Transcript
Page 1: THE SOLITARY PULMONARY NODULE: SPN - KAP Kenyakapkenya.org/repository/CPDs/Conferences/Annual2012/SOLITARY P… · THE SOLITARY PULMONARY NODULE: SPN BY Dr Mureithi C.J.M. & DR NYALE

THE SOLITARY PULMONARY NODULE: SPN

BY Dr Mureithi C.J.M. & DR NYALE G.M Consultant Physician/ Pulmonologist

TKH

“Practical management tips” Importance cum difficulty of arriving at a diagnosis

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DEFINITION

• A single discrete

– pulmonary opacity that is surrounded by normal lung tissue

– that is not associated with adenopathy or atelectasis

• 3cm or less in diameter

• Aka: coin lesion, small pulmonary peripheral lesions, T1N0M0 (TNM7).

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Prevalence

• 1 - 2 per 1000 CXR (90% CO-INCIDENTAL)

– failure rate to Dx SPN on CXRs:25 - 90% CHEST 2003; 123:89S–96S

• CT scan screening: higher prevalence's.

• Local data: ? KENYA – A recent study in Cape Town of resectable lung cancer Median size of

tumour at DX was 61.5 mm Nanguzgambo A. J Thorac Oncol. 2011 Feb;6(2):343-50

• overall malignancy rate of 10-68%

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Major Question: is this a cancer?

Fishman’s Pulmonary Diseases and Disorders;4th Edition, 2008

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Risk factors for malignancy

• Age

• smoking history:

• prior history of malignancy.

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Nodule x-ristics associated with malignancy

• Nodule size

• Edges

• Consistency / Cavitations

• Calcification

• Growth rate

• Densitometry

• Location

• Metabolic rate

Radiology 2005; 237:395–400

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Risk factors for malignancy

www.chestx-ray.com/spn/spnprob.html

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Nodule size

• < 5 mm: 0 to 1% malignant

• 5 to 10 mm: 6 to 28% malignant

• > 20 mm: 64 to 82% malignant

• masses(>3 cm): 80 to 99 % malignant

CHEST 2007; 132:94S–107S

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Edges/margins/borders

Fishman’s Pulmonary Diseases and Disorders;4th Edition, 2008

Increased cancer risk

smooth edges: 20 - 30%; irregular, lobulated, or spiculated: 33 - 100%

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Nodule consistency • Solid: 7 to 9% malignancy

• Non-solid nodules:18% malignancy

• Partially Solid: 63% malignancy

• Densitometry:> 185 hu <9% cancer

• Cavity wall:

– <5 mm = 95% benign

– 5 to 15 mm = 73% benign

– >15 mm = 84% malignant

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Calcification patterns

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SPNs Growth rate: Volume Doubling Time (VDT)

• Volume = 4/3(π)r3 or 1/6(π)D3

E.g: 10mm SPN ------> 13mm --------------> 20mm

(0.524ml) (1.151 ml) (4.190 ml)

• Benign SPNs VDT: < 20 days OR > 400 days.

• Traditional practice: repeat CT scans @ at 3, 6, 12, and 24 months.

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CXR • Threshold Nodule size

diameter 0.8 -1cm

• Margin: smooth, irregular, lobulated, or

spiculated (corona radiata)

• Calcification

• Growth rate: past CXR (last 2 yrs)

• if absent = rapid growth hence malignancy unlikely

• Not changed in size = benign

• Present but slow growing = ?malignant

Popcorn calcification

Radiology 2005; 237:395–400

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CT SCAN • picks 40 % more (>CXR)

• 3D location

• adjacent structures / remaining lung

• More detail on SPN e.g fat

• helps in staging

• assessing accessibility in Sx /Bx Popcorn calcification

Radiology 2005; 237:395–400

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HRCT • Same as CT but refined detail: ? Necessity

• Lower sensitivity & specificity

• Covers only 10% of lung

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Another reason why doctors need better pay!

blackberry phones!

• http://www.chestx-Ray.com/spn/spnprob.html

Lung cancer risk calculator models

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MAYO MODEL • N = 629 (Males=51%); size= 4–30 mm)

Pre-test probability of a malignant SPN = ex/(1+ex) x = 26.8272 + (0.0391*age) + (0.7917*smoke) +(1.3388*cancer) +

(0.1274*diameter) + (1.0407*spiculation)+ (0.7838*upper) Where: e =the base of the natural logarithm age=patient’s age in years smoke = smoking history (1 =current or former smoker, 0 = never smoker) cancer =extrathoracic CA >5 years (1 = yes, 0 = no or not specified) Diameter= largest nodule measurement (in mm) on initial CXR/ CT scan Spiculation = spiculation on imaging (1 = yes, 0 =no or not specified) upper = location in upper lobe/s (1 = yes, 0 = no).

Mayo clin proc 1999; 74: 319 – 329

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VA MODEL • N=375 patients (98%male); size = 7–30 mm

Pre-test probability of a malignant SPN = ex/(1+ex)

x =28.404+ (2.061*smoke) + (0.779*age10) + (0.112*diameter) 2 (0.567*yearsquit10)

Where:

e = the base of the natural logarithm

smoke =smoking Hx (1 = current or former smoker, 0 = neversmoker)

age10 = age in years at Dx SPN divided by 10

Diameter= the largest in mm reported on initial CXR/CTscan

yearsquit10 = the number of years sincequitting smoking, divided by 10 (0 indicates not applicable).

