seminar final spn
TRANSCRIPT
Approach to the Approach to the Solitary Pulmonary NoduleSolitary Pulmonary Nodule
The Solitary Pulmonary NoduleThe Solitary Pulmonary Nodule
• The term “solitary pulmonary nodule” (SPN) describes a well-circumscribed, rounded, smooth edged, dense pulmonary lesion, 3 cm or less in diameter, that is completely surrounded by lung parenchyma
• Is NOT associated with atelectasis , pleural effusion or adenopathy , does not touch the hilum or mediastinum
• “Coin lesion” .The older term “coin lesion” has been replaced by SPN since these lesions are spherical, not flat.
• Lesions > 3 cm called “MASSES” and often malignant
• The term “solitary pulmonary nodule” (SPN) describes a well-circumscribed, rounded, smooth edged, dense pulmonary lesion, 3 cm or less in diameter, that is completely surrounded by lung parenchyma
• Is NOT associated with atelectasis , pleural effusion or adenopathy , does not touch the hilum or mediastinum
• “Coin lesion” .The older term “coin lesion” has been replaced by SPN since these lesions are spherical, not flat.
• Lesions > 3 cm called “MASSES” and often malignant
The Solitary Pulmonary NoduleThe Solitary Pulmonary Nodule
• Since the SPN by definition is a radiographic finding, radiologic workup is intrinsic to the diagnostic workup
• The initial step in evaluation is to determine whether the abnormality is in fact a solitary pulmonary nodule.
• This assessment is important because up to 20% of suspected nodules prove to be entities mimicking a solitary pulmonary nodule such as rib fractures, skin lesions, or composite areas of increased opacity
• Since the SPN by definition is a radiographic finding, radiologic workup is intrinsic to the diagnostic workup
• The initial step in evaluation is to determine whether the abnormality is in fact a solitary pulmonary nodule.
• This assessment is important because up to 20% of suspected nodules prove to be entities mimicking a solitary pulmonary nodule such as rib fractures, skin lesions, or composite areas of increased opacity
The Solitary Pulmonary NoduleThe Solitary Pulmonary Nodule
• Incidence of cancer from 10 – 70%• Found on 0.09 to 0.20 % of all CXRs• (approximately 1 in 500)• 150,000 SPNs found annually• 90% Solitary pulmonary nodules are most
often detected incidentally when a chest x-ray is taken for other reasons.
• Increased further with incidental findings on CT
• Incidence of cancer from 10 – 70%• Found on 0.09 to 0.20 % of all CXRs• (approximately 1 in 500)• 150,000 SPNs found annually• 90% Solitary pulmonary nodules are most
often detected incidentally when a chest x-ray is taken for other reasons.
• Increased further with incidental findings on CT
Why is it concerning?
• SPN are concerning for what they could represent
• The absolute #1 concern is if the SPN is the harbinger of a malignancy
• What is more critical is the fact that the earlier you diagnose the malignancy the better the survival rate will be
Why is it concerning• Chest. 1997 Jun;111(6):1486-7
• Patients with stage IA (T1N0M0) disease have the best prognosis.
• These patients have a 61 to 75% 5-year survival following surgical resection
• Radiol Clin North Am 2000; 38:1–9 • Unfortunately almost 50% of patients have
extrathoracic spread by the time of diagnosis• these patients only had a 15% 5 year survival
Why is it concerning?
• With these numbers in mind, it is absolutely critical to give the SPN the attention it deserves
• If not worked up properly it will effectively push patients who do carry a malignancy with in the SPN from the 75% survival into the 15% survival
• That is just unacceptable
• Basic strategy is to identify malignant versus benign
• Nodules prove to be malignant in 40% of cases• Most often Bronchogenic carcinoma (25% )• Most common benign is hamartoma
Solitary Pulmonary Nodule
Solitary pulmonary noduleA solitary nodule is assumed to be
primary lung cancer until proved otherwise . One must consider the relationship of age to the incidence of malignancy .
Age (Yr) Malignancy (%)
35-44 15
45-49 26
50-59 41
60-69 50
70-79 70
Most solitary pulmonary nodules should be resected after through investigations, shows that systemic dissemination has not yet occured . Review of previous chest films may help determine the growth pattern of the nodule . A malignant nodule will usually have a doubling time of 20-500 days .
