Seminar Final SPN

Approach to the Approach to the Solitary Pulmonary NoduleSolitary Pulmonary Nodule

The Solitary Pulmonary NoduleThe Solitary Pulmonary Nodule

• The term “solitary pulmonary nodule” (SPN) describes a well-circumscribed, rounded, smooth edged, dense pulmonary lesion, 3 cm or less in diameter, that is completely surrounded by lung parenchyma

• Is NOT associated with atelectasis , pleural effusion or adenopathy , does not touch the hilum or mediastinum

• “Coin lesion” .The older term “coin lesion” has been replaced by SPN since these lesions are spherical, not flat.

• Lesions > 3 cm called “MASSES” and often malignant

• The term “solitary pulmonary nodule” (SPN) describes a well-circumscribed, rounded, smooth edged, dense pulmonary lesion, 3 cm or less in diameter, that is completely surrounded by lung parenchyma

• Is NOT associated with atelectasis , pleural effusion or adenopathy , does not touch the hilum or mediastinum

• “Coin lesion” .The older term “coin lesion” has been replaced by SPN since these lesions are spherical, not flat.

• Lesions > 3 cm called “MASSES” and often malignant


• Since the SPN by definition is a radiographic finding, radiologic workup is intrinsic to the diagnostic workup

• The initial step in evaluation is to determine whether the abnormality is in fact a solitary pulmonary nodule.

• This assessment is important because up to 20% of suspected nodules prove to be entities mimicking a solitary pulmonary nodule such as rib fractures, skin lesions, or composite areas of increased opacity

• Since the SPN by definition is a radiographic finding, radiologic workup is intrinsic to the diagnostic workup

• The initial step in evaluation is to determine whether the abnormality is in fact a solitary pulmonary nodule.

• This assessment is important because up to 20% of suspected nodules prove to be entities mimicking a solitary pulmonary nodule such as rib fractures, skin lesions, or composite areas of increased opacity


• Incidence of cancer from 10 – 70%• Found on 0.09 to 0.20 % of all CXRs• (approximately 1 in 500)• 150,000 SPNs found annually• 90% Solitary pulmonary nodules are most

often detected incidentally when a chest x-ray is taken for other reasons.

• Increased further with incidental findings on CT

• Incidence of cancer from 10 – 70%• Found on 0.09 to 0.20 % of all CXRs• (approximately 1 in 500)• 150,000 SPNs found annually• 90% Solitary pulmonary nodules are most

often detected incidentally when a chest x-ray is taken for other reasons.

• Increased further with incidental findings on CT

Why is it concerning?

• SPN are concerning for what they could represent

• The absolute #1 concern is if the SPN is the harbinger of a malignancy

• What is more critical is the fact that the earlier you diagnose the malignancy the better the survival rate will be

Why is it concerning• Chest. 1997 Jun;111(6):1486-7

• Patients with stage IA (T1N0M0) disease have the best prognosis.

• These patients have a 61 to 75% 5-year survival following surgical resection

• Radiol Clin North Am 2000; 38:1–9 • Unfortunately almost 50% of patients have

extrathoracic spread by the time of diagnosis• these patients only had a 15% 5 year survival

Why is it concerning?

• With these numbers in mind, it is absolutely critical to give the SPN the attention it deserves

• If not worked up properly it will effectively push patients who do carry a malignancy with in the SPN from the 75% survival into the 15% survival

• That is just unacceptable

• Basic strategy is to identify malignant versus benign

• Nodules prove to be malignant in 40% of cases• Most often Bronchogenic carcinoma (25% )• Most common benign is hamartoma

Solitary Pulmonary Nodule

Solitary pulmonary noduleA solitary nodule is assumed to be

primary lung cancer until proved otherwise . One must consider the relationship of age to the incidence of malignancy .

Age (Yr) Malignancy (%)

35-44 15

45-49 26

50-59 41

60-69 50

70-79 70

Most solitary pulmonary nodules should be resected after through investigations, shows that systemic dissemination has not yet occured . Review of previous chest films may help determine the growth pattern of the nodule . A malignant nodule will usually have a doubling time of 20-500 days .

