Chest imaging in up to 50-yo non symptomatic smokers

G Ferretti CHU Grenoble FRANCE

� CT acquisitions in people > 50 yo � Lung cancer screening studies � Early detection of pulmonary fibrosis �  Screening for asbestosis

have increased our need to better understand the morphology of the lung in aging population and particularly in those who have smoking habits

Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010

Aging +/- cigarette smoking

�  Abnormalities without clinical consequences ◦  “Wrinkles” within the lung

�  Abnormalities with potentially severe evolution ◦  Lung nodules ◦  Emphysema ◦  Respiratory broncholitis ◦  NSIP/UIP pattern ◦  Chronic bronchitis ◦  Air trapping

“WRINKLES” WITHIN THE LUNG

Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010

55 yo patient GGO Opacity in the posterior lung ILD ? Re scan the patient in prone position

Increase pulmonary density in a 67yo patient suspected of PE due to incomplete inspiration and contrast injection Confusing pattern for ILD

Fibrosis adjacent to spinal osteophytes Localized GGO or reticular pattern near dorsal Osteophytes (right side >>> left side No evolution in time Not related to asbestose exposure Not indicative of early UIP

Otake S. AJR 2002;179:893–896.

Aging pattern of the lung (1)

�  Bronchial dilatation (Richards DW Bull NYAM 1956)

�  Enlargement of alveolar spaces : senile emphysema? (Janssens JP ERJ 1999)

84 yo woman asymptomatic

70 yo smoker man Thickening of bronchial walls

Localized fibrosis of lung parenchyma •  Sub pleural reticulation in 60% of asymptomatic

subjects > 75 yo vs 0% < 55 yo

•  Interlobular septal enlargement more frequent in older persons

Copley SJ Radiology 2009

Aging lung (2)

� Pulmonary cysts with thin walls in 25% of subjects > 75yo but absent in < 55yo ◦ These cysts are related to aging but not to

tobacco ◦ Their volume is limited

Copley SJ Radiology 2009

72  yo  asymptoma+c  female      

ABNORMALITIES WITH POTENTIALLY SEVERE EVOLUTION

Emphysema

�  the link between smoking and emphysema is well demonstrated ◦  Interstitial abnormalities used to be called

“dirty lung” on CXR ◦ Respiratory bronchiolitis / RB ILD has been

described more recently �  Centrilobular GGO micronodules �  Upper lung

Bronchiolite respiratoire

Pathologie tabagique : EXCES DE MACROPHAGES Bronchiolite respiratoire

–  inflammation chronique bronchiolaire, macrophages tatoué

Bronchiolite respiratoire avec infiltration pulmonaire diffuse (RB-ILD)

–  Extension dans l ’espace des anomalies TDM. Pneumopathie interstitielle desquamative (DIP))

5  years  la2er  

*Remy-­‐Jardin  et  al,  Radiology  1993,  186:  107-­‐115  **Remy-­‐Jardin  et  al,  Radiology  1993,  186:  643-­‐651  ***  Remy-­‐Jardin  et  al  Radiology,  2002,  222:  261-­‐70  

65 yo patient 43 PY Asymptomatic ENT polyps CXR then CT

Tobacco and ILD

� Do smokers develop limited and progressive pulmonary fibrosis ? ◦ Remain controversial ◦  Experts supports that smoking is a direct

cause for developing UIP/NSIP

Cordier  JF  et  Co8n  V  ERJ  2013  

l  2007, 58 yo man chronic cough

l  What do you see?

2007 2012

21  │  

l  2012 , heterogeneous distribution of ILD l  Reticulation l  Honey combing l  Bronchectasis l  Sub pleural distribution

l  UIP pattern

Raghu  G  AJRCCM  2011  

692 heavy smokers from the Multicentric Italian Lung Detection (MILD) Four CT patterns were considered:

•  usual interstitial pneumonia(UIP) •  other chronic interstitial pneumonia (OCIP) •  respiratory bronchiolitis (RB) •  indeterminate

the evolution of ILD after 3 yrs was assessed UIP pattern in 0.3% OCIP pattern 3.8% progression three (25%) of 12 RB pattern in 15.7% indeterminate pattern in 3%

The lung of smokers in screening program for lung cancer

Sverzella+  N    ERJ  2011    

� Age, male sex and current smoking status were factors associated with the presence of OCIP and UIP pattern

� Thin-section CT features of ILD, probably representing smoking-related ILD, are not uncommonin a lung cancer screening population and should not be overlooked.

Sverzella+  N    ERJ  2011    

•  884 smokers from the NLST –  ILD at base line –  ILD were classified into

•  nonfibrotic (ground-glass opacity, consolidation, mosaic attenuation), •  fibrotic (GGO with reticular pattern, reticular pattern, honeycombing).

