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The Lung Nodule

The Lung Nodule. Rohit Kumar, MD Assistant Professor of Medicine Thomas Jefferson University. Outline. Definition Risks of malignancy Approach to diagnosis Current guidelines for follow up Cases. Definition.

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The Lung Nodule

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  1. The Lung Nodule Rohit Kumar, MD Assistant Professor of Medicine Thomas Jefferson University

  2. Outline • Definition • Risks of malignancy • Approach to diagnosis • Current guidelines for follow up • Cases

  3. Definition • A radiographic opacity ( approximately round) that is < 3 cm in diameter, completely surrounded by pulmonary parenchyma. ( no associated adenopathy, atelectesis or pleural abnormalities) .

  4. Why should we find nodules? • Smoking continues to be a highly prevalent • Most lung cancer presents at a later stage • Survival for late stage lung cancer is still poor • Malignant nodules represent a potentially curable form of lung cancer • Recent trials indicate screening might be beneficial

  5. CXR Studies • 4 Randomized Clinical Trials in 1970s • Mayo Clinic Study • Czech Study • Sloan Kettering study • Johns Hopkins study CXR + Sputum cytology vs. Usual Care CXR + Sputum cytology vs. CXR alone

  6. PLCO CXR Smoker + Non-smoker Age 55-74 Randomize 150,000 No Screen Year 0 1 2 3 ………… 20

  7. National Lung Screening Trial CT 30 pack years Age 55-74 Randomize 52,000 CXR Year 0 1 2 3 4 5 6 7

  8. NLST – Study population 55 to 74 years At least 30 pack-year smoking history If former smokers, had quit within previous 15 years Inclusion criteria Exclusion criteria • Previous lung cancer • CT chest within 18 months before enrollment • Hemoptysis • Unexplained weight loss of more than 15 lbs in last year 60%Males 90%Whites 50%former smokers 75%less than 64 years old

  9. NLST- Results 1060 • 20% reduction in lung cancer specific mortality • 247 deaths/ 100,000 person-years compared to • 309 deaths/ 100,000 person-years • 6.7% reduction in overall mortality 941 Number Needed to Screen – 320 443 356

  10. Epidemiology • 1 in 500 CXR’s demonstrates a lung nodule • >150,000 nodules are identified each year • Incidence of cancer in nodules ranges between 10% to 70% ( 35%) • Most nodules are benign- infection / hamartoma • ELCAP – 23% subjects had nodules, 2.7% malignant • Mayo Clinic – 1500 pts: 70% had nodules, 1.4% malignant

  11. DDx “Benign” Lesions Vascular AV malformations Pulmonary artery aneurysm Infectious Tuberculosis MAI Aspergilloma Histoplasmosis Echinococcus Blastomycosis Cryptococcus Coccidiomycosis Ascariasis Difofilaria Inflammatory Rheumatoid nodule Sarcoidosis Wegener’s granuloma Congenital Bronchogenic cyst Other Rounded atelectasis Pulmonary Amyloidosis Tumors Hamartoma Lipoma Fibroma

  12. DDx Malignant Nodules Primary Lung Cancer Non-small cell Squamous cell Adenocarcinoma Large cell Bronchoalveolar carcinoma Small cell Carcinoid Lymphoma Metastatic Cancers Colon Testicular Breast Melanoma Sarcoma Renal Cell Carcinoma

  13. Decision to perform follow up studies should depend on …. • Nodule Size • Nodule characteristics ( morphology) • Growth rate ( doubling time) • Patient risk profile

  14. Nodule Size • > 3 cm – Mass ► should be biopsied/ removed • Size Likelihood of malignancy • < 3 mm 0.2% • 4-7 mm 0.9% • 8-20 mm 18% • > 20 mm 50% Midthun et al. Lung cancer 2003

  15. Nodule Growth Rate • A 30% increase in diameter represents doubling of volume ( assuming lesions are spherical) • Depends on nodule morphology: • Solid nodules – 149 days • Sub solid nodules – 457 days • Pure Ground Glass – 813 days • Doubling time of malignant tumors is rerely less than a month or more than a year • Stability of a solid nodule over 2 years is considered a sign of benignity

  16. Nodule Morphology • Opacification of underlying parenchyma • Solid Ground Glass • Borders • Calcification • Fat - benign • Cavitation • Air bronchograms • Location in the Upper Lobes malignant

  17. Borders Spiculated Scalloped Smooth Corona radiata sign 80-90% of spiculated nodules are malignant !

  18. Calcification Malignant Benign Popcorn Central/ Laminated Eccentric/ Stippled

  19. The Sub Solid Nodule Atypical Adenomatous Hyperplasia BAC Adenocarcinoma

  20. Patient Factors • Age • Smoking • Various prediction models: • Family history of lung cancer • Pneumonia • Occupational exposure

  21. Risks of Malignancy ___________________________________

  22. SPN-chance of malignancy Cummings, ARRD 1986;134:453 & Toomes, Cancer 1983;51:534

  23. Factors Affecting Malignant Probability of SPN Likelihood Ratio Gurney JW. Radiology, 1993.

  24. Risk Factors Ost et al, NEJM: June 2003

  25. Management ___________________________________

  26. Key Notes • Compare OLD films • Compare OLD films • Compare OLD films • Assess patient risk • Assess operability

  27. SPN management strategy Excision High risk lesion, low risk pt Biopsy Intermediate risk Observation Low risk lesion, high risk pt Requires serial CT scans Bx if change When in doubt, take it out.

  28. Management of Nodules < 8 mm

  29. Fleischner Society Guidelines

  30. This does not apply to….. • Patients with known or suspected malignant/ metastatic disease. • Patients < 35 yrs – unless other cancer. • Patients with unknown fever.

  31. Management of Nodules > 8 mm

  32. Management of Nodules > 8 mm

  33. Following Subsolid Nodules • 2 year rule does not apply • Change in the solid component • TBNA indicatedfor non surgical pts, multifocal disease, and where proof of malignancy needed before surgery.

  34. Following Subsolid Nodules • Pure GGO: • < 5 mm : No follow up • 5-10 mm : 3-6 month, then annually for 3-5 year • > 10 mm : 3-6 month, then surgery • GGO with Solid component: • > 10 mm: Consider PET scan, then Surgery

  35. 32 year old, non-smoker, with recurrent sinus infections Differential Diagnosis? Work-up?

  36. Answer Differential Diagnosis Wegener’s Granulomatosis Cavitary Pneumonia TB Squamous Cell Carcinoma Other lung cancer Approach Lab tests (ANCA) Sputum culture & cytology FOB Trial of antibiotics PET less likely to help in diagnosis PET good for disease outside the chest

  37. 65 year-old smoker; 2 cm nodule Peripheral or central? Approach?

  38. Answers Peripheral lesion Best approach: Assess for surgical candidacy PFTs PET scan +/- Head CT/MRI If good candidate  VATS If not good  CT-guided biopsy

  39. 42 year-old smoker from Ohio Differential Diagnosis? What next?

  40. PET scan – does it help you? SUV 2.0

  41. Answer: Blastomycosis

  42. 42 year old smoker with weight loss Differential Diagnosis? Next Step?

  43. CT scan • What next?

  44. Answer PET scan Surgical Candidate? VATS vs. TTNA Diagnosis: Lymphoma

  45. Cases 66 yr male smoker with FEV1 0.7L

  46. Cases 57 yr asthmatic female from Puerto Rico with cough

  47. ELCAP • PET sensitivity • CT sensitivity • Yield of bronchoscopy vs needle vs navigation/ ebus

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