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22/09/2015
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Case Based Discussion: State of the Art Management of Lung Nodules
Dr. Elsie T. Nguyen
Dr. Kazuhiro Yasufuku
Organ Imaging : September 25 2015
1. To review guidelines for follow up and management of solid and sub‐solid nodules
2. To review low dose CT chest technique
3. To highlight some pitfalls when reporting the chest CT
4. To describe various options for surgical management of nodules
OBJECTIVES
Case 1
• 64 year old woman with chronic cough, CT chest completed to rule out bronchiectasis as a cause
• 35 pack year history of smoking, quit 5 years ago
• No constitutional symptoms
• No SOB, chest pain, or hemoptysis
• No other significant medical history
Solitary Solid Spiculated Nodule
• No adenopathy
• Moderate
emphysema
• No other findings
What would you do next?
• A) Follow up chest CT in 3 months
• B) Let it go
• C) CT guided biopsy
• D) Bronchoscopy
• E) PET‐CT
Chest. 2013;143(3):840‐846.
Algorithm for initial detection of Solitary Pulmonary Nodule
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Algorithm for evaluation of solid nodules SOLITARY PULMONARY NODULE
.
Recommendations for Follow‐up and Management ofNodules Detected Incidentally at Non‐screening CT
McMahon et al. Radiology 237, November 2005; 395‐400
Lobectomy is the Standard
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• Anatomical lobectomy with systematic hilar lymph node dissection is the standard of surgical treatment for lung cancer
Ann Thorac Surg 1995; 60(3): 615-622
Different Approaches
• Thoracotomy •VATS
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Minimally Invasive (VATS) Lobectomy
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J Thorac Cardiovasc Surg 2010;139:366-78
VATS Lobectomy ‐ Technique
•VATS Instruments • Endoscopic Staplers
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Same work on the insideDifferent incision on the outside
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VATS Lobectomy – Oncologic Outcome
• There are no studies that report or suggest a difference in ability to achieve complete resection in patients with stage I or II NSCLC
• There is evidence that there is equivalence in selected patients with stage IIIA after induction therapy
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da Vinci Robotic Lobectomy
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Robotic Lobectomy
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Robotic Lobectomy – Oncologic results
• Multi‐institutional retrospective review (n=325)
• Majority clinical stage I (IA, 247; IB, 63)
• Conversion rate: 8% (27/325)
• Morbidity 25.2% (82/325)
• Mortality 0.3% (1/325)
• Major complication rate 3.7% (12/325)
• p stage: IA, 54%, IB, 22%, IIA, 13%, IIB, 5%, IIIA, 6%
• Overall 5 year survival 80% (CI 73‐88)
• IA 91%, IB 88%, II 49%
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Park. J Thorac Cardiovasc Surg 2012;143:383-9
CALGB 140503
• Phase III Randomized Trial of Lobectomy vs Sublobar Resection for Small (<2cm) Peripheral NSCLC
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Randomization
SurgeryConfirmation of NSCLC on PathN0 status on frozen section
(4R, 7, 10R on right)(5or6, 7, 10L on left)
Lobectomy Limited Resection
VATS Segmental Resection
• Extensive central lobular emphysema (upper lobe predominant)
• 18x14mm peripheral ill‐defined nodule
• Stage IA, NSCLC
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Case 2
59 year old woman investigated with CT chest for ? Interstitial lung disease in 2009
• History of mixed connective tissue disease
• Due to a finding in the RUL, follow up CT chest examinations were completed
• Asymptomatic
• Normal PFTs
Case 2
• Low Dose CT chest Technique:
• 135 kv, 50 mA, dose usually 1‐2 mSv
• No contrast
• Helical acquisition
• 3mm reconstruction
• FOV 35‐40 cm
Case 2 59F RUL abnormality
2009 2012 2015
Case 2
• Always compare with most recent previous as well as baseline examination to detect small changes in density or overall size for sub‐solid nodules (GGO), new solid component
• Changes occur very slowly as they are slow growing lesions
• Make sure you are comparing similar slice reconstructions (3mm versus 5mm)
Can Texture Analysis Help?
• Differentiation of AAH/AIS/min invasive vsinvasive adenocarcinoma
• Better assessment of change over time
Pure GGO Sub‐Solid
Texture and Volumetric Analysis
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What would you do next?
• A) Follow up chest CT in 3 months
• B) Lobectomy
• C) CT guided FNA biopsy
• D) Microcoil localization prior to VATS
• E) PET‐CT
Case 2 RUL Growing Sub‐Solid Nodule
• Next step may vary depending on institution and availability/expertise locally in radiology and thoracic surgery
• Sub‐ solid nodules have higher risk of malignancy than solid nodules
• Growing sub‐solid nodules especially with enlarging solid component should be resected
Algorithm for evaluation of sub-solid nodules
V.Patel et al. Chest. 2013;143(3):840-846.