Early Resection
• Studies have proven that early resection results in 5-year survival rate of 50%
• If nodule is 1cm or less rate is about 80%• Survival rate after discovery of bronchogenic
carcinoma is 15% and hence the importance of early discovery in terms of cure
Differential Diagnosis• Neoplasms
• Malignant – • Metastasis, • Primary Lung Carcinoma• Benign Tumors
• Inflammatory• Granulomas
• TB, • Histo, • Sarcoid, etc.),
• Abscess, • Hydatid Cyst, • Fungus Ball, • Org. Pneumonia, • Bronchiectatic cyst
Differential Diagnosis
• Vascular• Infarct, • Pulm Vein anomaly, • Rheum Nodule, • Wegener’s, • AVM, • Pulm Art Aneurys (behcets disease)
• Developmental• Bronchogenic cyst, • Pulmonary sequestration
• Nipple shadow It is important to note that the majority of
SPN are of a benign etiology
Benign nodules• Hamartoma 8% (popcorn lesion)• Granuloma• Rheumatoid granuloma, • Healed infarct, • Pulmonary anurysm, • Wagener’s granulomatosis• Hemangioma• Schwannoma• Fibroma• Lipoma• Leiomyoma• Teratoma
SO now if we have a patient with an SPN on CXR or CT what to be done?
Postgrad Med 2003;114(2):29-35
• Ask (history, profession, habits, sign, symptoms)• Assess (X-ray, age, size, shape, margins, calcification, position,)• Assign (benign or malignant)• Advice (Follow up)• Arrange (CT, PET)• Attain (Biopsy)• Attempt (Surgical Resection)
Assessing Growth
• There are three categories to place the patient in assessing growth
• No change in two years / or Growth Rate of benign nature
• Indeterminate because of no old studies• Growth Rate of possible malignancy
No change in two years
• Radiologic stability is the best predictor of a benign etiology.
• Since the 1950’s it has been well established that if the SPN has not grown in 2 years it is benign. (JAMA 1958; 166:210–215 )
• If old radiographs show no change in two years, no further work up is needed
Benign vs. Malignant Doubling Time• The time it takes for the apparent volume to
double is referred to as the doubling time• one doubling in volume is equivalent to the
nodule diameter increasing by only 26% to 28%
• Benign nodules representing acute inflammatory changes have a doubling time of less than 20 days
• In contrast, stable granulomas and hamartomas may enlarge slowly and have a doubling time of more than 500 days
Semin Ultrasound CT MR 2000;21(2):97-115
Benign vs. Malignant Doubling Time
• If the SPN has a doubling time of <20 days or >500 days the patient is in the clear and can be followed
• If however the SPN doubling time falls in between 20 and 500 days the SPN must be assumed malignant until proven otherwise and surgical intervention is now recommended.
Postgrad Med 1997;101(3):145-50
Growth of a Nodule
• Malignant nodules grow at a constant rate expressed as doubling time
• This usually falls between 20 and 500 days with a median of 120 days
• An increase of 28% in nodule diameter indicates doubling
• Benign lesions grow slowly with doubling time exceeding 500 days
• It is almost conclusively a benign lesion if size is stable for 2 years ( doubling time exceeding 720 days )
• A doubling time of less than 20 days signifies inflammatory process
Growth of a Nodule
Growth Rate:Doubling Time
• Volume = 4/3 r 3
• 28% increase in diameter results in doubling of volume
• Non-malignant disease: less than 20 days or greater than 500 days
• Malignant lesions: 20 to 500 days Av.120
Malignant Doubling Time• With the numbers crunch, biopsy in this
case is not worth the risks because a malignant diagnosis would not change resection therapy
• So in this case, surgical resection is highly recommended
• If the patient is reluctant or the risk of surgery is really high and if diagnosis is likely to be sure of before going to the OR, then biopsy can be undertaken.
