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Management of common findings in chest imaging
reports
Dr. Demetris Patsios Assistant Professor Medical Imaging
University of Toronto Joint Department of Medical Imaging
University Health Network, Mount Sinai Hospital and Women’s College Hospital, Toronto.
Disclosures
None
Objec�ves
Discuss the assessment and management of solid and subsolid pulmonary nodules
Current evidence based recommenda�ons for prompt and standardised review
Lung cancer screening detected nodules have influenced our current management of such findings
Introduc�on
The range of abnormal findings involve: – Lung parenchyma – Medias�num – Hila – Pleura – Bony thorax
O�en the findings are incidental to the symptoms that prompted the examina�ons
Introduc�on
The range of abnormal findings involve: – Lung parenchyma – Medias�num – Hila – Pleura – Bony thorax
O�en the findings are incidental to the symptoms that prompted the examina�ons
Introduc�on The range of abnormal findings involve:
– Lung parenchyma: pulmonary nodules – Medias�num – Hila – Pleura – Bony thorax
O�en pulmonary nodules are incidental to the symptoms that prompted the examina�ons – 0.09-‐7% of Chest Radiographs – 3% of Abdominal examina�ons – 13 % of Pulmonary angiograms
JB Alpert et al AJR 2012;1998:793-‐9 WB Hall et al Arch Int Med 2009;169:1961-‐5
Introduc�on 150,000 Americans are diagnosed with solitary pulmonary nodules annually
Prevalence between 8-‐51% in screening studies
Prevalence of malignancy 1.1-‐12%
Specificity of imaging tests is low M. Wahidi et al Chest 2007; 132: 94S-‐107S
Introduc�on
Increasing use of imaging
Follow up studies of nonspecific findings contribute to costs and radia�on exposure to the affected popula�on
The detec�on of findings can have a drama�c impact on the pa�ents’ quality of life, emo�onal well-‐being
Introduc�on Given the nonspecific nature of many radiographic findings, management strategies and guidelines have been developed
Fleischner Society: Interna�onal, mul�disciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest (founded 1969) www.fleischner.org
Benefits of evidence based guidelines have been demonstrated in other fields of medicine
H MacMahon Radiology 2010; 255:14-‐15
Early Lung Cancer Ac�on Project ELCAP
0
5
10
15
20
25
1 2
% nodules found
23%
7%
CT CXR
CT vs CXR in smokers
C Henschke et al. Lancet, 1999;354(9173):99-‐105
ELCAP: Screening Results
% cancers found
0
0.5
1
1.5
2
2.5
3
1 2
2.7%
0.7%
CT CXR
C Henschke et al. Lancet, 1999;354(9173):99-‐105
ELCAP: Screening Results
% Stage I cancers found
0
0.5
1
1.5
2
2.5
3
1 2
2.7%
0.7%
CT CXR
2.3%
0.4%
C Henschke et al. Lancet, 1999;354(9173):99-‐105
Impact on mortality?
National Lung Cancer Screening Trial (NLST): randomized trial – compared Low Dose CT (LDCT) with CXR – outcome: mortality – launched in September 2002 – closed in Feb 2004
The Na�onal Lung Screening Trial Research Team . N Engl J Med 2011;365:395-‐409
Impact on mortality?
Na�onal Lung Cancer Screening Trial (NLST): randomized trial results October 2010 53,456 par�cipants 33 sites in USA > 30 Pack Year smoking history
The Na�onal Lung Screening Trial Research Team . N Engl J Med 2011;365:395-‐409
Impact on mortality?
Na�onal Lung Cancer Screening Trial (NLST): randomized trial results October 2010 356 deaths in LDCT arm 443 deaths in Chest X Ray group 20.3% reduc�on Met the standard for sta�s�cal significance Recommended to end the study
The Na�onal Lung Screening Trial Research Team . N Engl J Med 2011;365:395-‐409
Pulmonary Nodules
Spherical radiographic well or poorly defined opacity that measures up to 3cm in diameter and is completely surrounded by lung �ssue
A mass implies a solid or partly solid opacity greater than 3cm in diameter
D Hansell et al Radiology 2008:246 (3): 697-‐722
Defini�ons of nodules
Pure ground-‐glass nodule (GGN):
A focal area of increased lung a�enua�on that does not completely obscure the lung parenchyma. The margins of normal structures such as vessels remain outlined, and there are no areas of so� �ssue density
Journal of Thoracic Oncology • Volume 6, Number 2, February 2011 Lung Adenocarcinoma Classifica�on
Defini�ons of nodules
Part-‐ solid nodule: A focal opacity containing both solid and ground glass components. Areas of parenchymal architecture a re obscured wi th in .
