Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director,...

28
Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical Center 18 th Annual Perspectives in Thoracic Oncology

Transcript of Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director,...

Page 1: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 2: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Disclosures

• Research Funding– NIH, DOD– Integrated Diagnostics, Allegro Diagnostics,

• Scientific Advisory Board– Allegro Diagnostics

Page 3: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Nodule, Biopsy and Benign Disease RatesPe

rcen

t of p

atie

nts

in s

cree

ned

arm

2

3

0

1

4

5

RCT

Page 4: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Ost & Gould, AJRCCM 2011

Page 5: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Assessing the Probability of Cancer

• Most Important Factors to consider:– Nodule size and characteristics– Smoking history– Age– Family history of lung cancer– Emphysema

Page 6: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

http://www.brocku.ca/lung-cancer-risk-calculator

Page 7: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

http://www.brocku.ca/lung-cancer-risk-calculator

Page 8: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 9: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Guidelines

Page 10: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 11: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.
Page 12: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Recommendations for Subsolid NodulesNodule Type Management Recommendation

Solitary pure GGN

≤ 5 mm No CT follow-up required

Page 13: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Thick vs. Thin Sections for Small Nodules

Naidich D P et al. Radiology 2013;266:304-317

Page 14: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 15: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 16: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Serial Imaging to Assess Growth (1mm cuts)

Naidich D P et al. Radiology 2013;266:304-317

Page 17: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Rapid Enlargement of a GGO

Naidich D P et al. Radiology 2013;266:304-317

Page 18: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 19: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.
Page 20: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Rationale

• Part solid nodules have a high likelihood of malignancy

• Development of a solid component within a pure GGO

Page 21: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 22: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Multiple subsolid lesions with single dominant focus.

Naidich D P et al. Radiology 2013;266:304-317

Page 23: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

PET Scans

Erasmus, et al. Clinics in Chest Medicine 2008

Page 24: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

PET Scans

• Sensitivity ~ 85% • Specificity ~ 80%• Less accurate for:– Smaller lesions– Subsolid nodlues

Page 25: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

Establishing a Tissue Diagnosis

• Bronchoscopy vs. CT guided TTNA

Modality Sensitivity

Traditional bronchoscopy (screen detected) 15%

Navigational bronchoscopy 70%

CT guided TTNA 90%

Page 26: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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%

Page 27: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

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

Page 28: Screen discovered nodules: What next? Anil Vachani, MD, MS Assistant Professor of Medicine Director, Lung Nodule Program University of Pennsylvania Medical.

THANK YOU