SPNs and the SPNs and the Early Detection of Lung CancerEarly Detection of Lung CancerGeorge Erbacher D.O., FAOCRGeorge Erbacher D.O., FAOCR

Chair imaging/interventional radiology Chair imaging/interventional radiology OSUMCOSUMC

Radiology residency program directorRadiology residency program director

DEFINITION OF SOLITARY DEFINITION OF SOLITARY PULMONARY NODULE (SPN)PULMONARY NODULE (SPN)

Single round water density mass < 3 cmCompletely surrounded by lung

parenchymaIncidental finding 0.2% CXRs, 1% CT

MIMICS OF SPNMIMICS OF SPN

Chest wall lesionHealing rib fracture AVNAbscessPneumoniaImmune-RA/Wegeners granulomatosis etc.

MIMICS OF SPNMIMICS OF SPN

HematomaLung infarct/atelecatasisPleural plaqueBronchial atresia/SequestrationInhaled FBMOST COMMON: BENIGN

GRANULOMA/HAMARTOMA

PATIENT FEATURES PATIENT FEATURES INCREASING RISK OF INCREASING RISK OF

MALIGNANCYMALIGNANCY

SMOKING ESPECIALLY >20 PK/YEAROlder agePersonal history of malignancyFirst degree relative with lung cancerAsbestos/uranium/radon exposureOther workplace exposure- some aromatic

hydrocarbons, coal mines etc.

IMAGING FEATURES BENIGN IMAGING FEATURES BENIGN VS. MALIGNANTVS. MALIGNANT

Smaller less risk of malignancyWell defined borders tend to be benignIf a cavity –thin walls-favor benignPopcorn like calcification –benign –

characteristic of hamartomaDensity (HU) < 15-20 benignVery fast and very slow growing lesions are

likely benign-PREVIOUS COMPARISON IMAGES ARE CRITICAL

Epidemiology Lung Cancer in Epidemiology Lung Cancer in the Worldthe World

Most frequently diagnosed cancer (1.04M in 1990)

Leading cause of cancer mortality – 921K deaths

Most common cancer in males and #1 cause of cancer death

Incidence Lung Cancer in U.S.Incidence Lung Cancer in U.S.

171,600 cases diagnosed in 1999 (94K M; 77.6K F)

Leading cause of cancer death M & F (158.9K)

Kentucky highest mortality rate – 67.9/100K (37% above avg.)

Utah lowest mortality rate– 21.6/100K (56.4% below avg.)

U.S. Lung CancerU.S. Lung Cancer

1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with

brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

“Lung cancer is the leading cause of cancer mortality in the U.S. among both men and

women surpassing totals from breast, colon, and ovarian cancers

combined.” [1]

SurvivalSurvival

5 years – 14%

50% survive if diagnosed in early stage (small size IA 85 – 100% survival

Only 15% diagnosed in early stage

Tobacco SmokeTobacco Smoke

“Cigarette smoking is causally related to lung cancer…the magnitude of the effect far outweighs all other factors.”

Is leading cause of avoidable mortality in US, w/ about 434K preventable deaths per year

Cost to US economy $200 billion/year

US surgeon general

CXR Screening RevisitedCXR Screening Revisited

Analysis of the 4 RCT from 20 years ago (Mayo, Czech, Sloan-Kettering, Johns-Hopkins)

Czech & Mayo studies found increase in mortality in screened vs. controls (6% increase in Mayo) however 29% MORE lung cancer in screening vs. controls

CXR Screening RevisitedCXR Screening Revisited

Screened had 34% living @ 5yrs vs. 15% control (Sloan-Kettering, Johns-Hopkins similar results)

“Analysis of the randomized trials strongly suggests CXR screening is superior to no screening whatsoever”

Low Dose CT (LD CT)Low Dose CT (LD CT)Screening vs. CXRScreening vs. CXR

Rationale:LD CT greatly increases detection of small non-calcified nodules and of lung cancer at an earlier/more curable stage

LD CT showed non-calcified nodules 3x more commonly

LD CT showed malig. tumors 4x more commonly LD CT showed stage 1 tumors 6x more commonly

LD CT Indication (ELCAP)LD CT Indication (ELCAP)

> 60 y.o.a.

> 10 pk/y smoker & no previous cancer

Medically fit to undergo thoracic surgery

Baseline LD CT, then annuals

ELCAP Technique – Helical CTELCAP Technique – Helical CT

140 kVp, 40 mA2:1 Pitch, 10 mm slice thicknessScan entire lung in 1 breath hold @ end

inspiration after hyperventilationReconstruct images with bone algorithm in

overlapping 5 mm incrementsOnly lung windows (W1500, L-650)

reviewed

ELCAP ScoringELCAP Scoring

1-6 non-calcified nodules = positive

If no non-calcified nodules = negative

> 6 non-calcified nodules, diffuse bronchiectasis, ground glass opacities or combinations = diffuse disease

ELCAP Nodule DescriptionELCAP Nodule Description

Size (L & W/2)Location (lobe & distance from pleura)

peripheral if w/in 2 cm costal marginBenign calcificationsShape (round, non-round)Edge (smooth, non-smooth)

ELCAP “Benign Nodule”ELCAP “Benign Nodule”

Benign calcifications

Smooth edges

< 20 mm size

Guideline for Diagnostic Guideline for Diagnostic Intervention ELCAPIntervention ELCAP

Non-benign nodule on LD CT goes to diagnostic CT w/ high resolution imaging of abnormalities. If not benign per above criteria:– < 5mm : F/U high res CT 3 mo, 6 mo, 12 mo,

24 mo; no growth over 3 yrs=benign– 6-10 mm : bx, if not possible F/U per above– > 11mm : bx

