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SPNs and the Early Detection of Lung Cancer George Erbacher D.O., FAOCR Chair imaging/interventional radiology OSUMC Radiology residency program director. DEFINITION OF SOLITARY PULMONARY NODULE (SPN). Single round water density mass < 3 cm - PowerPoint PPT Presentation


  • SPNs and the Early Detection of Lung CancerGeorge Erbacher D.O., FAOCR

    Chair imaging/interventional radiology OSUMC

    Radiology residency program director

  • DEFINITION OF SOLITARY PULMONARY NODULE (SPN)Single round water density mass < 3 cmCompletely surrounded by lung parenchymaIncidental finding 0.2% CXRs, 1% CT


    Chest wall lesionHealing rib fracture AVNAbscessPneumoniaImmune-RA/Wegeners granulomatosis etc.

  • MIMICS OF SPNHematomaLung infarct/atelecatasisPleural plaqueBronchial atresia/SequestrationInhaled FBMOST COMMON: BENIGN GRANULOMA/HAMARTOMA

  • PATIENT FEATURES INCREASING RISK OF MALIGNANCYSMOKING 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 VS. MALIGNANTSmaller 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 the World

    Most frequently diagnosed cancer (1.04M in 1990)Leading cause of cancer mortality 921K deathsMost common cancer in males and #1 cause of cancer death

  • 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 rate21.6/100K (56.4% below avg.)

  • U.S. Lung Cancer1Dupuy, 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]

  • Survival5 years 14%

    50% survive if diagnosed in early stage (small size IA 85 100% survival

    Only 15% diagnosed in early stage

  • Tobacco SmokeCigarette smoking is causally related to lung cancerthe magnitude of the effect far outweighs all other factors.

    Is leading cause of avoidable mortality in US, w/ about 434K preventable deaths per yearCost to US economy $200 billion/year

    US surgeon general

  • CXR Screening RevisitedAnalysis 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 RevisitedScreened 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)Screening vs. CXRRationale:LD CT greatly increases detection of small non-calcified nodules and of lung cancer at an earlier/more curable stageLD CT showed non-calcified nodules 3x more commonlyLD CT showed malig. tumors 4x more commonlyLD CT showed stage 1 tumors 6x more commonly

  • 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 CT140 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 Scoring1-6 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 DescriptionSize (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 NoduleBenign calcifications

    Smooth edges

    < 20 mm size

  • Guideline for Diagnostic Intervention ELCAPNon-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=benign6-10 mm : bx, if not possible F/U per above> 11mm : bx

  • Fleishner Recommendations do NOT apply to patients:


  • Nodule Enhancement and metabolismCancer/Infection/inflammation- CT neovascularity- malignant nodules enhance > 20 Hounsfield Units (HU), benign < 15 HU

    Cancer/Infection/inflammation- increased glucose turnover- PET- SUVmax < 2.5 benignPET/CT HAS SENSITIVITY AND SPECIFICITY CLOSE TO 90% FOR NODULES 10 MM OR GREATER DIAMETER

  • PET/CT vs. Helical dynamic CT for SPNPET/CT MORE SENSITIVE (96% vs. 81%) and MORE ACCURATE (93% vs. 85%) than helical dynamic CT


  • Benign? NM in Lung Cancer

  • Role of PET in Lung Cancer

    Improves staging by ruling out mediastinal/distant diseaseUseful in evaluating response to therapyUseful in early detection recurrent disease

    Rad Clinics N.A. May 2000 p. 523

  • False Positive and Caveats PET/CTActive necrotizing granulomas and some chronic inflammatory conditions are +ANY PROCESS THAT HAS INCREASED UPTAKE OF GLUCOSE IS PET POSITIVE

  • What to do with Indeterminant CT W/U of SPNSerial radiographic F/U?

    CT alone to decide to surgerize or not?


    Surgery for pts w/ + or indeterminant CT?

  • Cost EffectivenessRadiographic F/U cost effective when probability of malignancy is low ( .90Over greatest range of probability .14 - .71 CT and PET/CT cost effectiveRad Clinics N.A. May 2000 p. 521-522

  • PRINCIPLES OF IMAGING IN ONCOLOGYImaging justified only if results will change therapy with patient benefitWhere there is an issue get tissue-biopsy when imaging is inconclusive (imaging guided?)Positive studies are more valuable/reliable than negative studiesThe diagnostic plan should progress logically from least to most invasive studiesAccurate assessment of initial disease extent is vital to selecting and sequencing appropriate treatment

  • Staging lung cancerStage 1A-T1N0MO= tumor < 3cm with no positive nodes and no metastasisStage 1B-T2N0M0- tumor > 3cm, no nodes, no metastasis

  • RFA in Pulmonary Applications

  • Lung25% 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]1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

  • Lung CancerAssessment of malignancy has required invasive diagnostic methodsNeedle biopsy (10% sampling error; 15% pneumothorax)Bronchoscopy (low sensitivity; occ. pneumothoraxMediastinoscopy (surgical procedure; limited to anterior mediastinum)Thoracotomy (open surgery; 1-3% mortality)FDG-PET expensive and not widely available

  • Lung CancerRadiofrequency 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]

    1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

  • Radiofrequency AblationNSC Lung Cancer3 cm RFA3 mo S/P RFA/XRT18 mo S/P RFA/XRT

  • KEYSExcellent H&PFind ComparisonsSend 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 doneIF PATIENT CANDIDATE FOR TREATMENT TISSUE DIAGNOSIS IS NEEDED

  • We at Diagnostic Imaging Associates are happy to helpFOR TULSA REFERRAL AREA CALL 918 599 5050/5094 TO TALK TO RADIOLOGIST

    FOR OUTSIDE TULSA REFERRAL AREA CALL CHRISTA -918 599 5031 and ask for radiologist at site nearest you

    Thank You

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