RADIOLOGY Cardiovascular System Dr. Abeer Kadem Radiologist.
May 28 – 30, 2015, Montréal, Québec A Canadian Approach to Lung Cancer Screening: What every...
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May 28 – 30, 2015, Montréal, Québec A Canadian Approach to Lung Cancer Screening: What every radiologist should know.
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Transcript of May 28 – 30, 2015, Montréal, Québec A Canadian Approach to Lung Cancer Screening: What every...
May 28 – 30, 2015, Montréal, Québec
A Canadian Approach to Lung Cancer Screening:What every radiologist should know.
May 28 – 30, 2015, Montréal, Québec
Disclosure Statement:
I have/had an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization, which could include:
Speakers bureau: HIT Global, IntermuneSubinvestigator on research sponsored by: Boehringer Ingelheim,
CSL Behring, Grifols
Lung cancer kills more Canadians than
breast, colon and prostate cancers combined.
1% of cancer donations.
7% of cancer research funding.
Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2014. Toronto, ON: Canadian Cancer Society; 2014.
Howlader N, et al. SEER Cancer Statistics Review, 1975-2011, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.
Faster and safer
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abd pel CT CT chest LD CT chest CXR
Comparative average dose in mSv
50 000 randomized to CXR vs low dose CT3 annual screensAge 55 to 74, > 30 pack years
Daria Manos
20% reduction in lung cancer specific mortality.
Screen 320 high risk smokers to prevent one death from lung cancer.
US Preventative Services Task Force
American Thoracic Society
American College of Chest Physicians
American Society of Clinical Oncology
Cancer Care Ontario
“YES! WE SHOULD SCREEN HIGH RISK PATIENTS!”
Canadian Preventative Services Task Force – release date Fall 2015
Lung nodules are very common
NLST data
Positive screen
False positive
True positive
Majority “positive CT” need nothing more than one additional surveillance CT.
Problems with existing definition of positive screen
Follow up
Myth: Size is the most important predictor of malignancy.
Change is more important than size.
Nodules ≥ 10 mm: multiple important variables.
Not all nodules ≥ 10mm need immediate work up.
Problems with existing definition of positive screen
Radiologist is more than a
well paid measuring tape.
13 months
CT too sophisticated a test to reduce to positive or negative results
Problems with existing definition of positive screen
Lu-RADS 1 No nodule
Lu-RADS 2 Benign nodule
Lu-RADS 3 Indeterminate (requires surveillance CT)
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
Lu-RADS 5 Malignant by CT
Lu-RADS 6 Tissue malignant
NEGATIVE
INDETERMINATE
POSITIVE
LU-RADS • Communicates level of concern.• Groups nodules based on the best management.
• Recognizes not all worrisome nodules need same work up.• Maintain safety but control work up costs.• Reassurance that work up plan is appropriate.
• Identifies nodules for which negative PET/CT, bronchoscopy or biopsy would be discordant.
• Provides a roadmap for general radiologists.• Provides a framework for comparable data.
LU-RADS 1 – return to screening
No nodule
Direct participant to smoking cessation support.
Explain limitations of screening.
Describe and instruct re: concerning symptoms.
LU-RADS 2 – return to screening
• Small nodules• < 5mm
LU-RADS 2 – return to screening
• Small nodules• < 5mm
• Stable nodules• Solid stable for 2 years• Subsolid stable for 5 years
• Benign nodules• PFO• Round atelectasis• Benign calcification• Hamartoma• Specific benign tissue
LU-RADS 2 – return to screening
No benefit follow up before next annual screen.
Risk of lung cancer in next 2 years lower than prior to CT.
• Small nodules• < 5mm
• Stable nodules• Solid stable for 2 years• Subsolid stable for 5 years
• Benign nodules• PFO• Round atelectasis• Benign calcification• Hamartoma• Specific benign tissue
69 year old smoker
One year Two years Three years
Some of these nodules will be early cancer but overall no benefit for early follow up CT.
Lu-RADS 1 No nodule
Lu-RADS 2 Benign nodule
Lu-RADS 3 Indeterminate (requires surveillance CT)
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
Lu-RADS 5 Malignant by CT
Lu-RADS 6 Tissue malignant
LU-RADS 3 – Indeterminate recall for
surveillance low dose CT
3 SMALL
3 LARGE
3 SMALL
5-9 mmNot stable long enough to call benign
Too small for PET, biopsy, bronchRisk of cancer not high enough to justify work up.
LU-RADS 3 – Indeterminate recall for surveillance low dose CT
Patients assume all nodules are cancer. (Wiener. Chest 2013).
Myth: 30-50% of lung nodules are malignant
Journal of Nuclear Medicine 1999, Chest 2003, JTO 2011
http://www.brocku.ca/lung-cancer-risk-calculator
For small solid nodules:
Size is important but change is more important.