Early Resection

• Studies have proven that early resection results in 5-year survival rate of 50%

• If nodule is 1cm or less rate is about 80%• Survival rate after discovery of bronchogenic

carcinoma is 15% and hence the importance of early discovery in terms of cure

Differential Diagnosis• Neoplasms

• Malignant – • Metastasis, • Primary Lung Carcinoma• Benign Tumors

• Inflammatory• Granulomas

• TB, • Histo, • Sarcoid, etc.),

• Abscess, • Hydatid Cyst, • Fungus Ball, • Org. Pneumonia, • Bronchiectatic cyst

Differential Diagnosis

• Vascular• Infarct, • Pulm Vein anomaly, • Rheum Nodule, • Wegener’s, • AVM, • Pulm Art Aneurys (behcets disease)

• Developmental• Bronchogenic cyst, • Pulmonary sequestration

• Nipple shadow It is important to note that the majority of

SPN are of a benign etiology

Benign nodules• Hamartoma 8% (popcorn lesion)• Granuloma• Rheumatoid granuloma, • Healed infarct, • Pulmonary anurysm, • Wagener’s granulomatosis• Hemangioma• Schwannoma• Fibroma• Lipoma• Leiomyoma• Teratoma

SO now if we have a patient with an SPN on CXR or CT what to be done?

Postgrad Med 2003;114(2):29-35

• Ask (history, profession, habits, sign, symptoms)• Assess (X-ray, age, size, shape, margins, calcification, position,)• Assign (benign or malignant)• Advice (Follow up)• Arrange (CT, PET)• Attain (Biopsy)• Attempt (Surgical Resection)

Assessing Growth

• There are three categories to place the patient in assessing growth

• No change in two years / or Growth Rate of benign nature

• Indeterminate because of no old studies• Growth Rate of possible malignancy

No change in two years

• Radiologic stability is the best predictor of a benign etiology.

• Since the 1950’s it has been well established that if the SPN has not grown in 2 years it is benign. (JAMA 1958; 166:210–215 )

• If old radiographs show no change in two years, no further work up is needed

Benign vs. Malignant Doubling Time• The time it takes for the apparent volume to

double is referred to as the doubling time• one doubling in volume is equivalent to the

nodule diameter increasing by only 26% to 28%

• Benign nodules representing acute inflammatory changes have a doubling time of less than 20 days

• In contrast, stable granulomas and hamartomas may enlarge slowly and have a doubling time of more than 500 days

Semin Ultrasound CT MR 2000;21(2):97-115

Benign vs. Malignant Doubling Time

• If the SPN has a doubling time of <20 days or >500 days the patient is in the clear and can be followed

• If however the SPN doubling time falls in between 20 and 500 days the SPN must be assumed malignant until proven otherwise and surgical intervention is now recommended.

Postgrad Med 1997;101(3):145-50

Growth of a Nodule

• Malignant nodules grow at a constant rate expressed as doubling time

• This usually falls between 20 and 500 days with a median of 120 days

• An increase of 28% in nodule diameter indicates doubling

• Benign lesions grow slowly with doubling time exceeding 500 days

• It is almost conclusively a benign lesion if size is stable for 2 years ( doubling time exceeding 720 days )

• A doubling time of less than 20 days signifies inflammatory process

Growth of a Nodule

Growth Rate:Doubling Time

• Volume = 4/3 r 3

• 28% increase in diameter results in doubling of volume

• Non-malignant disease: less than 20 days or greater than 500 days

• Malignant lesions: 20 to 500 days Av.120

Malignant Doubling Time• With the numbers crunch, biopsy in this

case is not worth the risks because a malignant diagnosis would not change resection therapy

• So in this case, surgical resection is highly recommended

• If the patient is reluctant or the risk of surgery is really high and if diagnosis is likely to be sure of before going to the OR, then biopsy can be undertaken.

