SPNs and the SPNs and the Early Detection of Lung CancerEarly Detection of Lung CancerGeorge Erbacher D.O., FAOCRGeorge Erbacher D.O., FAOCR
Chair imaging/interventional radiology Chair imaging/interventional radiology OSUMCOSUMC
Radiology residency program directorRadiology residency program director
DEFINITION OF SOLITARY DEFINITION OF SOLITARY PULMONARY NODULE (SPN)PULMONARY NODULE (SPN)
Single round water density mass < 3 cmCompletely surrounded by lung
parenchymaIncidental finding 0.2% CXRs, 1% CT
MIMICS OF SPNMIMICS OF SPN
Chest wall lesionHealing rib fracture AVNAbscessPneumoniaImmune-RA/Wegeners granulomatosis etc.
MIMICS OF SPNMIMICS OF SPN
HematomaLung infarct/atelecatasisPleural plaqueBronchial atresia/SequestrationInhaled FBMOST COMMON: BENIGN
GRANULOMA/HAMARTOMA
PATIENT FEATURES PATIENT FEATURES INCREASING RISK OF INCREASING RISK OF
MALIGNANCYMALIGNANCY
SMOKING ESPECIALLY >20 PK/YEAROlder agePersonal history of malignancyFirst degree relative with lung cancerAsbestos/uranium/radon exposureOther workplace exposure- some aromatic
hydrocarbons, coal mines etc.
IMAGING FEATURES BENIGN IMAGING FEATURES BENIGN VS. MALIGNANTVS. MALIGNANT
Smaller less risk of malignancyWell defined borders tend to be benignIf a cavity –thin walls-favor benignPopcorn like calcification –benign –
characteristic of hamartomaDensity (HU) < 15-20 benignVery fast and very slow growing lesions are
likely benign-PREVIOUS COMPARISON IMAGES ARE CRITICAL
Epidemiology Lung Cancer in Epidemiology Lung Cancer in the Worldthe World
Most frequently diagnosed cancer (1.04M in 1990)
Leading cause of cancer mortality – 921K deaths
Most common cancer in males and #1 cause of cancer death
Incidence Lung Cancer in U.S.Incidence Lung Cancer in U.S.
171,600 cases diagnosed in 1999 (94K M; 77.6K F)
Leading cause of cancer death M & F (158.9K)
Kentucky highest mortality rate – 67.9/100K (37% above avg.)
Utah lowest mortality rate– 21.6/100K (56.4% below avg.)
U.S. Lung CancerU.S. Lung Cancer
1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with
brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
“Lung cancer is the leading cause of cancer mortality in the U.S. among both men and
women surpassing totals from breast, colon, and ovarian cancers
combined.” [1]
SurvivalSurvival
5 years – 14%
50% survive if diagnosed in early stage (small size IA 85 – 100% survival
Only 15% diagnosed in early stage
Tobacco SmokeTobacco Smoke
“Cigarette smoking is causally related to lung cancer…the magnitude of the effect far outweighs all other factors.”
Is leading cause of avoidable mortality in US, w/ about 434K preventable deaths per year
Cost to US economy $200 billion/year
US surgeon general
CXR Screening RevisitedCXR Screening Revisited
Analysis of the 4 RCT from 20 years ago (Mayo, Czech, Sloan-Kettering, Johns-Hopkins)
Czech & Mayo studies found increase in mortality in screened vs. controls (6% increase in Mayo) however 29% MORE lung cancer in screening vs. controls
CXR Screening RevisitedCXR Screening Revisited
Screened had 34% living @ 5yrs vs. 15% control (Sloan-Kettering, Johns-Hopkins similar results)
“Analysis of the randomized trials strongly suggests CXR screening is superior to no screening whatsoever”
Low Dose CT (LD CT)Low Dose CT (LD CT)Screening vs. CXRScreening vs. CXR
Rationale:LD CT greatly increases detection of small non-calcified nodules and of lung cancer at an earlier/more curable stage
LD CT showed non-calcified nodules 3x more commonly
LD CT showed malig. tumors 4x more commonly LD CT showed stage 1 tumors 6x more commonly
LD CT Indication (ELCAP)LD CT Indication (ELCAP)
> 60 y.o.a.
