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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
The Lung Nodule

Rohit Kumar, MD

Assistant Professor of Medicine

Thomas Jefferson University

outline
Outline
  • Definition
  • Risks of malignancy
  • Approach to diagnosis
  • Current guidelines for follow up
  • Cases
definition
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
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
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

slide6
PLCO

CXR

Smoker +

Non-smoker

Age 55-74

Randomize

150,000

No Screen

Year 0 1 2 3 ………… 20

national lung screening trial
National Lung Screening Trial

CT

30 pack years

Age 55-74

Randomize

52,000

CXR

Year 0 1 2 3 4 5 6 7

nlst study population
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

nlst results
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

epidemiology
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
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

ddx malignant nodules
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

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

nodule growth rate
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
Nodule Morphology
  • Opacification of underlying parenchyma
    • Solid Ground Glass
  • Borders
  • Calcification
  • Fat - benign
  • Cavitation
  • Air bronchograms
  • Location in the Upper Lobes

malignant

borders
Borders

Spiculated Scalloped Smooth

Corona radiata sign

80-90% of spiculated nodules are malignant !

calcification
Calcification

Malignant

Benign

Popcorn

Central/ Laminated

Eccentric/ Stippled

the sub solid nodule
The Sub Solid Nodule

Atypical Adenomatous

Hyperplasia

BAC

Adenocarcinoma

patient factors
Patient Factors
  • Age
  • Smoking
  • Various prediction models:
    • Family history of lung cancer
    • Pneumonia
    • Occupational exposure
slide21

Risks of Malignancy

___________________________________

spn chance of malignancy
SPN-chance of malignancy

Cummings, ARRD 1986;134:453 & Toomes, Cancer 1983;51:534

slide23

Factors Affecting Malignant Probability of SPN

Likelihood Ratio

Gurney JW. Radiology, 1993.

risk factors
Risk Factors

Ost et al, NEJM: June 2003

slide25

Management

___________________________________

key notes
Key Notes
  • Compare OLD films
  • Compare OLD films
  • Compare OLD films
  • Assess patient risk
  • Assess operability
spn management strategy
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.

this does not apply to
This does not apply to…..
  • Patients with known or suspected malignant/ metastatic disease.
  • Patients < 35 yrs – unless other cancer.
  • Patients with unknown fever.
following subsolid nodules
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.
following subsolid nodules1
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
answer
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
65 year-old smoker; 2 cm nodule

Peripheral or central?

Approach?

answers
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
42 year-old smoker from Ohio

Differential Diagnosis?

What next?

answer1
Answer:

Blastomycosis

42 year old smoker with weight loss
42 year old smoker with weight loss

Differential Diagnosis?

Next Step?

ct scan
CT scan
  • What next?
answer2
Answer

PET scan

Surgical Candidate?

VATS vs. TTNA

Diagnosis: Lymphoma

cases
Cases

66 yr male smoker with FEV1 0.7L

cases1
Cases

57 yr asthmatic female from Puerto Rico with cough

slide48

ELCAP

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