Solitary Pulmonary Nodule Is the nodule benign or malignant? Should it be investigated or observed? Should it be surgically resected? SOLITARY

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  • Solitary Pulmonary Nodule
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  • Is the nodule benign or malignant? Should it be investigated or observed? Should it be surgically resected? SOLITARY PULMONARY NODULE SPN On Chest Radiography would raise several questions
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  • SOLITARY PULMONARY NODULE ~ 150,000 solitary pulmonary nodule (or coin lesions) are detected annually in the US and often discovered incidentally at CxR or CT or 1-2 SPNs per 500 CxR Definition : Single, round and discrete pulmonary opacity that measure
  • The probability of a SPN being malignant rises with increasing patient age. A study of malignancy in 955 patients in 1983: - 65% > 50 y/o - 35% < 50 y/o But have to be cautious in assuming that a SPN in a young person is benign. SOLITARY PULMONARY NODULE Patient Age
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  • History of smoking strong association of cigarette smoking with primary lung CA Previously diagnosed malignancy increases the likelihood that SPN may represent metastatic disease. ~ 10-30% of resected malignant pulmonary nodules are metastatic from extrathoracic malignancies. Underlying Risk Factors SOLITARY PULMONARY NODULE
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  • Size of the Lesion : - Small lesions tend to be benign - Over 80% of lesion > 5cm. are malignant SOLITARY PULMONARY NODULE - In fact, 25-35% of SPN under 1 cm have been shown to be malignant
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  • Growth Rate : -A nodule that is stable for 2 years is almost always benign. -Doubling time a 25% increase in diameter -Most malignancy doubling time: 30-465 days. -Some like osteosarcoma or germ cell tumor can double faster. SOLITARY PULMONARY NODULE
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  • Calcification : -Calcium are present in > 50% of benign nodules. -Benign calcification appears as laminated central or diffuse pattern. -Calcium may present in 15% of malignant nodule, but usually eccentrically located. SOLITARY PULMONARY NODULE
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  • Diagnostic tools for evaluation of lung nodules: X-ray or CT scan Bronchoscopy (including direct biopsy, needle biopsy and brushing and washing for cytology) Percutaneous fine needle aspiration biopsy. PET/CT Scan Excisional Biopsy - Video assisted - Thoracotomy SOLITARY PULMONARY NODULE
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  • Percutaneous Needle Biopsy (PNB) - Reliable with reported sensitivity 64-97% for diagnosis malignancy. - In benign disease, the accuracy varies between 50-80%. - Relatively Safe with Pneumothorex complication rate 30% and 5-10% requiring chest tube drainage. - There is no doubt that PNB reduce the number of patients require thoracotomy. SOLITARY PULMONARY NODULE
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  • PET/CT Scan - The sensitivity of PET for diagnosing lung cancer approaches 95% with a specificity of over 85%. - One study has demonstrated that for SPNs, a negative PET scan associated with only a 4.7% risk of malignancy. - False-negative PET scan are usually associated with lesions < 1 cm. in size & in BAC. SOLITARY PULMONARY NODULE
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  • Tissue characterization of SPN:Comparative study between helical CT and integrated PET/CT Methods: 119 Pt. with SPN-underwent both enhanced spiral CT and PET/CT scan On spiral CT, a nodule was considered malignant with enhancement of >25 HU On PET/CT, nodules were considered malignant with Max. SUV >3.5 The sensitivity, specificity and accuracy were compared
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  • Results: There were 79 malignant & 40 benign nodule Sensitivity, specificity and accuracy of enhanced CT were 81%, 93% & 85% Those on PET/CT were 96% e p=0.008, 88% e p=0.72 & accuracy 93% e p=0.011 Conclusion: PET/CT may be performed as 1 st line test for SPN JNM 2006;47(3)443-
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  • Video-Assisted thoracic excisional biopsy - Safe and highly effective in diagnosing and often in treating solitary pulmonary nodule. - But smaller lesion may be difficult to localize. - Series from the Brigham and Womens Hospital reported successful resection of lesions < 1 cm in diameter without any localization techniques. (N Engl J Med 1995, 52:515) SOLITARY PULMONARY NODULE
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  • Important decisions made by patients physician and by patient himself. Often patient decides between follow-up or surgery SOLITARY PULMONARY NODULE Who makes surgical decision?
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  • Decision may be influenced by numerous factors including the probability that the nodule is malignant, risks of surgery, accuracy of biopsy technique and fear that delay in surgical resection may forfeit the possibility of cure. In addition, surgeon confidence and experience are important in decision making. SOLITARY PULMONARY NODULE
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  • The management options : include -wait and watch strategy or -Immediate surgery -Biopsy of the nodule based on which decision is taken. SOLITARY PULMONARY NODULE
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  • Solitary Pulmonary Nodule Action is not a substitute for judgment
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  • Wait and watch strategy -There are no studies demonstrating a decrease in survival when patient is kept under observation for few months to assess the growth of the nodule. -Observation is advisable when the risk of malignancy is low, the risk of surgery is high or the patient refused further invasive procedures. SOLITARY PULMONARY NODULE
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  • -The proponents of immediate surgery argue that if surgery is delayed, it allows time for the growth of the nodule and therapy reduce the chance of a 5 year survival. -Cummings et. al. (proposed the use of decision analysis based on the probability that the nodule is malignant using Bayes Theorem and four variables I.e. age, history of smoking, diameter of the nodule and prevalence of malignancy. The average of life expectancy in years of various strategies was then compared. SOLITARY PULMONARY NODULE
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  • In patients with calculated probability of malignancy greater than 75-80%, early surgery appeared slightly superior to the needle biopsy. In patients with probability of malignancy less than 75-80%, needle biopsy was slightly superior to immediate surgery. Decision Observation was suggested when the likelihood of malignancy was
  • Approach to the Management of Solitary Pulmonary Nodules SOLITARY PULMONARY NODULE New nodule identified on standard CT scanning Benign calcification pattern on CT or stability for 2 yr. on arcival films Ye s No further testing No Risk factors for surgery Predicted postoperative FEV 1 < 0.8 liter VO2 max < 10-15 ml/kg/min Does probability of cancer warrant surgery, given the Surgical risk? No Moderate probability of cancer (10-60%) Additional testing PET if nodule >1 cm in diameter Contrast-enhanced CT, depending on institutional expertise Transthoracic fine-needle aspiration biopsy if nodule is peripherally located * Bronchoscopy if air-bronchus sign present Low probability of cancer (