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Screen discovered nodules: What next ?. 18 th Annual Perspectives in Thoracic Oncology. Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical Center. Disclosures. Research Funding NIH, DOD

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Screen discovered nodules: What next ?

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Screen discovered nodules what next
Screen discovered nodules: What next?

18th Annual Perspectives in Thoracic Oncology

Anil Vachani, MD, MS

Assistant Professor of Medicine

Director, Lung Nodule Program

University of Pennsylvania Medical Center


Disclosures
Disclosures

  • Research Funding

    • NIH, DOD

    • Integrated Diagnostics, Allegro Diagnostics,

  • Scientific Advisory Board

    • Allegro Diagnostics


Nodule biopsy and benign disease rates
Nodule, Biopsy and Benign Disease Rates

5

RCT

4

3

Percent of patients in screened arm

2

1

0


Screen discovered nodules what next

Ost & Gould, AJRCCM 2011


Assessing the probability of cancer
Assessing the Probability of Cancer

  • Most Important Factors to consider:

    • Nodule size and characteristics

    • Smoking history

    • Age

    • Family history of lung cancer

    • Emphysema




Importance of nodule size
Importance of Nodule Size

NLST Investigators. NEJM 2013



Fleischner society guidelines
Fleischner Society Guidelines

McMahon, et al. Radiology 2005; 237:395-400


Recommendations for subsolid nodules
Recommendations for Subsolid Nodules


Screen discovered nodules what next

Thick vs. Thin Sections for Small Nodules

Naidich D P et al. Radiology 2013;266:304-317


Recommendations for subsolid nodules1
Recommendations for Subsolid Nodules


Pure ggn larger than 5mm
Pure GGN larger than 5mm

  • Lesions are frequently due to preinvasive AAH or AIS

  • Up to 20% of persistent GGOs are benign

  • Growth of a GGO can suggest presence of an invasive adenocarcinoma


Screen discovered nodules what next

Serial Imaging to Assess Growth (1mm cuts)

Naidich D P et al. Radiology 2013;266:304-317


Screen discovered nodules what next

Rapid Enlargement of a GGO

Naidich D P et al. Radiology 2013;266:304-317


Recommendations for subsolid nodules2
Recommendations for Subsolid Nodules


Rationale
Rationale

  • Part solid nodules have a high likelihood of malignancy

  • Development of a solid component within a pure GGO


Recommendations for subsolid nodules3
Recommendations for Subsolid Nodules


Screen discovered nodules what next

Multiple subsolid lesions with single dominant focus.

Naidich D P et al. Radiology 2013;266:304-317


Pet scans
PET Scans

Erasmus, et al. Clinics in Chest Medicine 2008


Pet scans1
PET Scans

  • Sensitivity ~ 85%

  • Specificity ~ 80%

  • Less accurate for:

    • Smaller lesions

    • Subsolidnodlues


Establishing a tissue diagnosis
Establishing a Tissue Diagnosis

  • Bronchoscopy vs. CT guided TTNA


Establishing a tissue diagnosis1
Establishing a Tissue Diagnosis

  • Bronchoscopy vs. CT guided TTNA

  • Data based on case series

  • Risks of CT guided TTNA

    • Pneumothorax 15-27%


Conclusions
Conclusions

  • Lung nodules are increasingly common

  • Important to elicit patient preferences

  • Management should include

    • Estimation of cancer risk

  • Nodules ≤ 8mm are infrequently malignant

    • CT scan surveillance is best option in most cases

  • If high likelihood of malignancy and low surgical risk, consider surgical evaluation

  • Emergence of peripheral blood biomarkers



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