Benign vs Malignant

• Age <40• nodule diameter<1.5• never smoked• nodule edge type1• doubling time >500 d• calcification in benign• Needle Bx: benign dis

• Needle Bx: Nonspecific

• >40• >1.5• ever smoked• type3• 20 to 500 days• indeterminate pattern• malignant disease• suspicious cells

High Resolution CT

• HRCT is the most sensitive and specific for assessing the size, shape, calcification and edge of a nodule

• Type 1 Type 2 Type 3 Type 4

Likelihood of cancer with the appearance of a nodule's edge

• Type 1 nodules :smooth, regular edge….20%. • Type 2 nodules: smooth, irregular edge…. 33%. • Type 3 nodules: spiculated edge…. 83%. • Type 4 nodules: fuzzy, multispiculated edge or

corona radiata…. 93%

Factors Influencing Probability of Malignancy

• Size• Growth rate• Number• Density

• Patient age• Gender• Smoking history• Occupational history

LUNG NODULEMALIGNANT FEATURES

• New or growing lesion• Spiculated margin• Large size (>3cm)

Spiculated nodule

MALIGNANT

Irregular contour

MALIGNANT

Spiculated margin

Bronchus leads to it

MALIGNANT

LUNG NODULEDEFINITE BENIGN

CHARACTERISTICS

• Absence of growth for 2 years• Definite benign calcifications• Extensive calcification• Smooth margins• Small size (< 3 cm)

Very white (like bone)

BENIGN

Smooth margin

BENIGN

BENIGN

BENIGN

Note the smooth contour

BENIGN

Homogeneous white= benign calcification

BENIGN GRANULOMA

Very subtle nodule

There it is

SMOOTH BENIGN

Postgrad Med 2003;114(2):29-35

Indeterminate Growth Rate

• This is where the real dilemma is created and every radiological and clinical clue must be taken into consideration to make a decision.

• First step is to look at all patterns of the SPN and determine if a “typically benign or malignant pattern can be found”

Calcification

• Radiographic pattern of calcium deposition is helpful

• Benign lesions tend to have central, laminated (bull’s eye), diffuse or popcorn pattern

• Malignant lesions have speckled or eccentric pattern

TYPES OF CALCIFICATION

• BENIGN• Central = granuloma• Nodule completely calcified = granuloma• Popcorn = hamartoma• Target = granuloma

• MALIGNANT• Spicculated or punctate = malignant• Eccentric = malignant

Benign Calcifications

Popcorn calcification=hamartoma

BENIGN

Hamartoma

• Regarded as benign developemental deformity• 1-3cms lesion containing cartilage, epithelium,

fibro-fatty tissue • Single, may be multiple • Slow growing• Ussually periphral • Central calcification • males

Popcorn CalcificationPopcorn Calcification

• Classic “popcorn” pattern often seen in hamartomas

• HRCT can show fat and cartilage in half of cases

• Classic “popcorn” pattern often seen in hamartomas

• HRCT can show fat and cartilage in half of cases

HAMARTOMA

HamartomaHamartoma

Fat

• Fat on CT • benign

hamartoma can be diagnosed with confidence

Benign Calcification:Popcorn Calcification

Popcorn Calcification

• Popcorn calcification or Chondroid Calcification

• Pattern typical of hamartomas

Granulomas

• About 40% of all SPNs are granulomas—small, granular inflammatory lesions.

• The word "granuloma" comes from the Latin word "granum," meaning "grain" or "seed."

• Granulomas are characterized by a nodular appearance and a unique cellular pattern that can be seen through a microscope.

Benign Calcification: Central Calcification

CalcificationCalcification

• Laminated or central pattern

• Typical of granuloma

• Laminated or central pattern

• Typical of granuloma

Histoplasmoma• Tend to B\L multiple with LN• Rarely slowly progressive apical or post.

pulm.nodule• Usually in presence of pre exist. lung ds. B’ectatic

or emphysema • Calcified centre smtime with calcified laminae• Prevalent in USA,also in many other tropical parts • Self limiting in 2-3 wks• Remnant calcified granuloma in lung .