Defini�ons of nodules
Solid nodule: A focal area of increased a�enua�on that completely obscures the lung parenchyma within. Any normal structures are obscured
Solid Pulmonary Nodules
Differen�al Diagnosis Benign en��es
Granuloma Hamartoma Arteriovenous malforma�on Pulmonary infarc�on Cysts Mimics of Solid Pulmonary Nodules Infec�on
– Tuberculoma, lung abscess, atypical mycobacteria, nocardia, histoplasmosis, sep�c embolus
Inflammatory – Rheumatoid arthri�s, granulomatosis polyangii�s, sarcoid
Differen�al Diagnosis Malignant en��es
Non Small Cell Lung Cancer Pulmonary metastasis Carcinoid Teratoma Leiomyoma
Evalua�on-‐ Morphology
Size Margin Cavita�on A�enua�on
Evalua�on-‐ Morphology
Size Margin Cavita�on A�enua�on
Evalua�on-‐ Morphology
The likelihood of malignancy increases with the nodule diameter
Lesions larger than 3cm are more likely to be malignant
A smaller lesion of course does not exclude malignancy
.�Solitary pulmonary nodule (SPN) size and corresponding likelihood of malignancy
V Patel et al Chest. March 2013;143(3):825-‐839.
Evalua�on-‐ Morphology
Size Margin Cavita�on A�enua�on
Bronchovascular bundle thickening
Aoki et al; Radiology; September 2001
Coarse spicula�on
Aoki et al; Radiology; September 2001
Evalua�on-‐ Morphology
Size Margin Cavita�on A�enua�on
Evalua�on-‐ Morphology
Necro�c malignant nodules e.g. Squamous cell carcinoma Benign lesions e.g. Abscess, granuloma, vasculi�des, early stages of Langerhans cell his�ocytosis, pulmonary infarc�on Small lucencies may be seen in adenocarcinoma in situ or lepidic predominant adenocarcinomata “bubbly lucencies” Mucus impac�on of airways
Cavita�on
Wall thickness:
– <4mm 93% are benign
– >16mm 97% are malignant
– 5-‐15mm 50% are benign and 50% are malignant
Adenocarcinoma with cavity
Fat
Fat is good in the majority of cases Present in about 60% of hamartomata Rare causes include
– Lipoid pneumonia – Liposarcoma metastases – Renal cell carcinoma
Biopsy proven hamartoma
Lipoid pneumonia
Loca�on Perifissural nodules
– Well defined, smoothly marginated – In contact, with or closely related to a fissure – Most commonly oval or triangular shaped – Most likely lymph nodes
Frequent incidental findings in high risk individuals Although they may show increased size, none eventually develop into lung cancer Their malignancy poten�al is low Avoid unnecessary follow up or invasive examina�ons
MI Ahn et al Radiology 2010 (254):949-‐956
Stable Perifissural Nodules
Stable Perifissural Nodules
Calcifica�on (Benign) Central Diffuse Laminated Popcorn
The plain Chest Radiograph is not sensi�ve in detec�ng calcifica�on within a pulmonary nodule Sensi�vity of 50% and specificity of 87% CT best assesses the presence of calcifica�on
Trotman-‐Dickerson, Baumert B. Semin Thorac Cardiovasc Surg 2003;14(3):250-‐260
Diffuse calcifica�on
Calcified Granuloma
Calcifica�on
No obvious calcifica�on on plain film
Calcifica�on
Benign diffuse calcifica�on not detected on CXR best seen on CT
Calcifica�on (malignant)
Eccentric Amorphous
Beware of bone forming metastases
Evalua�on-‐Growth
Change in diameter/ volume Malignant solid pulmonary nodules have a volume doubling �me of 20-‐400 days with a majority having a volume doubling �me of <100 days Volume doubling of <20 days indicates very rapid growth and is usually associated with benign infec�ous process
S Friberg, S Ma�son J Surgical Oncology 1997;65 (4): 284-‐297 AO Soubani Postgrad Med J 2008; 84 (995): 459-‐466
V. Patel et al Chest. 2013;143(3):825-‐839.
.
