Pulmonary Nodules •Brief intro to lung cancer and screening programs •Work-up of a pulmonary nodule

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Pulmonary Nodules

Matt Landman Resident in Research

Faculty Facilitator – Dr. Eric Grogan

Resident Teaching Conferences - 2010

• Goal is to have a broad-based curriculum and hopefully not just another conference

• Want you to learn something • Mainly case-based with faculty facilitators • Supplemental materials available • SCORE – weekly email reminders

– Weekly questions based on that weeks reading – May or may not relate to RTC

• After January ABSITE review, moving upstairs in Light Hall

http://portal.surgicalcore.org/

http://www.portal.surgicalcore.org/

www.nccn.org

Fall 2010 Resident Teaching Conferences September 24, 2010 No Grand Rounds VMS Oral Exams RTC/Skills Labs only

October 1, 2010 title TBA Dr. Addison May Thoracic Trauma

October 8, 2010 title TBA Dr. John Morris, Jr. Hand Lecture

October 15, 2010 title TBA Dr. Jose Diaz Adrenal Masses

October 22, 2010

L.W. Edwards Lecture

“Toward Better Strategies for Improving

Surgical Quality”

Dr. John D. Birkmeyer,

University of Michigan Rocking Chair Conference

October, 29, 2010

Holcomb Lecture title TBA Dr. Brad Warner Pediatric Surgery Case Presentations

November 5, 2010 title TBA Dr. Bryan Collier Disclosure Training - Guillamondegui

November 12, 2010 title TBA

Frederick A. Moore, MD

Chief, General Surgery

Head, Division of Surgical Critical

Care & Acute Care Surgery

The Methodist Hospital

Houston, TX Trauma/EGS Case Presentations

November 19, 2010

Rollin Daniel Lecture Rollin Daniel lecture Rollin Daniel lecture Cardiothoracic Case Presentations

November 26, 2010 No Grand Rounds Thanksgiving Holiday NO RTC

December 3, 2010 MPMMIC Research Meeting

December 10, 2010

title TBA John Alverdy MD FACS

open

December 17, 2010 No Grand Rounds VMS Oral Exams RTC/Skills Labs only

December 24, 2010 No Grand Rounds Christmas Break

NO RTC

December 31, 2010 No Grand Rounds New Year's Eve

NO RTC

Objectives

• Brief intro to lung cancer and screening programs

• Work-up of a pulmonary nodule

– Understand risk of cancer given nodule/patient characteristics

– How long do you follow a nodule? Who get’s additional imaging? Timing of imaging?

– Understand additional work-up and treatment for lung malignancy

How might this appear on the Oral Boards?

• “In a routine pre-op chest x-ray, a 59 year-old smoker was found to have a RUL 3cm pulmonary nodule.”

• What do you do? – Work-up

– Pre-op work-up

– Staging

– Operative considerations

– Post-op treatment

http://articles.cnn.com/2010-05-31/world/indonesia.smoking.baby_1_aldi-anti-smoking-measures-smoke?_s=PM:WORLD

Lung Cancer 101

• Most common cause of cancer deaths in the U.S. – male and female

• 80% - Non-small cell lung cancer

– Adenocarcinoma, SCC, large cell

• Of all presenting with cancer – only 20% surgically resectable

• Stage I with complete surgical resection  70% 5-year survival

Sellke: Sabiston and Spencer’s Surgery of the Chest, 8th edition

Lung cancer screening programs result in discovery of earlier cancers than the

standard diagnostic methods?

1 2

0%0%

1. True

2. False

Lung cancer screening projects have been shown to decrease lung cancer- related mortality but are prohibitive

due to cost.