Histoplasmoma

a

Solid or Central Calcification

• A solid calcified SPN is found in association with prior granulomatous infection, most commonly histoplasmosis or tuberculosis

Histoplasmoma

Hydatid cyst • Echinococcus infection• Human accidental intermediate host• Slow steadily growing• Spherical lession with well defined edges or

uniform density• Ussually multiple and bilateral • May rupture to give salty expectoration• Thus cyst with level,… later calcified walls• Casoni test ,latex agglutination ,complement

fixation test diagnostic

Hydatid cyst in lung.

This patient had a

single large cyst in the

left lung.

Rheumatoid nodules • A \ w arthritis , fibrosis • > Men, middle age,• RA factor may be positive • May have chylous pleural effussion, • Single or multiple nodules With or without

cavitation • Ussually 1-3 cms may be upto 10 cms ,• Subpleural commonly • Nodule in coalminers “Caplan Syndrome”

Arteriovenous malformation

Other benign tumors

• fibromas (fibrous connective tissue), • lipomas (fat), • leiomyomas (smooth muscle), • hemangiomas (dilated blood vessels), • papillomas (epithelial cells).

Speckled or Punctate Calcification

• Speckled or Punctate calcifications

• Represent malignant calcification and

• Should not be taken as benign

Eccentric Calcification

• Eccentric Calcification

• a sign of malignant potential

CalcificationCalcification

• Suggests benign diagnosis• With CT the reference standard,

• CXR has sensitivity 50%, • specificity 87%, and • PPV 93% for identifying calcification

• Suggests benign diagnosis• With CT the reference standard,

• CXR has sensitivity 50%, • specificity 87%, and • PPV 93% for identifying calcification

Postgrad Med 2003;114(2):29-35

Radiological Findings

• If you have definitive findings suggestive of benign pattern than no further work up is needed.

• If still no answer after SCTIE or other radiologic finding further work up is needed

Size • Size of the SPN can also help out at this point to

help make a decision• In general, smaller nodules are more likely to be

benign and larger lesions malignant • 80% of benign SPNs are less than 2 cm in

diameter• However, small size is not necessarily reliable

evidence of benignity because 15% of malignant nodules are less than 1 cm in diameter approximately 42% are less than 2 cm in diameter

Radiographics 20:43, 2000

Size of SPN

• Most SPN are less than 2 cm in diameter• Malignant nodules

• 40% less than 2 cm • 15% less than 1 cm • 1% less than 7 mm• 0% less than 5 mm

Margins

• Smooth, well-defined margins most often indicate a benign nodule

• However 21% of malignant nodules have a smooth well-defined margin

• a lobulated margin may reflect uneven growth of a SPN and can indicate malignancy

• although 25% of benign nodules, particularly hamartomas, are lobulated

Radiology 179:469, 1991

Patterns of MarginsPatterns of Margins

• Corona radiata sign• Fine linear strands

extending 4-5 mm outward

• Spiculated on CXRs• 84 – 90% are malignant

• Corona radiata sign• Fine linear strands

extending 4-5 mm outward

• Spiculated on CXRs• 84 – 90% are malignant



Spiculated lipoid pneumonia

Spiculated lipoid pneumonia


• Scalloped border• Intermediate probability

of cancer• Smooth border suggestive

of benign diagnosis

• Scalloped border• Intermediate probability

of cancer• Smooth border suggestive

of benign diagnosis

Other CharacteristicsOther Characteristics

• Air bronchograms and pseudocavitation more commonly malignant

• Cavitation with thick (>15 mm vs < 5 mm) more often maligant

• Air bronchograms and pseudocavitation more commonly malignant

• Cavitation with thick (>15 mm vs < 5 mm) more often maligant

Air BronchogramsAir Bronchograms

Cavitation

• Although cavitation can occur in necrotic malignant SPNs, inflammatory lesions can also cavitate.

• The thickness of the cavity wall can be helpful in distinguishing benign from malignant lesions.

• Cavities with a greatest wall thickness less than 5 mm are almost always benign

• whereas most of those with a maximal wall thickness greater than 15 mm are malignant

Cavitation

Thick walled cavity which came back as squamous cell carcinoma.