> 10 pk/y smoker & no previous cancer
Medically fit to undergo thoracic surgery
Baseline LD CT, then annuals
ELCAP Technique – Helical CTELCAP Technique – Helical CT
140 kVp, 40 mA2:1 Pitch, 10 mm slice thicknessScan entire lung in 1 breath hold @ end
inspiration after hyperventilationReconstruct images with bone algorithm in
overlapping 5 mm incrementsOnly lung windows (W1500, L-650)
reviewed
ELCAP ScoringELCAP Scoring
1-6 non-calcified nodules = positive
If no non-calcified nodules = negative
> 6 non-calcified nodules, diffuse bronchiectasis, ground glass opacities or combinations = diffuse disease
ELCAP Nodule DescriptionELCAP Nodule Description
Size (L & W/2)Location (lobe & distance from pleura)
peripheral if w/in 2 cm costal marginBenign calcificationsShape (round, non-round)Edge (smooth, non-smooth)
ELCAP “Benign Nodule”ELCAP “Benign Nodule”
Benign calcifications
Smooth edges
< 20 mm size
Guideline for Diagnostic Guideline for Diagnostic Intervention ELCAPIntervention ELCAP
Non-benign nodule on LD CT goes to diagnostic CT w/ high resolution imaging of abnormalities. If not benign per above criteria:– < 5mm : F/U high res CT 3 mo, 6 mo, 12 mo,
24 mo; no growth over 3 yrs=benign– 6-10 mm : bx, if not possible F/U per above– > 11mm : bx
Fleishner Recommendations do Fleishner Recommendations do NOT apply to patients:NOT apply to patients:
<35 Y.O.A. with low risk of lung cancerWho have fever/signs of infection
Fleishner Nodule CT Fleishner Nodule CT Reassessment Reassessment
RecommendationsRecommendations
NONCONTRASTTHIN COLLIMATIONLIMITED COVERAGE-JUST REGION
OF INTERESTLOW DOSE
Nodule Enhancement and Nodule Enhancement and metabolismmetabolism
Cancer/Infection/inflammation- CT neovascularity- malignant nodules enhance > 20
Hounsfield Units (HU), benign < 15 HU
Cancer/Infection/inflammation- increased glucose turnover- PET- SUVmax < 2.5 benign
PET/CT HAS SENSITIVITY AND SPECIFICITY CLOSE TO 90% FOR NODULES 10 MM OR GREATER DIAMETER
PET/CT vs. Helical dynamic CT PET/CT vs. Helical dynamic CT for SPNfor SPN
PET/CT
MORE SENSITIVE (96% vs. 81%) and MORE ACCURATE (93% vs. 85%) than helical dynamic CT
Caveats for PET/CT:Caveats for PET/CT:NO STANDARIZATION FROM NO STANDARIZATION FROM ONE MACHINE TO ANOTHER ONE MACHINE TO ANOTHER
AND POOR AND POOR STANDARDIZATION OFTEN STANDARDIZATION OFTEN
BETWEEN EXAMINATIONS ON BETWEEN EXAMINATIONS ON THE SAME MACHINE.THE SAME MACHINE.
EXPERIENCE OF EXPERIENCE OF TECHNOLOGISTS-TECHNOLOGISTS-
RADIOLOGISTS VARIES RADIOLOGISTS VARIES WIDELYWIDELY
BenignBenign? NM in Lung Cancer? NM in Lung Cancer
Role of PET in Lung CancerRole of PET in Lung Cancer
Improves staging by ruling out mediastinal/distant disease
Useful in evaluating response to therapyUseful in early detection recurrent disease
Rad Clinics N.A. May 2000 p. 523
False Positive and Caveats False Positive and Caveats PET/CTPET/CT
Active necrotizing granulomas and some chronic inflammatory conditions are +
ANY PROCESS THAT HAS INCREASED UPTAKE OF GLUCOSE IS PET POSITIVE
What to do with Indeterminant What to do with Indeterminant CT W/U of SPNCT W/U of SPN
Serial radiographic F/U?
CT alone to decide to surgerize or not?
PET/CT
Surgery for pts w/ + or indeterminant CT?
Cost EffectivenessCost Effectiveness
Radiographic F/U cost effective when probability of malignancy is low (<0.14)
CT alone F/U cost effective when probability of malignancy is high (.71 - .91)
Surgery alone is most cost effective when probability of malignancy is very high > .90
Over greatest range of probability .14 - .71 CT and PET/CT cost effective
Rad Clinics N.A. May 2000 p. 521-522
PRINCIPLES OF IMAGING IN PRINCIPLES OF IMAGING IN ONCOLOGYONCOLOGY
Imaging justified only if results will change therapy with patient benefit
“Where there is an issue get tissue”-biopsy when imaging is inconclusive (imaging guided?)
Positive studies are more valuable/reliable than negative studies
The diagnostic plan should progress logically from least to most invasive studies
Accurate assessment of initial disease extent is vital to selecting and sequencing appropriate treatment
Staging lung cancerStaging lung cancer
Stage 1A-T1N0MO= tumor < 3cm with no positive nodes and no metastasis
Stage 1B-T2N0M0- tumor > 3cm, no nodes, no metastasis
RFA in Pulmonary ApplicationsRFA in Pulmonary Applications
LungLung
25% of patients are candidates for lung resection. [1]
RT and chemotherapy together have a combined 5 year survival rate of 5%. [1]
RF ablation can potentially provide direct cytoreduction, which could make RT and chemotherapy more effective. [1]
1 Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
Lung CancerLung Cancer
Assessment of malignancy has required invasive diagnostic methods– Needle biopsy (10% sampling error; 15%
pneumothorax)– Bronchoscopy (low sensitivity; occ. pneumothorax– Mediastinoscopy (surgical procedure; limited to
anterior mediastinum)– Thoracotomy (open surgery; 1-3% mortality)
FDG-PET expensive and not widely available
“Radiofrequency ablation of lung tumors may be a promising option for nonsurgical candidates given the suboptimal outcomes with current
treatment options.” [1]
“The overall 5-year survival rate for all stages combined is only 15%.” [1]
Lung CancerLung Cancer
1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
Radiofrequency AblationRadiofrequency AblationNSC Lung CancerNSC Lung Cancer
3 cm RFA3 cm RFA 3 mo S/P 3 mo S/P RFA/XRTRFA/XRT
18 mo S/P 18 mo S/P RFA/XRTRFA/XRT
KEYSKEYS
Excellent H&P Find Comparisons Send the above to your radiologist then call and
discuss the case-have the radiologist lay out the work up as local resources dictate what will be done
IF PATIENT CANDIDATE FOR TREATMENT TISSUE DIAGNOSIS IS NEEDED
We at Diagnostic Imaging We at Diagnostic Imaging Associates are happy to helpAssociates are happy to help
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