Benign vs Malignant
• Age <40• nodule diameter<1.5• never smoked• nodule edge type1• doubling time >500 d• calcification in benign• Needle Bx: benign dis
• Needle Bx: Nonspecific
• >40• >1.5• ever smoked• type3• 20 to 500 days• indeterminate pattern• malignant disease• suspicious cells
High Resolution CT
• HRCT is the most sensitive and specific for assessing the size, shape, calcification and edge of a nodule
• Type 1 Type 2 Type 3 Type 4
Likelihood of cancer with the appearance of a nodule's edge
• Type 1 nodules :smooth, regular edge….20%. • Type 2 nodules: smooth, irregular edge…. 33%. • Type 3 nodules: spiculated edge…. 83%. • Type 4 nodules: fuzzy, multispiculated edge or
corona radiata…. 93%
Factors Influencing Probability of Malignancy
• Size• Growth rate• Number• Density
• Patient age• Gender• Smoking history• Occupational history
LUNG NODULEMALIGNANT FEATURES
• New or growing lesion• Spiculated margin• Large size (>3cm)
Spiculated nodule
MALIGNANT
Irregular contour
MALIGNANT
Spiculated margin
Bronchus leads to it
MALIGNANT
LUNG NODULEDEFINITE BENIGN
CHARACTERISTICS
• Absence of growth for 2 years• Definite benign calcifications• Extensive calcification• Smooth margins• Small size (< 3 cm)
Very white (like bone)
BENIGN
Smooth margin
BENIGN
BENIGN
BENIGN
Note the smooth contour
BENIGN
Homogeneous white= benign calcification
BENIGN GRANULOMA
Very subtle nodule
There it is
SMOOTH BENIGN
Postgrad Med 2003;114(2):29-35
Indeterminate Growth Rate
• This is where the real dilemma is created and every radiological and clinical clue must be taken into consideration to make a decision.
• First step is to look at all patterns of the SPN and determine if a “typically benign or malignant pattern can be found”
Calcification
• Radiographic pattern of calcium deposition is helpful
• Benign lesions tend to have central, laminated (bull’s eye), diffuse or popcorn pattern
• Malignant lesions have speckled or eccentric pattern
TYPES OF CALCIFICATION
• BENIGN• Central = granuloma• Nodule completely calcified = granuloma• Popcorn = hamartoma• Target = granuloma
• MALIGNANT• Spicculated or punctate = malignant• Eccentric = malignant
Benign Calcifications
Popcorn calcification=hamartoma
BENIGN
Hamartoma
• Regarded as benign developemental deformity• 1-3cms lesion containing cartilage, epithelium,
fibro-fatty tissue • Single, may be multiple • Slow growing• Ussually periphral • Central calcification • males
Popcorn CalcificationPopcorn Calcification
• Classic “popcorn” pattern often seen in hamartomas
• HRCT can show fat and cartilage in half of cases
• Classic “popcorn” pattern often seen in hamartomas
• HRCT can show fat and cartilage in half of cases
HAMARTOMA
HamartomaHamartoma
Fat
• Fat on CT • benign
hamartoma can be diagnosed with confidence
Benign Calcification:Popcorn Calcification
Popcorn Calcification
• Popcorn calcification or Chondroid Calcification
• Pattern typical of hamartomas
Granulomas
• About 40% of all SPNs are granulomas—small, granular inflammatory lesions.
• The word "granuloma" comes from the Latin word "granum," meaning "grain" or "seed."
• Granulomas are characterized by a nodular appearance and a unique cellular pattern that can be seen through a microscope.
Benign Calcification: Central Calcification
CalcificationCalcification
• Laminated or central pattern
• Typical of granuloma
• Laminated or central pattern
• Typical of granuloma
Histoplasmoma• Tend to B\L multiple with LN• Rarely slowly progressive apical or post.
pulm.nodule• Usually in presence of pre exist. lung ds. B’ectatic
or emphysema • Calcified centre smtime with calcified laminae• Prevalent in USA,also in many other tropical parts • Self limiting in 2-3 wks• Remnant calcified granuloma in lung .
Histoplasmoma
a
Solid or Central Calcification
• A solid calcified SPN is found in association with prior granulomatous infection, most commonly histoplasmosis or tuberculosis
Histoplasmoma
Hydatid cyst • Echinococcus infection• Human accidental intermediate host• Slow steadily growing• Spherical lession with well defined edges or
uniform density• Ussually multiple and bilateral • May rupture to give salty expectoration• Thus cyst with level,… later calcified walls• Casoni test ,latex agglutination ,complement
fixation test diagnostic
Hydatid cyst in lung.