After 2 years of stability classify as LU-RADS 2 (benign).
Serial growth upstages.
LU-RADS 3 small (nodules 5-9 mm)
≥ 10 mm but CT or clinical features suggest inflammatory
Follow in 4 to 12 weeks.
3 LARGE
LU-RADS 3 – Indeterminate recall for surveillance low dose CT
Asymptomatic patients
LU-RADS 3 – requires surveillance CT
Follow up CTs
ED last monthPneumonia 3 mos ago
LU-RADS 3 – requires surveillance CT
Follow up CTs
3 large: Requires surveillance
Nodules ≥ 10 mm with clinical or CT features suggesting transient process possible
even if patient asymptomatic.
73 year old 50+ pack year current smoker
One year earlier 6 months later
3 months later
Up to 50% of ground glass opacities in asymptomatic patients resolve on follow up.
LU-RADS 3L: Possibly transient:
BaselineSubsolid Ill-defined gg halo air bronchograms
Clinical features
New large nodules
What CT features suggest “possibly transient?”
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
POSITIVE CT
Lu-RADS 4 4A – low risk4B – likely low aggressive adenocarcinoma
4C – likely malignant
4A LOW RISK
Nodule ≥ 10mm with benign but not definitive CT features.
Hamartoma without fatNon-calcified granuloma? round atelectasis, not
definitive
POSITIVE – but low risk
Any relevant priors?PET –good NPV hereCore biopsySerial CT
Discussion
POSITIVE – but low risk
4A LOW RISK
Nodule ≥ 10mm with benign but not definitive CT features.
Hamartoma without fatNon-calcified granuloma? round atelectasis, not
definitive
POSITIVE – but low risk
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
POSITIVE CT
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
4B LIKELY AIS or MIA
Consider risks of surgery, wishes of patientSurgical biopsy vs monitor with CTLimitations of PET, bronch, perc biopsy
LU-RADS 4: worrisome
Non transientSubsolid ≥ 10 mmNo solid or ≤ 5mm solid portion
1 year2 years 4 years 5 years6 years7 years
GG neoplasm may grow very slowly. Will the competing cause of death be more important?
5 years
Focal ground glass opacity can progress to invasive adenocarcinoma.
11 years
Beware of growth:
Persistent + growth = near 100% neoplastic*
* Chang. Chest. 2013
Growth can be missed
8 years
Beware increase in density
8 years
9.5 years 10 years
Was the NLST long enough to evaluate these lesions?
• How to manage?• Biopsy?• To faciltate non surgical
treatment
• New GGO:• Marked FDG uptake
in GGO more likely to be inflammatory
• AIS by definition does not metastasize
PET?
• Mild FDG uptake in persistent GGO strongly predictive of neoplasm
• Useful to plan surgery when multiple lesions present
Treatment for subsolid neoplasm
• Screening studies criticized for overtreatment of indolent disease.• Was the NLST long enough to determine this?
• Consider competing causes of death.• In situ disease in lung is difficult to resect
• Compared to breast, cervix, colon.
• No uniform approach
Resect all persistent GGO?
Resect when solid portion develops
vs.
Approach to GG neoplasm
• GG neoplasm common incidental finding• Persistent GG - high likelihood of in situ
neoplasm.• GGO neoplasm unlikely invasive or metastatic
but can develop into invasive disease with mets.• Treatment decisions:
• Need to reflect size and change of nodule• Comorbidity and competing causes of death• Wishes of patient
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
POSITIVE CT
Lu-RADS 4 4A – low risk
4B – likely low aggressive adenocarcinoma
4C – likely malignant
CT: Likely malignant
21 months
Worrisome change
CT: Likely malignant
Malignant rate depends on local rate of granulomatous infection.
Worrisome baseline
CT: Likely malignant
Negative PETbronchperc biopsy
is discordant and should prompt team discussion.
Do we need a new paradigm?
CT shows SPN
Biopsy, bronchoscopy, PET
Treat
New approach
• Not every worrisome nodule detected by CT requires the same work up.
• For some nodules negative work up will be reassuring, for other nodules it will not be.
• In addition to distinguishing benign from malignant nodules, CT can also help predict nodule aggression.
• Screening CT for lung cancer has arrived in Canada. Will grow exponentially in next 10 years.
• Screening CT presents challenges to radiologists, including legal concerns. • Subtle slow growth in subsolid neoplasm.• Overcalling new or inflammatory nodules.
• Use serial CT, clinical evaluation, PET, biopsy and brochoscopy as team players not a hierarchy.
Last words
• Our behaviour as radiologists in these initial stages has the power to make or break screening.
Last words