1 2

0%0%

1. True

2. False

Lung Cancer Screening

• 1960-1964 – London

– 55K males followed 3 years

• CXR (q3m) vs. CXR at T0 and at 3 years

– Screened – found more cancer, increased resectability

– No difference in lung-cancer related mortality

• 1970s – 3 studies using CXR & sputum cytology

– No differences in lung cancers found and lung-cancer- related mortality

• Low-dose CT scan screening programs – No differences in cancer-related mortality

• Ongoing screening trials

• Other screening methods – Additional sputum evaluation techniques

– Molecular techniques for circulating tumor cells

– Fluorescence bronchoscopy

• Still controversial – most moving to CT scans vs. CXR given sensitivity and specificity

Lung Cancer Screening

Solitary Pulmonary Nodule

• Big question – malignant or not? • Large majority are benign (~80%) • Nodule characteristics predicting malignancy

– Nodule size - #1 – Change in nodule size on repeat imaging – Nodule borders (ex. Smooth vs. spiculated) – Solitary vs. multiple nodules – Solid vs. non-solid

• Patient characteristics predicting malignancy – Smoking (# of cigs/day as well as # of years) – Age – Occupational exposures (asbestos, radon, etc.)

Slide from Grogan Grand Rounds Presentation, October 16, 2009 Available on General Surgery Website at: http://www.mc.vanderbilt.edu/root/vumc.php?site=GSR&doc=25692

Solitary Pulmonary Nodule – Work Up

• History & Physical – Noting cancer, infection risk factors

– Other symptoms, paraneoplastic symptoms

• Old Imaging  Baseline Chest CT and upper abdomen

• Nodule Size and repeat imaging

• Concerning Mediastinal/cervical nodes  PET/CT and biopsy

• Biopsy (nodule and mediastinum) vs. surgical removal of nodule with mediastinal lymph node dissection/sampling

Imaging

• Limits of detection

– CXR – 7 – 10mm

– CT – < 5 mm

– PET – 1.0 – 1.2 cm

72 y/o F presents with nodule found on pre-op workup for non- cancer operation presents with this CT scan

http://www.ajronline.org/cgi/content/full/183/2/293#FIG3

http://www.ajronline.org/content/vol183/issue2/images/large/08_03_0124_02A.jpeg

Solitary Pulmonary Nodules

• 5 – 15 mm  repeat imaging in 3 months

– Solid higher risk for cancer than non-solid lesions

• >15mm  Early follow up (infectious concerns 1 month) vs. Biopsy

– Patient risk factors may play a role in decision

Nodule on Repeat Imaging

• Resolution  obviously good

• Stable  repeat imaging – follow x 2year

• Stable but with mediastinal lymphadenopathy (nodes >1cm)  CT-PET and biopsy

• Increased in size  PET and biopsy vs. VATS – Change in nodule diameter or increase in solid portion of

nodule • Nodules 10mm – 20% change

– Rapid changes over short time period more likely infection

TNM Staging

Case Presentations

Patient RG 67 y/o M presents with left lung mass found in workup for shoulder pain

PMHx – DM, COPD, HTN, Hyperparathyroid, Arthritis

Additional History? smoking history, environmental exposures, cough, hemoptysis, weight changes, infectious disease history, voice changes, cervical lymphadenopathy, weakness, chest pain

Differential Diagnosis Cancer (primary or met), infectious (mycoses, TB, abscess), inflammatory, congenital

Patient RG - Next Steps

• Risk of malignancy?

– High given size of lung mass, enlarged mediastinal nodes

• If lung cancer – probable clinical stage?

– 9.5 cm with mediastinal nodes, no mets

– If includes pleural effusion?

• Next steps?

– PET/CT

– Biopsy – both primary lesion and mediastinal nodes

Biopsy 11/24/08

• CT-guided core needle biopsy – approached from left anterior chest

• Diffuse Large B-cell lymphoma

• Referred to Hematology for treatment

– CHOP and Rituxan

Sellke: Sabiston and Spencer’s Surgery of the Chest, 8th edition

Mediastinal Node Biopsy

• Techniques – Cervical Mediastinoscopy

• Indications – Lymph node enlargement >1cm on CT

– Hypermetabolic lymph nodes on PET

• Relative indications – T2 or T3 tumors

– Adenocarcinoma or large cell carcinoma

• Will not get aortopulmonary window and para-aortic lymph nodes (levels 5 and 6)

– Chamberlain Procedure • Left anterior/parasternal approach, incision over 2nd rib, +/-

costal cartilage is removed, retrosternal extrapleural space is explored

Learning Poin