Micropapillary predominance Travis W et al J Thorac Oncol 2011; 6(2):244 85 Solid predominant with mucin production J Thorac Imaging Volume 27, Number 6, November 2012 Radiologic Implications of New Lung Adenocarcinoma Classification Sub solid nodules: Differential Diagnosis Adenocarcinoma spectrum Pulmonary Lymphoma Benign etiology: Infection Focal fibrosis or scarring Focal inflammatory process: Organising pneumonia, eosinophilic lung disease or Non specific interstitial pneumonia (NSIP) GROUND GLASS AND SUB SOLID NODULES Fleischner Society Guidelines Naidich DP et al Radiology 2013 266(1):304 17 Case 3 85F with ovarian cancer What would you do next? A) Follow up chest CT in 3 months B) RUL, LUL and LLL Lobectomy C) CT guided FNA biopsy D) Microcoil localization prior to VATS E) PET CT 7
Diagnostic Approach to Pulmonary Nodules Minimally Invasive Biopsy Bronchoscopic biopsy CT guided FNA Surgical biopsy VATS Thoracotomy VATS (Video assisted thoracoscopic surgery) Procedure of choice for surgical biopsy of peripheral pulmonary nodule Limitation Identification of the nodule Lack of digital palpation in small, non solid deep nodules May require conversion to thoracotomy 43 44 Surgical Biopsy Issues VATS Visible with VATS if within 5mm of the visceral pleura Nodules deeper than 5mm need to be palpated for localization prior to resection Non solid nodules, especially GGO, are difficult to palpate Localizing Techniques VATS Intraoperative imaging CT Thoracic ultrasound Preoperative CT guided marking Liquid material (contrast media, colored adhesive agents, dyes) Radionuclides Wires (hookwires, microcoils) Preoperative bronchoscopic marking Dye Fiducials Radiology 2002; 225: 511-518 45 46 Microcoil Technique Microcoil Technique Pleural marking nodules<3cm within 3 cm of pleural surface non palpable (GGO,subsolid, too deep) No pleural marking 8
Case 3 85F with ovarian cancer OBJECTIVES 2010 Part solid nodule was resected with microcoil localization and VATS Dx: minimally invasive adenoca other nodules showed slow growth 2010 2010 1. To review guidelines for follow up and management of solid and sub solid nodules 2. To review low dose CT chest technique 3. To highlight some pitfalls when reporting the chest CT 4. To describe various options for surgical management of nodules 2015 2015 Take Home Points Thank you! Guidelines for CT follow up of incidental solid nodules is different from sub solid nodules Sub solid nodules are slow growing; always compare with oldest CT chest available PET CT is often negative due to low metabolic activity Variation in slice reconstruction can vary appearance of nodules Sub solid nodules have higher risk of malignancy than solid nodules Thoracic surgery should be consulted as many noninvasive options exist for both diagnosis and treatment CT Patterns Among IASLC/ATS/ERS Lung Adenocarcinoma Subtypes Predominant Histologic Subtype Nonmucinous AIS MIA Appearance on CT Scan Most often pure GGN or partly solid nodule with solid component < 5 mm Lepidic (nonmucinous) Most often partly solid nodule with solid component > 5 mm or solid nodule; less commonly pure GGN Papillary Acinar Micropapillary Solid Invasive mucinous adenocarcinoma Solid nodule Solid nodule Unknown Solid Consolidation, air bronchograms; less often pure GGN V Patel et al. Chest. 2013; 143(3):825-839. 9
Differential diagnosis GGO Evaluation with CT MALT MALT 7 years later Subsolid nodules best evaluated with thin section images < 2.5 mm Quantify solid vs. ground glass components 10