This patient had a
single large cyst in the
left lung.
Rheumatoid nodules • A \ w arthritis , fibrosis • > Men, middle age,• RA factor may be positive • May have chylous pleural effussion, • Single or multiple nodules With or without
cavitation • Ussually 1-3 cms may be upto 10 cms ,• Subpleural commonly • Nodule in coalminers “Caplan Syndrome”
Arteriovenous malformation
Other benign tumors
• fibromas (fibrous connective tissue), • lipomas (fat), • leiomyomas (smooth muscle), • hemangiomas (dilated blood vessels), • papillomas (epithelial cells).
Speckled or Punctate Calcification
• Speckled or Punctate calcifications
• Represent malignant calcification and
• Should not be taken as benign
Eccentric Calcification
• Eccentric Calcification
• a sign of malignant potential
CalcificationCalcification
• Suggests benign diagnosis• With CT the reference standard,
• CXR has sensitivity 50%, • specificity 87%, and • PPV 93% for identifying calcification
• Suggests benign diagnosis• With CT the reference standard,
• CXR has sensitivity 50%, • specificity 87%, and • PPV 93% for identifying calcification
Postgrad Med 2003;114(2):29-35
Radiological Findings
• If you have definitive findings suggestive of benign pattern than no further work up is needed.
• If still no answer after SCTIE or other radiologic finding further work up is needed
Size • Size of the SPN can also help out at this point to
help make a decision• In general, smaller nodules are more likely to be
benign and larger lesions malignant • 80% of benign SPNs are less than 2 cm in
diameter• However, small size is not necessarily reliable
evidence of benignity because 15% of malignant nodules are less than 1 cm in diameter approximately 42% are less than 2 cm in diameter
Radiographics 20:43, 2000
Size of SPN
• Most SPN are less than 2 cm in diameter• Malignant nodules
• 40% less than 2 cm • 15% less than 1 cm • 1% less than 7 mm• 0% less than 5 mm
Margins
• Smooth, well-defined margins most often indicate a benign nodule
• However 21% of malignant nodules have a smooth well-defined margin
• a lobulated margin may reflect uneven growth of a SPN and can indicate malignancy
• although 25% of benign nodules, particularly hamartomas, are lobulated
Radiology 179:469, 1991
Patterns of MarginsPatterns of Margins
• Corona radiata sign• Fine linear strands
extending 4-5 mm outward
• Spiculated on CXRs• 84 – 90% are malignant
• Corona radiata sign• Fine linear strands
extending 4-5 mm outward
• Spiculated on CXRs• 84 – 90% are malignant
Patterns of MarginsPatterns of Margins
Patterns of MarginsPatterns of Margins
Spiculated lipoid pneumonia
Spiculated lipoid pneumonia
Patterns of MarginsPatterns of Margins
• Scalloped border• Intermediate probability
of cancer• Smooth border suggestive
of benign diagnosis
• Scalloped border• Intermediate probability
of cancer• Smooth border suggestive
of benign diagnosis
Other CharacteristicsOther Characteristics
• Air bronchograms and pseudocavitation more commonly malignant
• Cavitation with thick (>15 mm vs < 5 mm) more often maligant
• Air bronchograms and pseudocavitation more commonly malignant
• Cavitation with thick (>15 mm vs < 5 mm) more often maligant
Air BronchogramsAir Bronchograms
Cavitation
• Although cavitation can occur in necrotic malignant SPNs, inflammatory lesions can also cavitate.
• The thickness of the cavity wall can be helpful in distinguishing benign from malignant lesions.
• Cavities with a greatest wall thickness less than 5 mm are almost always benign
• whereas most of those with a maximal wall thickness greater than 15 mm are malignant
Cavitation
Thick walled cavity which came back as squamous cell carcinoma.