RADIOGRAPHIC PRESENTATIONS OF LUNG

CANCER

• Mass or nodule• Atelectasis (lung collapse)• Non-resolving pneumonia• Mediastinal lymph node enlargement

ADENOCARCINOMA

• Peripheral• Spiculated• < 4 cm• Uncommon Hilar and mediastinal lymph

node enlargement Early metastases to brain, adrenals, liver, bone

• Can arise from an existing scar - scar carcinoma

ADENOCARCINOMA

Peripheral

ADENOCARCINOMA

Small

ADENOCARCINOMA

SQUAMOUS CELL CARCINOMA

• Central endobronchial• post obstructive pneumonia• atelectasis


Central hilarCalcified

granuloma

Central hilarmass

Ascending aorta

SVCMain pulmonaryartery

Descending aorta



• Apical - Pancoast or superior sulcus tumour

PANCOAST TUMOUR

Destroyed 3rd rib

Destroyed 3rd rib

Mass

PANCOAST TUMOUR


• Slow growing (1 - 10 cm)• Cavitation (10 - 20%)

• DDx - lung abscess

• Late metastases

Central cavity


DDX - Lung abscess

SMALL CELL LUNG CANCER

• Central > peripheral• Massive hilar and mediastinal adenopathy• Early distant spread

SMALL CELL CARCINOMA

Large mass

Large mediastinalnodes



LARGE CELL CARCINOMA

• Large peripheral mass ~ 7 cm• Rapid growth• Early distant spread



Large peripheral mass


Largeperipheral mass


Large peripheralmass

LARGE CELLCARCINOMA

BRONCHIOLOALVEOLAR CARCINOMA

• Peripheral nodule• Non-resolving focal “pneumonia”• Diffuse bilateral “pneumonia”

• hilar and mediastinal nodal enlargement uncommon• distant spread uncommon

Looks like pneumoniabut …….

BRONCHIOLOALVEOALR CELL CARCINOMA

Air bronchogram

BRONCHIOLOALVEOLAR CARCINOMA

Airbronchogram

Multifocal

BRONCHIOLOALCEOLAR CELL CARCINOMA

Air space disease

BAC

No Specific Pattern Found

• With no specific finding, all risk factors must be taken into account.

• Trying to milk the SPN for as much information it can be

• It may help stratify the risk in the patient

Indeterminate SPN

• After milking the SPN for all its characteristics it is now important to milk the patient for all relevant information

• Key points include: • smoking history; • symptoms; • comorbid conditions (particularly severe emphysema); • history and type of prior malignancy; • prior infections and environmental exposures.

Work-up of SPN: CXR

• No change in two years - no further evaluation• Characteristic calcifications of benign disease• Lateral films for “hidden” lesions• Initial CXR then serial CT Scans

Decision Making

Postgrad Med 2003;114(2):29-35

N Engl J Med 348:2535-2542

Clinical Decision

• Now after evaluating the entire clinical picture and clinically identifiable risks its time to determine where they fall into Low, Moderate or High risk

• Pretest probability of cancer determines most cost-effective strategy

• Low : radiographic follow-up• Intermediate : CT and PET• High : CT followed by biopsy or surgery• Very high : surgery*

Low risk indeterminate SPN

• 30 year old male, never smoked, • nodule is <1cm with no previous studies, • no environmental exposure, • Review all prior CXR• No specific pattern found• Get CT scans• found on CT not seen on CXR

• If probability of cancer is <10% wait and watch• Can follow for two years

Moderate Risk

• Now we have a patient who isnt clearly low risk. • Maybe older age, • questionable smoke or environmental history but

not quite screaming high risk, what to do?• If it is high thoracotomy should intervene• Bronch & NAB reserved for pt who are reluctant

to go for surgery before Dx• PET SCAN is now recommended

• PET is slightly more effective,noninvasive• If PET is +ve but other criteria are low for

malignancy, then ANB is needed to R/O infectious granulomas

CT Scan

• CT can help distinguish a solitary pulmonary lesion from multiple pulmonary nodules

