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Screen discovered nodules: What next ?

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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  1. 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

  2. Disclosures • Research Funding • NIH, DOD • Integrated Diagnostics, Allegro Diagnostics, • Scientific Advisory Board • Allegro Diagnostics

  3. Nodule, Biopsy and Benign Disease Rates 5 RCT 4 3 Percent of patients in screened arm 2 1 0

  4. Ost & Gould, AJRCCM 2011

  5. Assessing the Probability of Cancer • Most Important Factors to consider: • Nodule size and characteristics • Smoking history • Age • Family history of lung cancer • Emphysema

  6. http://www.brocku.ca/lung-cancer-risk-calculator

  7. http://www.brocku.ca/lung-cancer-risk-calculator

  8. Importance of Nodule Size NLST Investigators. NEJM 2013

  9. Guidelines

  10. Fleischner Society Guidelines McMahon, et al. Radiology 2005; 237:395-400

  11. Recommendations for Subsolid Nodules

  12. Thick vs. Thin Sections for Small Nodules Naidich D P et al. Radiology 2013;266:304-317

  13. Recommendations for Subsolid Nodules

  14. 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

  15. Serial Imaging to Assess Growth (1mm cuts) Naidich D P et al. Radiology 2013;266:304-317

  16. Rapid Enlargement of a GGO Naidich D P et al. Radiology 2013;266:304-317

  17. Recommendations for Subsolid Nodules

  18. Rationale • Part solid nodules have a high likelihood of malignancy • Development of a solid component within a pure GGO

  19. Recommendations for Subsolid Nodules

  20. Multiple subsolid lesions with single dominant focus. Naidich D P et al. Radiology 2013;266:304-317

  21. PET Scans Erasmus, et al. Clinics in Chest Medicine 2008

  22. PET Scans • Sensitivity ~ 85% • Specificity ~ 80% • Less accurate for: • Smaller lesions • Subsolidnodlues

  23. Establishing a Tissue Diagnosis • Bronchoscopy vs. CT guided TTNA

  24. Establishing a Tissue Diagnosis • Bronchoscopy vs. CT guided TTNA • Data based on case series • Risks of CT guided TTNA • Pneumothorax 15-27%

  25. 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

  26. THANK YOU

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