RADIOGRAPHIC PRESENTATIONS OF LUNG
CANCER
• Mass or nodule• Atelectasis (lung collapse)• Non-resolving pneumonia• Mediastinal lymph node enlargement
ADENOCARCINOMA
• Peripheral• Spiculated• < 4 cm• Uncommon Hilar and mediastinal lymph
node enlargement Early metastases to brain, adrenals, liver, bone
• Can arise from an existing scar - scar carcinoma
ADENOCARCINOMA
Peripheral
ADENOCARCINOMA
Small
ADENOCARCINOMA
SQUAMOUS CELL CARCINOMA
• Central endobronchial• post obstructive pneumonia• atelectasis
SQUAMOUS CELL CARCINOMA
Central hilarCalcified
granuloma
Central hilarmass
Ascending aorta
SVCMain pulmonaryartery
Descending aorta
SQUAMOUS CELL CARCINOMA
SQUAMOUS CELL CARCINOMA
• Apical - Pancoast or superior sulcus tumour
PANCOAST TUMOUR
Destroyed 3rd rib
Destroyed 3rd rib
Mass
PANCOAST TUMOUR
SQUAMOUS CELL CARCINOMA
• Slow growing (1 - 10 cm)• Cavitation (10 - 20%)
• DDx - lung abscess
• Late metastases
Central cavity
SQUAMOUS CELL CARCINOMA
DDX - Lung abscess
SMALL CELL LUNG CANCER
• Central > peripheral• Massive hilar and mediastinal adenopathy• Early distant spread
SMALL CELL CARCINOMA
Large mass
Large mediastinalnodes
SMALL CELL CARCINOMA
SMALL CELL CARCINOMA
LARGE CELL CARCINOMA
• Large peripheral mass ~ 7 cm• Rapid growth• Early distant spread
LARGE CELL CARCINOMA
LARGE CELL CARCINOMA
Large peripheral mass
LARGE CELL CARCINOMA
Largeperipheral mass
LARGE CELL CARCINOMA
Large peripheralmass
LARGE CELLCARCINOMA
BRONCHIOLOALVEOLAR CARCINOMA
• Peripheral nodule• Non-resolving focal “pneumonia”• Diffuse bilateral “pneumonia”
• hilar and mediastinal nodal enlargement uncommon• distant spread uncommon
Looks like pneumoniabut …….
BRONCHIOLOALVEOALR CELL CARCINOMA
Air bronchogram
BRONCHIOLOALVEOLAR CARCINOMA
Airbronchogram
Multifocal
BRONCHIOLOALCEOLAR CELL CARCINOMA
Air space disease
BAC
No Specific Pattern Found
• With no specific finding, all risk factors must be taken into account.
• Trying to milk the SPN for as much information it can be
• It may help stratify the risk in the patient
Indeterminate SPN
• After milking the SPN for all its characteristics it is now important to milk the patient for all relevant information
• Key points include: • smoking history; • symptoms; • comorbid conditions (particularly severe emphysema); • history and type of prior malignancy; • prior infections and environmental exposures.
Work-up of SPN: CXR
• No change in two years - no further evaluation• Characteristic calcifications of benign disease• Lateral films for “hidden” lesions• Initial CXR then serial CT Scans
Decision Making
Postgrad Med 2003;114(2):29-35
N Engl J Med 348:2535-2542
Clinical Decision
• Now after evaluating the entire clinical picture and clinically identifiable risks its time to determine where they fall into Low, Moderate or High risk
• Pretest probability of cancer determines most cost-effective strategy
• Low : radiographic follow-up• Intermediate : CT and PET• High : CT followed by biopsy or surgery• Very high : surgery*
Low risk indeterminate SPN
• 30 year old male, never smoked, • nodule is <1cm with no previous studies, • no environmental exposure, • Review all prior CXR• No specific pattern found• Get CT scans• found on CT not seen on CXR
• If probability of cancer is <10% wait and watch• Can follow for two years
Moderate Risk
• Now we have a patient who isnt clearly low risk. • Maybe older age, • questionable smoke or environmental history but
not quite screaming high risk, what to do?• If it is high thoracotomy should intervene• Bronch & NAB reserved for pt who are reluctant
to go for surgery before Dx• PET SCAN is now recommended
• PET is slightly more effective,noninvasive• If PET is +ve but other criteria are low for
malignancy, then ANB is needed to R/O infectious granulomas
CT Scan
• CT can help distinguish a solitary pulmonary lesion from multiple pulmonary nodules
• CT Scan with contrast to evaluate mediastinum• Serial scans at 3, 6, 12, and 24 months• Can consider trial of antibiotics prior to repeat scan in 6
weeks• Newer CT techniques
• Volumetric analysis • Multi-slice scanner