• CT Scan with contrast to evaluate mediastinum• Serial scans at 3, 6, 12, and 24 months• Can consider trial of antibiotics prior to repeat scan in 6

weeks• Newer CT techniques

• Volumetric analysis • Multi-slice scanner

Contrast-Enhanced CTContrast-Enhanced CT

• Degree on enhancement on spiral CT after injection of contrast

• One study used an increase in attenuation of 20 Hounsfield units as threshold for malignant lesions

• Sensitivity 95-100%, • specificity 70-93%*• Local expertise varies

• Degree on enhancement on spiral CT after injection of contrast

• One study used an increase in attenuation of 20 Hounsfield units as threshold for malignant lesions

• Sensitivity 95-100%, • specificity 70-93%*• Local expertise varies

*Zhang, Radiology 1997;205:471-8*Zhang, Radiology 1997;205:471-8

Spiral CT with IV contrast Enhancement (SCTIE)

• Computed tomography (CT) (particularly thin-section CT) is 10–20 times more sensitive than standard radiography and allows objective, quantitative assessment of calcification

• SCTIE the imaging modality of choice for the SPN and should be obtained on all newly diagnosed SPNs

• A number of benign etiologies for SPNs have a characteristic appearance on CT

CT DensitometryCT Densitometry

• Involves measurement of attenuation values• Expressed in Hounsfield units, as compared to

reference “phantom”• Usually higher for benign nodules• Allows for identification of 35 – 55% of

subsequently identified benign lesions

• Involves measurement of attenuation values• Expressed in Hounsfield units, as compared to

reference “phantom”• Usually higher for benign nodules• Allows for identification of 35 – 55% of

subsequently identified benign lesions

CT DensitometryCT Densitometry

• One large, multicenter trial, only 1 of 66 nodules identified as benign later found to be malignant*

• Cutoff used was 264 Hounsfield units• More conventional cutoff is 185, which yielded a

higher false negative rate

• One large, multicenter trial, only 1 of 66 nodules identified as benign later found to be malignant*

• Cutoff used was 264 Hounsfield units• More conventional cutoff is 185, which yielded a

higher false negative rate

*Zerhouni, Radiology 1986;160:319-27*Zerhouni, Radiology 1986;160:319-27

Lung cancer screening

New CT techniques detect suspicious nodules 3x

more than CXR, malignant tumors 4x and stage 1

tumors 6x

Henschke et al: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999;354:99-105

PET Scan

• Highly valuable noninvasive tool

PET SCAN

• Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) has proven to be an excellent mode of tumor imaging

• 18-FDG (fluorodeoxyglucose)• increased uptake by metabolically active cells • does not enter glycolysis

PET SCAN

• Increased activity is demonstrated in cells with high metabolic rates, as is seen in tumors and areas of inflammation

• Taken up by cells in glycolysis but is bound within cells and cannot enter normal glycolytic pathway

• It can also tell us about if any metastatic disease is present thus altering treatment

Limitations Positron Emission Tomography


• However the spatial resolution of PET is currently 7 to 8 mm, and so the imaging of SPNs < 1 cm is unreliable

• False negatives in tumors with low uptake such as bronchoalveolar cell carcinoma It is 95% sensitive for identifying malignancy and 85% specific

• However the spatial resolution of PET is currently 7 to 8 mm, and so the imaging of SPNs < 1 cm is unreliable

• False negatives in tumors with low uptake such as bronchoalveolar cell carcinoma It is 95% sensitive for identifying malignancy and 85% specific



• False positive results may occur in lesions that contain active infection or inflammatory tissue (histoplasmomas)

• High post test likelihood of malignancy (14%) in high risk patients with negative PET

• False positive results may occur in lesions that contain active infection or inflammatory tissue (histoplasmomas)

• High post test likelihood of malignancy (14%) in high risk patients with negative PET

Thoracic PET Scan: Potential Sources of Error

• False Positive Results:

Metabolically active infectious or inflammatory lesions:

Sarcoidosis. Rheumatoid nodules. TB. Fungal granuloma. Others.

• False Negative Results:

Tumors with low metabolic activities:

Bronchoalveolar CA. Carcinoid tumors. Mets: renal cell and testis.

