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DEFINITION OF SOLITARY PULMONARY NODULE (SPN)

SPNs and the Early Detection of Lung Cancer George Erbacher D.O., FAOCR Chair imaging/interventional radiology OSUMC Radiology residency program director. DEFINITION OF SOLITARY PULMONARY NODULE (SPN). Single round water density mass < 3 cm

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DEFINITION OF SOLITARY PULMONARY NODULE (SPN)

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  1. SPNs and the Early Detection of Lung CancerGeorge Erbacher D.O., FAOCRChair imaging/interventional radiology OSUMCRadiology residency program director

  2. DEFINITION OF SOLITARY PULMONARY NODULE (SPN) • Single round water density mass < 3 cm • Completely surrounded by lung parenchyma • Incidental finding 0.2% CXRs, 1% CT

  3. MIMICS OF SPN • Chest wall lesion • Healing rib fracture • AVN • Abscess • Pneumonia • Immune-RA/Wegeners granulomatosis etc.

  4. MIMICS OF SPN • Hematoma • Lung infarct/atelecatasis • Pleural plaque • Bronchial atresia/Sequestration • Inhaled FB • MOST COMMON: BENIGN GRANULOMA/HAMARTOMA

  5. PATIENT FEATURES INCREASING RISK OF MALIGNANCY • SMOKING ESPECIALLY >20 PK/YEAR • Older age • Personal history of malignancy • First degree relative with lung cancer • Asbestos/uranium/radon exposure • Other workplace exposure- some aromatic hydrocarbons, coal mines etc.

  6. IMAGING FEATURES BENIGN VS. MALIGNANT • Smaller less risk of malignancy • Well defined borders tend to be benign • If a cavity –thin walls-favor benign • Popcorn like calcification –benign –characteristic of hamartoma • Density (HU) < 15-20 benign • Very fast and very slow growing lesions are likely benign-PREVIOUS COMPARISON IMAGES ARE CRITICAL

  7. Epidemiology Lung Cancer in the World • Most frequently diagnosed cancer (1.04M in 1990) • Leading cause of cancer mortality • 921K deaths • Most common cancer in males and #1 cause of cancer death

  8. Incidence Lung Cancer in U.S. • 171,600 cases diagnosed in 1999 (94K M; 77.6K F) • Leading cause of cancer death M & F (158.9K) • Kentucky highest mortality rate • 67.9/100K (37% above avg.) • Utah lowest mortality rate • 21.6/100K (56.4% below avg.)

  9. U.S. Lung Cancer “Lung cancer is the leading cause of cancer mortality in the U.S. among both men and women surpassing totals from breast, colon, and ovarian cancers combined.” [1] 1Dupuy, DE.Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

  10. Survival • 5 years – 14% • 50% survive if diagnosed in early stage (small size IA 85 – 100% survival • Only 15% diagnosed in early stage

  11. Tobacco Smoke • “Cigarette smoking is causally related to lung cancer…the magnitude of the effect far outweighs all other factors.” • Is leading cause of avoidable mortality in US, w/ about 434K preventable deaths per year • Cost to US economy $200 billion/year US surgeon general

  12. CXR Screening Revisited • Analysis of the 4 RCT from 20 years ago (Mayo, Czech, Sloan-Kettering, Johns-Hopkins) • Czech & Mayo studies found increase in mortality in screened vs. controls (6% increase in Mayo) however 29% MORE lung cancer in screening vs. controls

  13. CXR Screening Revisited • Screened had 34% living @ 5yrs vs. 15% control (Sloan-Kettering, Johns-Hopkins similar results) • “Analysis of the randomized trials strongly suggests CXR screening is superior to no screening whatsoever”

  14. Low Dose CT (LD CT)Screening vs. CXR • Rationale:LD CT greatly increases detection of small non-calcified nodules and of lung cancer at an earlier/more curable stage • LD CT showed non-calcified nodules 3x more commonly • LD CT showed malig. tumors 4x more commonly • LD CT showed stage 1 tumors 6x more commonly

  15. LD CT Indication (ELCAP) • > 60 y.o.a. • > 10 pk/y smoker & no previous cancer • Medically fit to undergo thoracic surgery • Baseline LD CT, then annuals

  16. ELCAP Technique – Helical CT • 140 kVp, 40 mA • 2:1 Pitch, 10 mm slice thickness • Scan entire lung in 1 breath hold @ end inspiration after hyperventilation • Reconstruct images with bone algorithm in overlapping 5 mm increments • Only lung windows (W1500, L-650) reviewed

  17. ELCAP Scoring • 1-6 non-calcified nodules = positive • If no non-calcified nodules = negative • > 6 non-calcified nodules, diffuse bronchiectasis, ground glass opacities or combinations = diffuse disease

  18. ELCAP Nodule Description • Size (L & W/2) • Location (lobe & distance from pleura) peripheral if w/in 2 cm costal margin • Benign calcifications • Shape (round, non-round) • Edge (smooth, non-smooth)