Solitary pulmonary nodule doubling �me.
Follow Up CT over 2 years
May 2010 August 2012
FDG PET/CT
Cau�on in applica�on of PET/CT to diagnose malignancy
83-‐100% sensi�vity
63-‐90% specificity
Advantages Disadvantages Accurate non invasive evalua�on Whole-‐body image detects extrapulmonary tumours Ability to stage known lung cancer
Lower sensi�vity for lesions < 8 mm
False posi�ves from inflamma�on
False nega�ves from tumors with low metabolic rate
Advantages and Disadvantages of FDG-‐PET Imaging
Nega�ve PET – resected Minimally invasive adenocarcinoma
Minimally invasive adenocarcinoma resected (wedge resec�on)
CT enhancement (with radiographic iodinated
intravenous contrast)
<15 H.U. likely benign
16-‐24 H.U. Indeterminate
>25 H.U. probably malignant
>20 H.U 98% sensi�vity for malignancy Swensen S J et al Radiology. 2000 Jan;214(1):73-‐80
Evalua�on-‐ Clinical
Increasing age
Smoking history
Presenta�on – Most cases asymptoma�c – Lung cancer does not lend itself to self-‐awareness (melanoma, breast)
– Haemoptysis
Evalua�on-‐ Clinical
Past Medical History – Malignancy: majority of solitary pulmonary nodules detected are malignant, equally or more likely to represent primary lung cancer rather than metastases except for sarcoma, melanoma and tes�cular malignancy
– Inters��al lung disease: In Idiopathic Pulmonary Fibrosis 9-‐38% prevalence of lung cancer
History of travel: – Histoplasmosis, coccidioidomycosis, cryptococcus, tuberculosis
Evalua�on-‐ Clinical Calcula�on of probability (SPN Calculator) www.chestx-‐ray.com
– Age – Smoking – Haemoptysis – Nodule diameter – Loca�on – Edge characteris�cs – Growth rate – Cavity wall thickness – Calcifica�on – Contrast enhancement on CT Scan >15 HU – PET Scan
SOLITARY PULMONARY NODULE FLEISCHNER SOCIETY
.
Recommenda�ons for Follow-‐up and Management of Nodules Smaller than 8 mm Detected Incidentally at Non screening CT
McMahon et al. Radiology 237, November 2005; 395-‐400
Fleischner Society Recommenda�ons
Do not apply
– History of malignancy – In young pa�ents – Febrile pa�ents – Subsolid nodules
V. Patel et al. Chest 2013;143(3):840-‐846.
Algorithm for ini�al detec�on of Solitary Pulmonary Nodule (SPN)
Algorithm for evalua�on of solid nodules
Subsolid Nodules
Evalua�on with CT
Subsolid nodules best evaluated with thin sec�on images < 2.5 mm and quan�fy solid vs ground glass components
Detec�on-‐ Background Lung cancer screening studies in Japan
– Noguchi classifica�on of adenocarcinoma Types A-‐F
– Clinicopathological characteris�s�cs and prognosis
Early Lung Cancer Ac�on Project (ELCAP) – 34% of subsolid nodules were malignant vs. 7%
solid nodules – Part solid Nodules: 63% malignant – Ground Glass Nodules: 18 % malignant
Noguchi M et al Cancer 1995 June 15; 75 (12): 2844-‐52 Henschke et al Am J Roentgenol. 2002 May; 178(5): 1053-‐7
Ground Glass component
<10%
10%-‐ 50%
>50%
Aoki T et al Radiology 2001;220 (3); 803-‐9
What are we raising the concern for in our reports?