Small tumors-<1cm.

Hyperglycemia-keep sugars below 150mg%.

PET Scan

• Allows more accurate identification of tumors, lymph nodes, and metastatic disease

• May provide staging information• Up to 14% of patients otherwise eligible for

surgery have occult extra thoracic disease on whole-body PET

• Benign disease Malignant disease • 96% sensitivity 96% sensitivity • 88% specificity 77% specificity

Pet Scan• Gould et al performed a meta-analysis of

the literature on pulmonary nodules and masses and PET scanning and found an overall sensitivity of 96.8% and specificity of 77.8% for detecting malignancy.

• PET scans also have a 96% sensitivity and 88% specificity with 94% accuracy in the diagnosis of benign nodules

JAMA 2001; 285:914–924

Utilization of PET Scans

• Negative PET in high risk patients still need tissue diagnosis…so why get it?

• PET not usually indicated unless it will change management

• So depending on the PET Scan result we can base our treatment

• If PET is positive than we can refer the patient to CT Surgery for resection options

• If PET is negative than can follow

Positron Emission TomographyPositron Emission Tomography

• CT combined with PET for staging was often superior to conventional approaches

• Reduced number of surgeries by 15%• Cost savings per patient

• CT combined with PET for staging was often superior to conventional approaches

• Reduced number of surgeries by 15%• Cost savings per patient

*Gambhir, J Clin Oncol 1998;16:2113-25*Gambhir, J Clin Oncol 1998;16:2113-25

Positron Emission TomographyPositron Emission Tomography

• More expensive than other imaging modalities• More expensive than other imaging modalities

*http://cms.hhs.gov, Dec 2002*http://cms.hhs.gov, Dec 2002

PET ImagesPET Images

Pieterman, NEJM 2000;343:254-61


PET ImagesPET Images



Integrated PET and CTIntegrated PET and CT

Lardinos, NEJM 2003;348:2500-7


Integrated PET and CTIntegrated PET and CT



Sample Pre-biopsy AlgorithmCHEST 2004; 125:1522-1529

Biopsy

• Bronchoscopic biopsy• CT guided

• Transthoracic needle aspiration (TTNA) Transthorathic needle aspiration (TTNAB) has a sensitivity of 80% to 90%

• Fine needle aspiration (FNA)• Surgical

• Video Assisted Thoracic Surgery (VATS) • Open

BRONCHOSCOPY

Bronchoscopy

• Limited role• Transbronchial needle aspiration of mediastinal lymph

nodes • Useful for large central lesions and endobronchial lesions• Can detect infection• No use in peripheral nodules

BronchoscopyBronchoscopy

• Useful for lesions at least 2 cm• Useful for lesions at least 2 cm

INDICATION FOR BRONCHOSCOPIC BIOPSY

• Central lesion ie. Near hilum


• Diagnostic yield varies in literature from 20 – 80%, depending on size of nodule and patient population

• Yield depends on nodule size and proximity to bronchial tree

• Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm

• 70% yield when CT reveals a bronchus leading to lesion

• Diagnostic yield varies in literature from 20 – 80%, depending on size of nodule and patient population

• Yield depends on nodule size and proximity to bronchial tree

• Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm

• 70% yield when CT reveals a bronchus leading to lesion


• Relatively low risk• Overall complication rate 5%• 3% risk of pneumothorax• 1% risk of hemorrhage• 0.24% risk of death

• Relatively low risk• Overall complication rate 5%• 3% risk of pneumothorax• 1% risk of hemorrhage• 0.24% risk of death

INDICATIONS FOR FNAB

• Peripheral lesion• Central lesion without significant distal collapse

DIAGNOSTIC YIELD OF FNAB

• 90 - 97%

FNAB TECHNIQUE

• Out-patient procedure• 22G needle• Image guidance

• fluoroscopy• computed tomography• ultrasound

Transthoracic FNA (TTFNA)Transthoracic FNA (TTFNA)

• Diagnostic yield up to 95% in peripheral lesions• Higher complication rate• Pneumothorax (10 - 30%)• Hemoptysis (30%)• About 5% of these require chest tube

• Diagnostic yield up to 95% in peripheral lesions• Higher complication rate• Pneumothorax (10 - 30%)• Hemoptysis (30%)• About 5% of these require chest tube

What are the limitations of Needle Biopsy of Lung Nodules?

