Transcript The Lung Nodule - Thomas Jefferson University

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
A
radiographic opacity ( approximately
round) that is < 3 cm in diameter,
completely surrounded by pulmonary
parenchyma. ( no associated adenopathy, atelectesis
or pleural abnormalities)
.
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
CXR STUDIES
4 Randomized Clinical Trials in 1970s
 Mayo Clinic Study
CXR + Sputum cytology
 Czech Study
vs.

Usual Care
Sloan Kettering study
 Johns Hopkins study

CXR + Sputum cytology
vs.
CXR alone
PLCO
CXR
Smoker +
Non-smoker
Age 55-74
Randomize
150,000
No Screen
Year
0
1
2
3
…………
20
NATIONAL LUNG SCREENING TRIAL
CT
30 pack years
Age 55-74
Randomize
52,000
CXR
Year
7
0
1
2
3
4
5
6
NLST – STUDY POPULATION
Exclusion criteria
Inclusion criteria
55 to 74 years
 At least 30 pack-year
smoking history
 If former smokers, had
quit within previous 15
years

Previous lung cancer
 CT chest within 18
months before
enrollment
 Hemoptysis
 Unexplained weight loss
of more than 15 lbs in
60%Males last year

90%Whites
50%former smokers
75%less than 64
years old
NLST- RESULTS
1060

941
20% reduction in lung
cancer specific
mortality
Number Needed to Screen
– 320
 247
deaths/ 100,000
person-years
compared to
443
 309 deaths/ 100,000
person-years
356

6.7% reduction in
overall mortality
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
DDX “BENIGN” LESIONS

Vascular



AV malformations
Pulmonary artery
aneurysm
Infectious










Tuberculosis
MAI
Aspergilloma
Histoplasmosis
Echinococcus
Blastomycosis
Cryptococcus
Coccidiomycosis
Ascariasis
Difofilaria

Inflammatory


Rheumatoid nodule
Sarcoidosis

Bronchogenic cyst

Rounded atelectasis
Pulmonary
Amyloidosis
Wegener’s granuloma
 Congenital



Other
Tumors



Hamartoma
Lipoma
Fibroma
DDX MALIGNANT NODULES
 Primary
Cancer

Lung
Non-small cell
Squamous cell
 Adenocarcinoma
 Large cell
 Bronchoalveolar
carcinoma




Small cell
Carcinoid
Lymphoma
 Metastatic
Cancers






Colon
Testicular
Breast
Melanoma
Sarcoma
Renal Cell
Carcinoma
DECISION TO PERFORM FOLLOW UP
STUDIES SHOULD DEPEND ON ….
 Nodule
Size
 Nodule characteristics ( morphology)
 Growth rate ( doubling time)
 Patient risk profile
NODULE SIZE
>
3 cm – Mass ► should be biopsied/
removed

Size
malignancy




< 3 mm
4-7 mm
8-20 mm
> 20 mm
Likelihood of
0.2%
0.9%
18%
50%
Midthun et al. Lung cancer 2003
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

NODULE MORPHOLOGY
 Opacification

Solid
of underlying parenchyma
Ground Glass
 Borders
 Calcification
 Fat
- benign
 Cavitation
 Air bronchograms
 Location in the Upper Lobes
malignant
BORDERS
Spiculated
Scalloped
Smooth
Corona radiata sign
80-90% of spiculated nodules are malignant !
CALCIFICATION
Malignant
Benign
Popcorn
Central/ Laminated
Eccentric/ Stippled
THE SUB SOLID NODULE
Atypical Adenomatous
Hyperplasia
BAC
Adenocarcinoma
PATIENT FACTORS
Age
 Smoking
 Various prediction models:

Family history of lung cancer
 Pneumonia
 Occupational exposure

Risks of Malignancy
___________________________________
SPN-CHANCE OF MALIGNANCY
60
% Malignancy
50
40
30
% Malignant
20
10
0
35 - 39
40-49
50-59
>60
Age
Cummings, ARRD 1986;134:453 & Toomes, Cancer 1983;51:534
Factors Affecting Malignant
Probability of SPN Likelihood Ratio
Spiculated Margins
5.54
Age > 70 years old
Size 2.1-3.0 cm
Doubling time < 465 days
4.16
3.67
3.40
Smoker
Age 50-69 years old
Size 1.1 to 2.0 cm
2.27
1.90
0.74
< 1 cm
0.52
Smooth Margins
Never Smoked
0.30
0.19
Doubling Time > 465 days
0.01
Gurney JW. Radiology, 1993.
RISK FACTORS
Ost et al, NEJM: June 2003
Management
___________________________________
KEY NOTES
Compare OLD films
 Compare OLD films
 Compare OLD films

Assess patient risk
 Assess operability

SPN MANAGEMENT STRATEGY

Excision


Biopsy


High risk lesion, low risk pt
Intermediate risk
Observation
Low risk lesion, high risk pt
 Requires serial CT scans
 Bx if change

When in doubt, take it out.
MANAGEMENT OF NODULES < 8 MM
FLEISCHNER SOCIETY GUIDELINES
THIS DOES NOT APPLY TO…..
Patients with known or suspected malignant/
metastatic disease.
 Patients < 35 yrs – unless other cancer.
 Patients with unknown fever.

MANAGEMENT OF NODULES > 8 MM
MANAGEMENT OF NODULES > 8 MM
FOLLOWING SUBSOLID NODULES
2 year rule does not apply
 Change in the solid component
 TBNA indicated for non surgical pts, multifocal
disease, and where proof of malignancy needed before
surgery.

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
32 YEAR OLD, NON-SMOKER, WITH
RECURRENT SINUS INFECTIONS
 Differential
 Work-up?
Diagnosis?
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
65 YEAR-OLD SMOKER; 2 CM NODULE
 Peripheral
central?
 Approach?
or
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

42 YEAR-OLD SMOKER FROM OHIO
 Differential
 What
next?
Diagnosis?
PET SCAN – DOES IT HELP YOU?
SUV 2.0
ANSWER:
Blastomycosis
42 YEAR OLD SMOKER WITH WEIGHT LOSS
 Differential
 Next
Step?
Diagnosis?
CT SCAN

What next?
ANSWER
PET scan
 Surgical Candidate?
 VATS vs. TTNA


Diagnosis: Lymphoma
CASES

66 yr male smoker with FEV1 0.7L
CASES
 57
yr asthmatic female from Puerto Rico with
cough
ELCAP
 PET sensitivity
 CT sensitivity
 Yield of bronchoscopy vs needle vs navigation/
ebus