Preinvasive lesions Atypical adenomatous hyperplasia
Atypical Adenomatous Hyperplasia
Considered precursor to adenocarcinoma Prolifera�on of Type II Pneumocytes or Clara Cell-‐like cells with mild to moderate cellular atypia Usually < 5 mm
Preinvasive lesions
Adenocarcinoma in situ
Adenocarcinoma in situ (AIS)
Pre-‐invasive lesions < 3cm Pure lepidic growth No stromal, vascular, lympha�c or pleural invasion N e e d c o m p l e t e histologic sampling for diagnosis Usually non mucinous
Minimally invasive adenocarcinoma
MINIMALLY INVASIVE LESIONS
Minimally invasive adenocarcinoma (MIA)
Lepidic predominant < 5 mm stromal invasion No lympha�c, vascular or pleural invasion Need complete histologic sampling for diagnosis
PREINVASIVE LESIONS
J Thorac Imaging Volume 27, Number 6, November 2012 Radiologic Implications of New Lung Adenocarcinoma Classification
V Patel et al. Chest. 2013; 143(3):825-‐839.
Predominant Histologic Subtype Appearance on CT Scan Nonmucinous
Most o�en pure GGN or partly solid nodule with solid component < 5 mm
AIS
MIA
Lepidic (nonmucinous) Most o�en partly solid nodule with solid component > 5 mm or solid nodule; less commonly pure GGN
Papillary Solid nodule Acinar Solid nodule Micropapillary Unknown Solid Solid
Invasive mucinous adenocarcinoma Consolida�on, air bronchograms; less o�en pure GGN
CT Patterns Among IASLC/ATS/ERS Lung Adenocarcinoma Subtypes
V Patel et al. Chest. 2013; 143(3):825-‐839.
Predominant Histologic Subtype Appearance on CT Scan Nonmucinous
Most o�en pure GGN or partly solid nodule with solid component < 5 mm
AIS
MIA
Lepidic (nonmucinous) Most o�en partly solid nodule with solid component > 5 mm or solid nodule; less commonly pure GGN
Papillary Solid nodule Acinar Solid nodule Micropapillary Unknown Solid Solid
Invasive mucinous adenocarcinoma Consolida�on, air bronchograms; less o�en pure GGN
CT Patterns Among IASLC/ATS/ERS Lung Adenocarcinoma Subtypes
Subsolid nodules differen�al diagnosis Adenocarcinoma spectrum
Lymphoma
Benign ae�ology: – Infec�on – Focal fibrosis or scarring – Focal inflammatory process: Organising pneumonia, eosinophilic lung disease or Non specific inters��al pneumonia (NSIP)
Subsolid nodules differen�al diagnosis
30-‐70% of subsolid nodules resolve on short term follow up
If they do persist: high probability of being malignant
Resolu�on in 3 months of a Ground glass pulmonary nodule
Subsolid nodules differen�al diagnosis
Retrospec�ve study in 49 pa�ents, 53 Ground glass nodules – 75% BAC or adenocarcinoma with predominant BAC
– 6% Atypical Adenomatous Hyperplasia – 19% Nonspecific Organising pneumonia/fibrosis
No significant morphologic features to dis�nguish between benign and malignant ground glass nodules
Kim HY et al Radiology 2007; 245;267-‐275
Differen�al diagnosis
In pa�ents with known extrapulmonary malignancy Persistent subsolid nodules have a high malignancy rate of 68% Most o�en primary lung cancers and not metastases Beware of acinar type metastases in GI malignancies such as pancrea�c cancer
Growth
We know that of the ground glass nodules that persist some are going to progress
We do not know which ones and when
Increase in size
Increase in density
Beware of the nodules that decrease in size but increase in density
Stable Ground glass nodule
2003 2015
Ground glass nodule 2004-‐2014
Variable growth of ground glass nodules in the same pa�ent
2009 2014
Growth Rates
61/82 cancers average volume doubling �me: 52-‐1733 days – Ground Glass Nodules 813 days – Part solid nodules 457 days – Solid nodules 149 days
Subsolid nodules stability over 2 years does not indicate benign ae�ology
Hasagawa M et al Br J Radiology 2000; 73;1252-‐59
Proposed guidelines for management of subsolid nodules
No high risk and low risk individuals
Adenocarcinoma occurs in non smokers and younger individuals (young , Asian females)
Case per case basis
GROUND GLASS AND SUBSOLID NODULES Fleischner Society guidelines