  19. ELCAP “Benign Nodule” • Benign calcifications • Smooth edges • < 20 mm size

  20. Guideline for Diagnostic Intervention ELCAP • Non-benign nodule on LD CT goes to diagnostic CT w/ high resolution imaging of abnormalities. If not benign per above criteria: • < 5mm : F/U high res CT 3 mo, 6 mo, 12 mo, 24 mo; no growth over 3 yrs=benign • 6-10 mm : bx, if not possible F/U per above • > 11mm : bx

  21. Fleishner Recommendations do NOT apply to patients: • <35 Y.O.A. with low risk of lung cancer • Who have fever/signs of infection

  22. Fleishner Nodule CT Reassessment Recommendations • NONCONTRAST • THIN COLLIMATION • LIMITED COVERAGE-JUST REGION OF INTEREST • LOW DOSE

  23. Nodule Enhancement and metabolism • Cancer/Infection/inflammation- CT neovascularity- malignant nodules enhance > 20 Hounsfield Units (HU), benign < 15 HU • Cancer/Infection/inflammation- increased glucose turnover- PET- SUVmax < 2.5 benign • PET/CT HAS SENSITIVITY AND SPECIFICITY CLOSE TO 90% FOR NODULES 10 MM OR GREATER DIAMETER

  24. PET/CT vs. Helical dynamic CT for SPN • PET/CT MORE SENSITIVE (96% vs. 81%) and MORE ACCURATE (93% vs. 85%) than helical dynamic CT

  25. Caveats for PET/CT:NO STANDARIZATION FROM ONE MACHINE TO ANOTHER AND POOR STANDARDIZATION OFTEN BETWEEN EXAMINATIONS ON THE SAME MACHINE.EXPERIENCE OF TECHNOLOGISTS-RADIOLOGISTS VARIES WIDELY

  26. Benign? NM in Lung Cancer

  27. Role of PET in Lung Cancer Improves staging by ruling out mediastinal/distant disease • Useful in evaluating response to therapy • Useful in early detection recurrent disease • Rad Clinics N.A. May 2000 p. 523

  28. False Positive and Caveats PET/CT • Active necrotizing granulomas and some chronic inflammatory conditions are + • ANY PROCESS THAT HAS INCREASED UPTAKE OF GLUCOSE IS PET POSITIVE

  29. What to do with Indeterminant CT W/U of SPN • Serial radiographic F/U? • CT alone to decide to surgerize or not? • PET/CT • Surgery for pts w/ + or indeterminant CT?

  30. Cost Effectiveness • Radiographic F/U cost effective when probability of malignancy is low (<0.14) • CT alone F/U cost effective when probability of malignancy is high (.71 - .91) • Surgery alone is most cost effective when probability of malignancy is very high > .90 • Over greatest range of probability .14 - .71 CT and PET/CT cost effective • Rad Clinics N.A. May 2000 p. 521-522

  31. PRINCIPLES OF IMAGING IN ONCOLOGY • Imaging justified only if results will change therapy with patient benefit • “Where there is an issue get tissue”-biopsy when imaging is inconclusive (imaging guided?) • Positive studies are more valuable/reliable than negative studies • The diagnostic plan should progress logically from least to most invasive studies • Accurate assessment of initial disease extent is vital to selecting and sequencing appropriate treatment

  32. Staging lung cancer • Stage1A-T1N0MO= tumor < 3cm with no positive nodes and no metastasis • Stage 1B-T2N0M0- tumor > 3cm, no nodes, no metastasis

  33. RFA in Pulmonary Applications

  34. Lung • 25% of patients are candidates for lung resection. [1] • RT and chemotherapy together have a combined 5 year survival rate of 5%. [1] • RF ablation can potentially provide direct cytoreduction, which could make RT and chemotherapy more effective. [1] 1Dupuy, DE.Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

  35. Lung Cancer • Assessment of malignancy has required invasive diagnostic methods • Needle biopsy (10% sampling error; 15% pneumothorax) • Bronchoscopy (low sensitivity; occ. pneumothorax • Mediastinoscopy (surgical procedure; limited to anterior mediastinum) • Thoracotomy (open surgery; 1-3% mortality) • FDG-PET expensive and not widely available

  36. Lung Cancer “The overall 5-year survival rate for all stages combined is only 15%.” [1] “Radiofrequency ablation of lung tumors may be a promising option for nonsurgical candidates given the suboptimal outcomes with current treatment options.” [1] 1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

  37. Radiofrequency AblationNSC Lung Cancer 18 mo S/P RFA/XRT 3 cm RFA 3 mo S/P RFA/XRT

  38. KEYS • Excellent H&P • Find Comparisons • Send the above to your radiologist then call and discuss the case-have the radiologist lay out the work up as local resources dictate what will be done • IF PATIENT CANDIDATE FOR TREATMENT TISSUE DIAGNOSIS IS NEEDED

  39. We at Diagnostic Imaging Associates are happy to help FOR TULSA REFERRAL AREA CALL 918 599 5050/5094 TO TALK TO RADIOLOGIST FOR OUTSIDE TULSA REFERRAL AREA CALL CHRISTA -918 599 5031 and ask for radiologist at site nearest you Thank You

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