Contrast-Enhanced CTContrast-Enhanced CT
• Degree on enhancement on spiral CT after injection of contrast
• One study used an increase in attenuation of 20 Hounsfield units as threshold for malignant lesions
• Sensitivity 95-100%, • specificity 70-93%*• Local expertise varies
• Degree on enhancement on spiral CT after injection of contrast
• One study used an increase in attenuation of 20 Hounsfield units as threshold for malignant lesions
• Sensitivity 95-100%, • specificity 70-93%*• Local expertise varies
*Zhang, Radiology 1997;205:471-8*Zhang, Radiology 1997;205:471-8
Spiral CT with IV contrast Enhancement (SCTIE)
• Computed tomography (CT) (particularly thin-section CT) is 10–20 times more sensitive than standard radiography and allows objective, quantitative assessment of calcification
• SCTIE the imaging modality of choice for the SPN and should be obtained on all newly diagnosed SPNs
• A number of benign etiologies for SPNs have a characteristic appearance on CT
CT DensitometryCT Densitometry
• Involves measurement of attenuation values• Expressed in Hounsfield units, as compared to
reference “phantom”• Usually higher for benign nodules• Allows for identification of 35 – 55% of
subsequently identified benign lesions
• Involves measurement of attenuation values• Expressed in Hounsfield units, as compared to
reference “phantom”• Usually higher for benign nodules• Allows for identification of 35 – 55% of
subsequently identified benign lesions
CT DensitometryCT Densitometry
• One large, multicenter trial, only 1 of 66 nodules identified as benign later found to be malignant*
• Cutoff used was 264 Hounsfield units• More conventional cutoff is 185, which yielded a
higher false negative rate
• One large, multicenter trial, only 1 of 66 nodules identified as benign later found to be malignant*
• Cutoff used was 264 Hounsfield units• More conventional cutoff is 185, which yielded a
higher false negative rate
*Zerhouni, Radiology 1986;160:319-27*Zerhouni, Radiology 1986;160:319-27
Lung cancer screening
New CT techniques detect suspicious nodules 3x
more than CXR, malignant tumors 4x and stage 1
tumors 6x
Henschke et al: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999;354:99-105
PET Scan
• Highly valuable noninvasive tool
PET SCAN
• Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) has proven to be an excellent mode of tumor imaging
• 18-FDG (fluorodeoxyglucose)• increased uptake by metabolically active cells • does not enter glycolysis
PET SCAN
• Increased activity is demonstrated in cells with high metabolic rates, as is seen in tumors and areas of inflammation
• Taken up by cells in glycolysis but is bound within cells and cannot enter normal glycolytic pathway
• It can also tell us about if any metastatic disease is present thus altering treatment
Limitations Positron Emission Tomography
Limitations Positron Emission Tomography
• However the spatial resolution of PET is currently 7 to 8 mm, and so the imaging of SPNs < 1 cm is unreliable
• False negatives in tumors with low uptake such as bronchoalveolar cell carcinoma It is 95% sensitive for identifying malignancy and 85% specific
• However the spatial resolution of PET is currently 7 to 8 mm, and so the imaging of SPNs < 1 cm is unreliable
• False negatives in tumors with low uptake such as bronchoalveolar cell carcinoma It is 95% sensitive for identifying malignancy and 85% specific
Limitations Positron Emission Tomography
Limitations Positron Emission Tomography
• False positive results may occur in lesions that contain active infection or inflammatory tissue (histoplasmomas)
• High post test likelihood of malignancy (14%) in high risk patients with negative PET
• False positive results may occur in lesions that contain active infection or inflammatory tissue (histoplasmomas)
• High post test likelihood of malignancy (14%) in high risk patients with negative PET
Thoracic PET Scan: Potential Sources of Error
• False Positive Results:
Metabolically active infectious or inflammatory lesions:
Sarcoidosis. Rheumatoid nodules. TB. Fungal granuloma. Others.