CHEST 2007; 131:383–388

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Management

• Low Probability (< 10%) – Follow with serial CT scans – Traditionally q3 months X 4 q6 months X 2 – ? Tissue sampling in future

• Intermediate Probability (10 – 60%)

– additional imaging – Tissue Sampling

• High Probability (>60%) – Excision – Imaging to r\o metastasis and stage patient.

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Management outline for SPNs

Fishman’s Pulmonary Diseases and Disorders;4th Edition, 2008

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SPN - follow up

Radiology 2005; 237:395–400

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Additional Imaging

“For the indeterminate SPNs /staging”

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Incremental dynamic CT (Contrast enhancement)

• Principle: Malignant SPNs have greater vascularity than benign nodules.

• uses serially increasing doses of iodinated IV contrast to

look for enhancement of nodules • < 15 HU = benign :> 20 HU =malignant (sensitivity: 98 -

100%; specificity: 54 - 93%)

CHEST 2007; 132:94S–107S

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PET SCAN • Based on increased glucose uptake and

metabolism by tumor cells.

• standardized uptake ratio/value (SUR/V): malignancy >2.5

• low sensitivity in SPNs < 1 cm. – new evidence of good sensitivity in 0.8 – 1 cm

• Detects mediastinal metastases/ staging

Am J Respir Crit Care Med 183;2011

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PET SCAN • A meta-analysis of 13 studies (n= 450)

: – sensitivity = 94.3%, – specificity = 83.3%.

– False-negative:

• BAC, • Carcinoids

• mucinous adenocarcinomas.

– False-positives: • granulomatous infections e.g. TB, fungi • inflammatory conditions e.g. R.A, sarcoidosis • uncontrolled hyperglycemia

• high negative predictive value:

– low-risk pts (Prob < 20%) + Neg PET= < 1% Malignancy

– high-risk pts (Prob >80%) + Neg PET = 14%

malignancy

Am J Respir Crit Care Med 183;2011

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PET/CT

+ =

Am J Respir Crit Care Med 183;2011

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PET/CT • Very good is determining SPN size (T stage)

• High NPV (esp Nodal spread ->no need for mediastinoscopy)

• Detects extra-thoracic metastasis better

• Reduces thoracotomies (total & futile)

• Mortality same as in PET alone

1. N Engl J Med 2003;348:2500-7.

2. Radiology 2003;229:526-33

3. Ann Thorac Surg 2004;78:1017-23

4. J Nucl Med 2007; 48:1761–1766

5. N Engl J Med 2009;361:32-9.

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Tissue Dx

“Ultimate

Diagnosis”

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Nodule Sampling

• Bronchoscopic techniques

• Percutaneous needle aspiration/ biopsy

• Surgically: VATS / Thoracotomy

Decision depends on: size, location, local expertise

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New & future advances

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spherical harmonics (SHs)

• Principle: malignant nodules have more complex shapes (e.g. spiculated) than benign nodules (e.g. smoothed)

Step 1 Step 3

Step 2

From Nano to Macro, 2011 IEEE International Symposium on Biomedical Imaging;March 30 2011-April 2 2011 Chicago, IL, USA

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Perfusion CT “dynamic area-detector CT” • Uses a quantitative first-pass perfusion 256 0r 320–detector row (CT) already in

use for brain, heart, and pancreas. (functional CT) • Principle: malignant nodules have higher blood flows and higher metabolism

hence extract more oxygen

• Potentially more specific and accurate than PET/CT

Radiology: Volume 258: Number 2—February 2011

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Radiology: Volume 258: Number 2—February 2011

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Virtual bronchoscopy (VB) + EBUS-GS

Am J Respir Crit Care Med 183;2011

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Locatable Guide (LG):

360° steerability for

navigation to lesions and

lymph nodes

Extended Working

Channel (EWC): Lock

EWC in place for

insertion of biopsy tools

and other catheters Patient Sensor Triplets:

Placed on patient and are

tracking sensors to show LG

position and account for

patient movement

Location Board: creates

electromagnetic field

Bronchoscopic Access:

LG and EWC go through

mouth/nose to steer through

bronchial tree to lesions and

lymph nodes

Planning Screen

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New lung cancer genes

• GWAS identified a SNP close to NAT subunit with susceptibility to lung cancer at 15q24–15q25.1 (markers rs1051730 andrs8034191)

• low- penetrance,

• high-frequency in lung-cancer pts

• risk may be independent of smoking behavior.

• Confirmed by 3 large GWAS – Amos CI et al. Genome-wide association scan of tag SNPs identifies a susceptibility locus for lung

cancer at 15q25.1. Nat Genet 2008;40:616-22

– Hung RJ et al.A susceptibility locus for lung cancer maps to nicotinic acetylcholine receptor subunit genes on 15q25. Nature 2008;452:633-7.

– Thorgeirsson TE et al. A variant associated with nicotine dependence, lung cancer and peripheral arterial disease. Nature 2008;452:638-42

1. N Engl J Med 2008;359:1367-80.

2. N Engl J Med 2008;359:2143-53.

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Thank you for your attention

Judas, what are the coins for?


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