Fleishner Recommendations do Fleishner Recommendations do NOT apply to patients:NOT apply to patients:

<35 Y.O.A. with low risk of lung cancerWho have fever/signs of infection

Fleishner Nodule CT Fleishner Nodule CT Reassessment Reassessment

RecommendationsRecommendations

NONCONTRASTTHIN COLLIMATIONLIMITED COVERAGE-JUST REGION

OF INTERESTLOW DOSE

Nodule Enhancement and Nodule Enhancement and metabolismmetabolism

Cancer/Infection/inflammation- CT neovascularity- malignant nodules enhance > 20

Hounsfield Units (HU), benign < 15 HU

Cancer/Infection/inflammation- increased glucose turnover- PET- SUVmax < 2.5 benign

PET/CT HAS SENSITIVITY AND SPECIFICITY CLOSE TO 90% FOR NODULES 10 MM OR GREATER DIAMETER

PET/CT vs. Helical dynamic CT PET/CT vs. Helical dynamic CT for SPNfor SPN

PET/CT

MORE SENSITIVE (96% vs. 81%) and MORE ACCURATE (93% vs. 85%) than helical dynamic CT

Caveats for PET/CT:Caveats for PET/CT:NO STANDARIZATION FROM NO STANDARIZATION FROM ONE MACHINE TO ANOTHER ONE MACHINE TO ANOTHER

AND POOR AND POOR STANDARDIZATION OFTEN STANDARDIZATION OFTEN

BETWEEN EXAMINATIONS ON BETWEEN EXAMINATIONS ON THE SAME MACHINE.THE SAME MACHINE.

EXPERIENCE OF EXPERIENCE OF TECHNOLOGISTS-TECHNOLOGISTS-

RADIOLOGISTS VARIES RADIOLOGISTS VARIES WIDELYWIDELY

BenignBenign? NM in Lung Cancer? NM in Lung Cancer

Role of PET in Lung CancerRole of PET in Lung Cancer

Improves staging by ruling out mediastinal/distant disease

Useful in evaluating response to therapyUseful in early detection recurrent disease

Rad Clinics N.A. May 2000 p. 523

False Positive and Caveats False Positive and Caveats PET/CTPET/CT

Active necrotizing granulomas and some chronic inflammatory conditions are +

ANY PROCESS THAT HAS INCREASED UPTAKE OF GLUCOSE IS PET POSITIVE

What to do with Indeterminant What to do with Indeterminant CT W/U of SPNCT W/U of SPN

Serial radiographic F/U?

CT alone to decide to surgerize or not?

PET/CT

Surgery for pts w/ + or indeterminant CT?

Cost EffectivenessCost Effectiveness

Radiographic F/U cost effective when probability of malignancy is low (<0.14)

CT alone F/U cost effective when probability of malignancy is high (.71 - .91)

Surgery alone is most cost effective when probability of malignancy is very high > .90

Over greatest range of probability .14 - .71 CT and PET/CT cost effective

Rad Clinics N.A. May 2000 p. 521-522

PRINCIPLES OF IMAGING IN PRINCIPLES OF IMAGING IN ONCOLOGYONCOLOGY

Imaging justified only if results will change therapy with patient benefit

“Where there is an issue get tissue”-biopsy when imaging is inconclusive (imaging guided?)

Positive studies are more valuable/reliable than negative studies

The diagnostic plan should progress logically from least to most invasive studies

Accurate assessment of initial disease extent is vital to selecting and sequencing appropriate treatment

Staging lung cancerStaging lung cancer

Stage 1A-T1N0MO= tumor < 3cm with no positive nodes and no metastasis

Stage 1B-T2N0M0- tumor > 3cm, no nodes, no metastasis

RFA in Pulmonary ApplicationsRFA in Pulmonary Applications

LungLung

25% of patients are candidates for lung resection. [1]

RT and chemotherapy together have a combined 5 year survival rate of 5%. [1]

RF ablation can potentially provide direct cytoreduction, which could make RT and chemotherapy more effective. [1]

1 Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

Lung CancerLung Cancer

Assessment of malignancy has required invasive diagnostic methods– Needle biopsy (10% sampling error; 15%

pneumothorax)– Bronchoscopy (low sensitivity; occ. pneumothorax– Mediastinoscopy (surgical procedure; limited to

anterior mediastinum)– Thoracotomy (open surgery; 1-3% mortality)

FDG-PET expensive and not widely available

“Radiofrequency ablation of lung tumors may be a promising option for nonsurgical candidates given the suboptimal outcomes with current

treatment options.” [1]

“The overall 5-year survival rate for all stages combined is only 15%.” [1]

Lung CancerLung Cancer

1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.

Radiofrequency AblationRadiofrequency AblationNSC Lung CancerNSC Lung Cancer

3 cm RFA3 cm RFA 3 mo S/P 3 mo S/P RFA/XRTRFA/XRT

18 mo S/P 18 mo S/P RFA/XRTRFA/XRT

KEYSKEYS

Excellent H&P Find Comparisons Send the above to your radiologist then call and

discuss the case-have the radiologist lay out the work up as local resources dictate what will be done

IF PATIENT CANDIDATE FOR TREATMENT TISSUE DIAGNOSIS IS NEEDED

We at Diagnostic Imaging We at Diagnostic Imaging Associates are happy to helpAssociates are happy to help

FOR TULSA REFERRAL AREA CALL 918 599 5050/5094 TO TALK TO RADIOLOGIST

FOR OUTSIDE TULSA REFERRAL AREA CALL CHRISTA -918 599 5031 and ask for

radiologist at site nearest you

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