• In a small number of cases, the tissue obtained during a biopsy may not be adequate for diagnosis.

• Needle biopsy is not cost-effective for small lesions one to two millimeters in diameter.

• The needle is too difficult to position into the nodule and the nodule is too small to provide enough tissue for an accurate diagnosis.

What are the limitations of Needle Biopsy of Lung Nodules?

• For patients with certain conditions a needle biopsy may not be recommended. • emphysema, • lung cysts, • blood coagulation disorder of any type, • insufficient blood oxygenation, • pulmonary hypertension, and • certain heart failure conditions,

• Alternatives to lung biopsy usually include continued follow-up with imaging and surgical removal of the abnormality.

CT-guided fine-needle aspiration biopsy

• The use of CT-guided fine-needle aspiration biopsy in solitary pulmonary nodules has been condemned historically as often being an unnecessary step in the workup of these patients.

Sample Post-biopsy AlgorithmCHEST 2004; 125:1522-1529

Thracoscpic Resctn of Lung Nodules

Lung cancer: Surgical options

• VATS• Segmentectomy• Lobectomy• Sleeve resection• Pneumonectomy

Surgery

• Thoracotomy to resect a malignant nodule carries significant death of 3% to 4% but for a benign lesion it is 0.3%

• Thoracoscopy carries less significant morbidity and lessens hospital stay

• It is not known if the 5-years survival is different between the two approaches

High Risk Patient

• 68 year old male, • 100 pack years of smoking, • Used to work with asbestos, and • Coughing up blood• RIGHT TO THE OR for resection.

Conclusion

• The main point is to make sure you give the SPN the respect it deserves.

• With timely diagnosis we can effectively prevent morbidity and mortality for our patients

• There is just no excuse for a patient to die because we did not work up the patient in a timely fashion.

Medicolegal Aspects

• Physicians should discuss the possibility of lung cancer presenting as a SPN in those patients who have lesions that cannot be confirmed to be benign based on their presence on old films with over 2 years of stability, or classic calcification typical of a benign lesion.

• Patients should play an active role in the decision to remove, evaluate with invasive procedures, or observe their SPN.

Medicolegal Aspects

• The pros and cons of pulmonary resection should be discussed and a recommendation made.

• This should be carefully documented in the patient record, and if observation is chosen, advice for follow up given.

• Then, it is important for the physician to insure that follow up actually occurs.

Postgrad Med 2003;114(2):29-35

Postgrad Med 2003;114(2):29-35

Postgrad Med 2003;114(2):29-35

Postgrad Med 2003;114(2):29-35

PrimaryTumor (T)

Description

T1A small tumor that is not locally advanced or invasiveCriteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the main bronchus

T2A larger tumor that is minimally advanced or invasiveCriteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but remains >2 cm from the main carina; may cause segmental or lobar atelectasis

T3

Any size tumor that is locally advanced or invasive up to but not including themajor intrathoracic structuresCriteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium; main bronchus within 2 cm of the main carina (not involving the main carina); may cause atelectasis of the entire lung

T4Any size tumor that is advanced or invasive into the major intrathoracic structuresCriteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, main carina; malignant pericardial or pleural effusion; presence of satellite tumor nodule(s) within the primary tumor lobe

RegionalLymph Node

Involvement (N)Description

N1Metastatic disease to nodes within the ipsilateral lungCriteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar nodes (nodal stations 10 through 14)

N2

Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to theprimary tumorCriteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes (nodal stations 1 through 9)

N3Metastatic disease to nodes distant to those included in N2Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral scalene and/or supraclavicular nodes

Metastases (M) Description

MO Local or regional disease, no distant metastases

M1 Disseminated disease, distant metastases present

Date post:	12-Jun-2015
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Seminar Final SPN

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