–  the rate of progression of ILAs on 2-year follow-up •  Résults

–  prevalence of equivocal ILD: 11.5% –  prevalence of ILD: 9.7%

•  Fibrotic 2.1% Progression 37%, improved 0% •  Non fibrotic 5.9% improved 49% •  Mixed 1.7%

•  The percentage of current smokers (P = .001) and mean number of cigarette pack-years (P = .001) were significantly higher in those with ILA than those without.

The lung of smokers in screening program for lung cancer

Jin  GY  Radiology  2013    

Air trapping

Need expiratory acquisitions seen in patients with normal PFT �  present in healthy asymptomatic nonsmoking

individuals (Verschakelen JA Eur Radiol 1998) �  more frequent in cigarette smokers (Mastora I Radiology

2001)

�  found in approximately 50% of asymptomatic subjects. The frequency of air trapping increased with age, and its severity increased with age and smoking (Lee KW Radiology 2000)

INSPIRATION   EXPIRATION  

Asymptoma+c  smokers  

•   82  asymptoma-c  persons  •   Air  trapping  present  in  50%  •   increased  Frequency  with  age  •   increased  Frequency  in  smokers  (>10PA)    

Lee  et  al  Radiology  2000,  214:  831-­‐36  

Tobacco and lung cancer

� Lung cancer is the leading cause of cancer-related deaths worldwide.

� 85% of lung cancer patients are smokers � Most patients are diagnosed with

advanced-stage tumors, precluding curative-intent treatment.

Raz D Chest 2007

Survival of untreated patients with lung cancer

The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. N Eng J Med 2011; 365(5): 395–409.

NLST showed a 20% decrease in lung-cancer-specific

mortality

�  US Preventive Service Task Force Humphrey MM Ann Intern Med 2013

�  The IASLC Heidi R J Thorac Oncol. 2013

�  The National Cancer Center Network Wood DE J Natl Compr Canc Netw 2012

�  The American Society of Clinical Oncology, �  The American Association of Chest Physician �  The American Association for Thoracic Surgery,

Mirkin JN JAMA 2012

�  French groups IFCT, SIT, GOLF S Couraud Ann Oncol 2013

Recommended individual screening for lung cancer

Guideline Recommendations

- aged between 55 and 74 years; - at least 30 pack-year tobacco exposure; - active smoker or quit during the last 15 years; - no serious progressive disease (history of cancer other than non-melanoma skin cancer or carcinoma in situ over the past 5 years1; severe co-morbidity, including respiratory insufficiency contraindicating invasive chest examination; prior hemoptysis; unexplained weight loss over 10% over the past 12 months); - no pulmonary infection over the 12 past weeks; - accepts repeated scans or additional investigations in the case of abnormal findings; - accepts considering help to quit smoking (active smokers).

Eligibility

CT CXR

3 types of nodules •  Solid •  Part-solid •  Nonsolid

Etiology VDT Prognostic Action

15.8% 1.9% cancer

4.3% 6.6% cancer

78.9% 1.1% cancer

McWilliams A NEJM 2013

NLST  

1  

2  

3  

NELSON  

1  

2  

3  

 N  screening  CT              N  posi-ve              N  Cancers   %  de  cancer/scr     Stade  I  

NLST 75 126

18 146 24.1%

649 3.6%

0.86% 61.6% (Baseline + rounds 1-2)  

NELSON 14 846

324 2.2%

126 38.9%

0.85% 69.8% (Baseline + round 1)  

 N  screening  CT              N  posi-ve              N  Cancers  

NLST 75 126

18 146 24.1%

649 3.6%

FP: 96.6% (Baseline + rounds 1-2)  

NELSON 14 846

324 2.2%

126 38.9%

FP: 61.1% (Baseline + round 1)  

Follow up of Pulmonary nodules (Fleischner, Radiology 2005)

Guidelines adapted to solid nodules only Specific guidelines for nGGO 2013

Positif test Nelson study

CT at 3-4 months GROWCAT C if VDT < 400 days

Positif

Negatif

1039mm3 at baseline to1539 mm3 at 3 months. T1N0M0 adenocarcinoma

A Marchiano Radiology 2009; 251

V = 4.19 x R3

V x 2 when R x 1.26

Reich JM Eur J Radiol 2011 ;80

Nair & Hansell Eur Radiol 2011; 21:2445–2454

NLST vs. NELSON

Couraud S Annals Oncology 2012.

Couraud S Annals Oncology 2012.

Conclusion � HRCT can demonstrate very early disease,

sometimes in people without symptoms or PFT abnormalities.

�  The lung of asymptomatic smokers > 50yo may be affected by ◦ Non significant abnormalities mainly related to

aging ◦  Significant diseases that should be followed

�  Smoking may have a premature aging effect on the lungs

Nyunoya T Am J Respir Crit Care Med 2009