• False Negative Results:
Tumors with low metabolic activities:
Bronchoalveolar CA. Carcinoid tumors. Mets: renal cell and testis.
Small tumors-<1cm.
Hyperglycemia-keep sugars below 150mg%.
PET Scan
• Allows more accurate identification of tumors, lymph nodes, and metastatic disease
• May provide staging information• Up to 14% of patients otherwise eligible for
surgery have occult extra thoracic disease on whole-body PET
• Benign disease Malignant disease • 96% sensitivity 96% sensitivity • 88% specificity 77% specificity
Pet Scan• Gould et al performed a meta-analysis of
the literature on pulmonary nodules and masses and PET scanning and found an overall sensitivity of 96.8% and specificity of 77.8% for detecting malignancy.
• PET scans also have a 96% sensitivity and 88% specificity with 94% accuracy in the diagnosis of benign nodules
JAMA 2001; 285:914–924
Utilization of PET Scans
• Negative PET in high risk patients still need tissue diagnosis…so why get it?
• PET not usually indicated unless it will change management
• So depending on the PET Scan result we can base our treatment
• If PET is positive than we can refer the patient to CT Surgery for resection options
• If PET is negative than can follow
Positron Emission TomographyPositron Emission Tomography
• CT combined with PET for staging was often superior to conventional approaches
• Reduced number of surgeries by 15%• Cost savings per patient
• CT combined with PET for staging was often superior to conventional approaches
• Reduced number of surgeries by 15%• Cost savings per patient
*Gambhir, J Clin Oncol 1998;16:2113-25*Gambhir, J Clin Oncol 1998;16:2113-25
Positron Emission TomographyPositron Emission Tomography
• More expensive than other imaging modalities• More expensive than other imaging modalities
*http://cms.hhs.gov, Dec 2002*http://cms.hhs.gov, Dec 2002
PET ImagesPET Images
Pieterman, NEJM 2000;343:254-61
Pieterman, NEJM 2000;343:254-61
PET ImagesPET Images
Pieterman, NEJM 2000;343:254-61
Pieterman, NEJM 2000;343:254-61
Integrated PET and CTIntegrated PET and CT
Lardinos, NEJM 2003;348:2500-7
Lardinos, NEJM 2003;348:2500-7
Integrated PET and CTIntegrated PET and CT
Lardinos, NEJM 2003;348:2500-7
Lardinos, NEJM 2003;348:2500-7
Sample Pre-biopsy AlgorithmCHEST 2004; 125:1522-1529
Biopsy
• Bronchoscopic biopsy• CT guided
• Transthoracic needle aspiration (TTNA) Transthorathic needle aspiration (TTNAB) has a sensitivity of 80% to 90%
• Fine needle aspiration (FNA)• Surgical
• Video Assisted Thoracic Surgery (VATS) • Open
BRONCHOSCOPY
Bronchoscopy
• Limited role• Transbronchial needle aspiration of mediastinal lymph
nodes • Useful for large central lesions and endobronchial lesions• Can detect infection• No use in peripheral nodules
BronchoscopyBronchoscopy
• Useful for lesions at least 2 cm• Useful for lesions at least 2 cm
INDICATION FOR BRONCHOSCOPIC BIOPSY
• Central lesion ie. Near hilum
BronchoscopyBronchoscopy
• Diagnostic yield varies in literature from 20 – 80%, depending on size of nodule and patient population
• Yield depends on nodule size and proximity to bronchial tree
• Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm
• 70% yield when CT reveals a bronchus leading to lesion
• Diagnostic yield varies in literature from 20 – 80%, depending on size of nodule and patient population
• Yield depends on nodule size and proximity to bronchial tree
• Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm
• 70% yield when CT reveals a bronchus leading to lesion
BronchoscopyBronchoscopy
• Relatively low risk• Overall complication rate 5%• 3% risk of pneumothorax• 1% risk of hemorrhage• 0.24% risk of death
• Relatively low risk• Overall complication rate 5%• 3% risk of pneumothorax• 1% risk of hemorrhage• 0.24% risk of death
INDICATIONS FOR FNAB
• Peripheral lesion• Central lesion without significant distal collapse
DIAGNOSTIC YIELD OF FNAB
• 90 - 97%
FNAB TECHNIQUE
• Out-patient procedure• 22G needle• Image guidance
• fluoroscopy• computed tomography• ultrasound
Transthoracic FNA (TTFNA)Transthoracic FNA (TTFNA)
• Diagnostic yield up to 95% in peripheral lesions• Higher complication rate• Pneumothorax (10 - 30%)• Hemoptysis (30%)• About 5% of these require chest tube
• Diagnostic yield up to 95% in peripheral lesions• Higher complication rate• Pneumothorax (10 - 30%)• Hemoptysis (30%)• About 5% of these require chest tube
What are the limitations of Needle Biopsy of Lung Nodules?
