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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
Nodule, Biopsy and Benign Disease RatesPe
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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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