Screen discovered nodules: What next?

Anil Vachani, MD, MSAssistant Professor of MedicineDirector, Lung Nodule Program

University of Pennsylvania Medical Center

18th Annual Perspectives in Thoracic Oncology

Disclosures

• Research Funding– NIH, DOD– Integrated Diagnostics, Allegro Diagnostics,

• Scientific Advisory Board– Allegro Diagnostics

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Ost & Gould, AJRCCM 2011

Assessing the Probability of Cancer

• Most Important Factors to consider:– Nodule size and characteristics– Smoking history– Age– Family history of lung cancer– Emphysema

http://www.brocku.ca/lung-cancer-risk-calculator

http://www.brocku.ca/lung-cancer-risk-calculator

Importance of Nodule Size

Nodule Size Confirmed Lung Cancer PPV (%)Yes No

4-7 mm 18 (7%) 3642 (53%) 0.5

7-10 mm 35 (13%) 2079 (30%) 1.7

11-20 mm 111 (41%) 821 (12%) 11.9

21-30 mm 58 (22%) 137 (2%) 29.7

> 30 mm 45 (17%) 64 (1%) 41.3

NLST Investigators. NEJM 2013

Guidelines

Fleischner Society Guidelines

Nodule Size Low Risk High Risk

≤ 4 mm No follow-up needed 12 mo

> 4-6 mm 12 mo 6-12 mo

> 6-8 mm 6-12 mo 3-6 mo

> 8 mm 3 mo, PET, and/or biopsy

McMahon, et al. Radiology 2005; 237:395-400

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

Thick vs. Thin Sections for Small Nodules

Naidich D P et al. Radiology 2013;266:304-317

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 years

Pure GGN larger than 5mm

• Lesions are frequently due to preinvasive AAH or AIS

• Up to 20% of persistent GGOs are benign• Growth of a GGO can suggest presence of an

invasive adenocarcinoma

Serial Imaging to Assess Growth (1mm cuts)

Naidich D P et al. Radiology 2013;266:304-317

Rapid Enlargement of a GGO

Naidich D P et al. Radiology 2013;266:304-317

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 yrs

Solitary part-solid Initial CT at 3 months; if persistent and solid component < 5mm, then yearly CT for min of 3 yrs. If persistent and solid component > 5mm, then biopsy or surgery

Rationale

• Part solid nodules have a high likelihood of malignancy

• Development of a solid component within a pure GGO

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

> 5 mm Initial CT at 3 months; annual surveillance CT for minimum 3 yrs

Solitary part-solid Initial CT at 3 months; if persistent and solid component < 5mm, then yearly CT for min of 3 yrs. If persistent and solid component > 5mm, then biopsy or surgery

Multiple subsolid nodules

Pure GGNs < 5 mm Obtain follow-up CT at 2 and 4 years

Pure GGNs > 5mm without a dominant lesion

Initial CT at 3 months; then annual surveillance for a minimum of 3 yrs

Dominant nodule with part solid or solid component

Initial CT at 3 months; If persistent, biopsy or surgical resection, especially for lesions with > 5mm solid component

Multiple subsolid lesions with single dominant focus.

Naidich D P et al. Radiology 2013;266:304-317

PET Scans

Erasmus, et al. Clinics in Chest Medicine 2008

PET Scans

• Sensitivity ~ 85% • Specificity ~ 80%• Less accurate for:– Smaller lesions– Subsolid nodlues

Establishing a Tissue Diagnosis

• Bronchoscopy vs. CT guided TTNA

Modality Sensitivity Traditional bronchoscopy (screen detected) 15%

Navigational bronchoscopy 70%

CT guided TTNA 90%

Establishing a Tissue Diagnosis

• Bronchoscopy vs. CT guided TTNA

• Data based on case series• Risks of CT guided TTNA– Pneumothorax 15-27%

Modality Sensitivity Traditional bronchoscopy (screen detected) 15%

Navigational bronchoscopy 70%

CT guided TTNA 90%

Conclusions• Lung nodules are increasingly common • Important to elicit patient preferences• Management should include– Estimation of cancer risk

• Nodules ≤ 8mm are infrequently malignant– CT scan surveillance is best option in most cases

• If high likelihood of malignancy and low surgical risk, consider surgical evaluation

• Emergence of peripheral blood biomarkers

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