Naidich DP et al Radiology 2013 266(1):304-‐17
Diagnos�c Algorithms
Screening detected nodules The Lung Repor�ng and Data System (LU-‐RADS) proposal – Classifies screening detected CTs by the nodule with the highest risk of malignancy
– The highest the level the risk of malignancy increases Categories 1-‐6
D Manos et a Can Assoc Rad J 2014 May; 65 (2) 121-‐134
Diagnos�c Algorithms
American College of Radiology Lung Rads Assessment Categories (0-‐ 4A, 4B, 4X, S, C)
Diagnos�c Algorithms Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014
Category Descriptor Category DescriptorPrimary
CategoryManagement
Incomplete - 0Additional lung cancer screening CT images
and/or comparison to prior chest CT examinations is needed
NegativeNo nodules and
definitely benign nodules
1
Benign Appearance or Behavior
Nodules with a very low likelihood of
becoming a clinically active cancer due to
size or lack of growth
2
Probably benign
Probably benign finding(s) - short term follow up suggested;
includes nodules with a low likelihood of
becoming a clinically active cancer
3 6 month LDCT
4A3 month LDCT; PET/CT may be used when
there is a ≥ 8 mm solid component
4B
chest CT with or without contrast, PET/CT and/or tissue sampling depending on the
*probability of malignancy and comorbidities. PET/CT may be used when
there is a ≥ 8 mm solid component.
Significant - other S
Prior Lung Cancer C
Findings for which additional diagnostic testing and/or tissue
sampling is recommended
Suspicious
Continue annual screening with LDCT in 12 months
Lung Cancer Rapid Assessment &Management Program (Lung RAMP) Funded by Cancer Care Ontario Time to Treat Program at Toronto East General Hospital: median �me from suspicion of lung cancer to diagnosis decreased from 128 days to 20 days. 33% were eventually diagnosed with lung cancer.
Suspected lung cancer (Chest X Ray, CT scan, posi�ve pathology)
Reduce wait �mes for appointments and diagnos�c tes�ng Reduce mul�ple visits During first 6 months of 2013, more than 120 pa�ents received a defini�ve diagnosis with an average wait �me of about 1 month from referral to diagnosis
DS Lo et al J Thorac Oncol 2007 (11): 1001-‐6 www.uhn.ca/Surgery
CT guided lung biopsy
Percutaneous fine needle aspiration lung biopsy is an accepted clinical tool used in the evaluation of suspicious lung nodules
Considered for any lung nodule (>5 mm)
Relative contraindications: – COPD, Pulmonary Arterial Hypertension, AVM, coagulopathy, previous pneumonectomy
CT guided lung biopsy Most common complication is pneumothorax: between 19-‐60%
Most occur within 1 hour
Asymptomatic and remain stable
Chest tube drainage will be required in 2-‐14% patients with Pneumothorax
Extensive evaluation of risk factors for developing a complication: procedural and patient-‐specific
CT guided lung biopsy Risk of Pneumothorax
• Technical Factors: • depth/size of lesion • loca�on of lesion • number of passes • needle size
• Subject factors: • underlying lung disease • compliance
CT guided lung biopsy Minimally invasive adenocarcinoma
Metasta�c adenocarcinoma, colon primary
Preopera�ve localisa�on with Microcoils
T1N0M0 Adenocarcinoma in situ 0,5 cm
Not palpable peroperatively
Preopera�ve localisa�on with Microcoils
Conclusions
Assess morphology carefully
Incorporate risk factors for malignancy
Significantly different guidelines for follow up of solid and subsolid pulmonary nodules
Persistent subsolid nodules have a higher malignancy rate compared to solid nodules
Conclusions Subsolid persistent nodules frequently correspond to the spectrum of disease seen in pulmonary adenocarcinoma Difficult to differen�ate on CT between benign and malignant features in subsolid nodules Subsolid nodules have an increased volume doubling �me therefore always consider much longer than 2 year stability
Thank you for your a�en�on
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