Subsolid nodules differential diagnosis
• 30‐70% of subsolid nodules resolve on short term follow up
• If they do persist: high probability of being malignant
GGO Resolution in 3 months
Courtesy Dr. D Patsios
Definitions of Sub‐solid Nodules
Pure ground‐glass nodule (GGN):
A focal area of increased lung attenuation that does not completely obscure the lung parenchyma
The margins of normal structures such as vessels remain outlined, and there are no areas of soft tissue density
Courtesy Dr. D Patsios
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Definitions of subsolid nodules
Sub‐ solid nodule:
A focal opacity containing both solid and ground glass components
Areas of parenchymal architecture are obscured within
Malignancy Risk in Sub‐Solid Nodules
• Early Lung Cancer Action Project (ELCAP)
– 34% of subsolid nodules were malignant vs. 7% solid nodules
– Sub‐solid (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
PREINVASIVE LESIONSAtypical adenomatous hyperplasia
Considered precursor to adenocarcinomaProliferation of Type II Pneumocytes or Clara Cell‐like cells with mild to moderate cellular atypiaUsually < 5 mm
Courtesy Dr. D Patsios
PREINVASIVE LESIONS
Adenocarcinoma in situ (formerly BAC)
Courtesy Dr. D Patsios
Adenocarcinoma in situ (AIS)
• Pre‐invasive lesions
• < 3cm
• Pure lepidic growth
• No stromal, vascular, lymphatic or pleural invasion
• Need complete histologic sampling for diagnosis
• Usually non mucinous
Courtesy Dr. D Patsios
Minimally invasive adenocarcinoma
MINIMALLY INVASIVE LESIONS
Courtesy Dr. D Patsios
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Minimally invasive adenocarcinoma (MIA)
• Lepidic predominant
• < 5 mm stromal invasion
• No lymphatic, vascular or pleural invasion
• Need complete histologic sampling for diagnosis
Courtesy Dr. D Patsios
Invasive lesions
Lepidic predominance Acinar predominance
Papillary predominance Micropapillary predominance
Solid predominant with mucin production
J Thorac Imaging Volume 27, Number 6, November 2012 Radiologic Implications of New Lung Adenocarcinoma Classification
Travis W et al J ThoracOncol 2011; 6(2):244‐85
Sub‐solid nodules: Differential Diagnosis
• Adenocarcinoma spectrum
• Pulmonary Lymphoma
• Benign etiology:
– Infection
– Focal fibrosis or scarring
– Focal inflammatory process: Organisingpneumonia, eosinophilic lung disease or Non specific interstitial pneumonia (NSIP)
GROUND GLASS AND SUB‐SOLID NODULESFleischner Society Guidelines
Naidich DP et al Radiology 2013 266(1):304‐17
Case 3 85F with ovarian cancer What would you do next?
• A) Follow up chest CT in 3 months
• B) RUL, LUL and LLL Lobectomy
• C) CT guided FNA biopsy
• D) Microcoil localization prior to VATS
• E) PET‐CT
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Diagnostic Approach to Pulmonary Nodules
• Minimally Invasive Biopsy• Bronchoscopic biopsy
• CT guided FNA
• Surgical biopsy• VATS
• Thoracotomy
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VATS (Video‐assisted thoracoscopic surgery)
• Procedure of choice for surgical biopsy of peripheral pulmonary nodule
• Limitation
• Identification of the nodule
• Lack of digital palpation in small, non‐solid deep nodules
• May require conversion to thoracotomy
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Surgical Biopsy Issues – VATS
• Visible with VATS if within 5mm of the visceral pleura
• Nodules deeper than 5mm need to be palpated for localization prior to resection
• Non‐solid nodules, especially GGO, are difficult to palpate
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Localizing Techniques ‐ VATS
• Intraoperative imaging• CT
• Thoracic ultrasound
• Preoperative CT guided marking• Liquid material (contrast media, colored adhesive agents, dyes)
• Radionuclides
• Wires (hookwires, microcoils)
• Preoperative bronchoscopic marking• Dye
• Fiducials
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Radiology 2002; 225: 511-518
Microcoil Technique
Pleural marking
No pleural marking
‐nodules<3cm‐within 3 cm of pleural surface‐non palpable (GGO,subsolid, too deep)
Microcoil Technique
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Case 3 85F with ovarian cancer
2010
2015
Part solid nodule was resected with microcoil localization and VATSDx: minimally invasive adenoca‐other nodules showed slow growth
2015
20102010
1. To review guidelines for follow up and management of solid and sub‐solid nodules
2. To review low dose CT chest technique
3. To highlight some pitfalls when reporting the chest CT
4. To describe various options for surgical management of nodules
OBJECTIVES
Take Home Points
• Guidelines for CT follow up of incidental solid nodules is different from sub‐solid nodules
• Sub‐solid nodules are slow growing; always compare with oldest CT chest available
• PET‐CT is often negative due to low metabolic activity• Variation in slice reconstruction can vary appearance of nodules
• Sub‐solid nodules have higher risk of malignancy than solid nodules
• Thoracic surgery should be consulted as many non‐invasive options exist for both diagnosis and treatment
Thank you!
V Patel et al. Chest. 2013; 143(3):825-839.
Predominant Histologic Subtype Appearance on CT Scan
NonmucinousMost often pure GGN or partly solid nodule with solid component < 5 mm
AIS
MIA
Lepidic (nonmucinous)Most often 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 adenocarcinomaConsolidation, air bronchograms; less often pure GGN
CT Patterns Among IASLC/ATS/ERS Lung Adenocarcinoma Subtypes
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Differential diagnosis‐ GGO
MALT MALT 7 years later
Evaluation with CT
• Subsolid nodules best evaluated with thin section images < 2.5 mm
• Quantify solid vs. ground glass components
