Management of common ﬁndings in chest imaging reports · Management of common ﬁndings in chest imaging reports Dr. Demetris Patsios Assistant Professor Medical Imaging University

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


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%


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


  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



  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


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


Part-‐ solid nodule: A focal opacity containing both solid and ground glass components. Areas of parenchymal architecture a re obscured wi th in .


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




  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.



Bronchovascular bundle thickening

Aoki et al; Radiology; September 2001

Coarse spicula�on

Aoki et al; Radiology; September 2001




  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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Management of common ﬁndings in chest imaging reports · Management of common ﬁndings in chest imaging reports Dr. Demetris Patsios Assistant Professor Medical Imaging University