• In a small number of cases, the tissue obtained during a biopsy may not be adequate for diagnosis.
• Needle biopsy is not cost-effective for small lesions one to two millimeters in diameter.
• The needle is too difficult to position into the nodule and the nodule is too small to provide enough tissue for an accurate diagnosis.
What are the limitations of Needle Biopsy of Lung Nodules?
• For patients with certain conditions a needle biopsy may not be recommended. • emphysema, • lung cysts, • blood coagulation disorder of any type, • insufficient blood oxygenation, • pulmonary hypertension, and • certain heart failure conditions,
• Alternatives to lung biopsy usually include continued follow-up with imaging and surgical removal of the abnormality.
CT-guided fine-needle aspiration biopsy
• The use of CT-guided fine-needle aspiration biopsy in solitary pulmonary nodules has been condemned historically as often being an unnecessary step in the workup of these patients.
Sample Post-biopsy AlgorithmCHEST 2004; 125:1522-1529
Thracoscpic Resctn of Lung Nodules
Lung cancer: Surgical options
• VATS• Segmentectomy• Lobectomy• Sleeve resection• Pneumonectomy
Surgery
• Thoracotomy to resect a malignant nodule carries significant death of 3% to 4% but for a benign lesion it is 0.3%
• Thoracoscopy carries less significant morbidity and lessens hospital stay
• It is not known if the 5-years survival is different between the two approaches
High Risk Patient
• 68 year old male, • 100 pack years of smoking, • Used to work with asbestos, and • Coughing up blood• RIGHT TO THE OR for resection.
Conclusion
• The main point is to make sure you give the SPN the respect it deserves.
• With timely diagnosis we can effectively prevent morbidity and mortality for our patients
• There is just no excuse for a patient to die because we did not work up the patient in a timely fashion.
Medicolegal Aspects
• Physicians should discuss the possibility of lung cancer presenting as a SPN in those patients who have lesions that cannot be confirmed to be benign based on their presence on old films with over 2 years of stability, or classic calcification typical of a benign lesion.
• Patients should play an active role in the decision to remove, evaluate with invasive procedures, or observe their SPN.
Medicolegal Aspects
• The pros and cons of pulmonary resection should be discussed and a recommendation made.
• This should be carefully documented in the patient record, and if observation is chosen, advice for follow up given.
• Then, it is important for the physician to insure that follow up actually occurs.
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
PrimaryTumor (T)
Description
T1A small tumor that is not locally advanced or invasiveCriteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the main bronchus
T2A larger tumor that is minimally advanced or invasiveCriteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but remains >2 cm from the main carina; may cause segmental or lobar atelectasis
T3
Any size tumor that is locally advanced or invasive up to but not including themajor intrathoracic structuresCriteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium; main bronchus within 2 cm of the main carina (not involving the main carina); may cause atelectasis of the entire lung
T4Any size tumor that is advanced or invasive into the major intrathoracic structuresCriteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, main carina; malignant pericardial or pleural effusion; presence of satellite tumor nodule(s) within the primary tumor lobe
RegionalLymph Node
Involvement (N)Description
N1Metastatic disease to nodes within the ipsilateral lungCriteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar nodes (nodal stations 10 through 14)
N2
Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to theprimary tumorCriteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes (nodal stations 1 through 9)
N3Metastatic disease to nodes distant to those included in N2Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral scalene and/or supraclavicular nodes
Metastases (M) Description
MO Local or regional disease, no distant metastases
M1 Disseminated disease, distant metastases present