Screen discovered nodules: What next?
18th Annual Perspectives in Thoracic Oncology
Anil Vachani, MD, MS
Assistant Professor of Medicine
Director, Lung Nodule Program
University of Pennsylvania Medical Center
Disclosures
• Research Funding
– NIH, DOD
– Integrated Diagnostics, Allegro Diagnostics,
• Scientific Advisory Board
– Allegro Diagnostics
Nodule, Biopsy and Benign Disease Rates
Percent of patients in screened arm
5
4
3
2
1
0
RCT
Ost & Gould, AJRCCM 2011
Assessing the Probability of Cancer
• Most Important Factors to consider:
– Nodule size and characteristics
– Smoking history
– Age
– Family history of lung cancer
– Emphysema
http://www.brocku.ca/lung-cancer-risk-calculator
http://www.brocku.ca/lung-cancer-risk-calculator
Importance of Nodule Size
Nodule Size
Confirmed Lung Cancer
Yes
PPV (%)
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
Guidelines
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
Recommendations for Subsolid Nodules
Nodule Type
Management Recommendation
Solitary pure GGN
≤ 5 mm
No CT follow-up required
Thick vs. Thin Sections for Small Nodules
Naidich D P et al. Radiology 2013;266:304-317
Recommendations for Subsolid Nodules
Nodule 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
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
Serial Imaging to Assess Growth (1mm cuts)
Naidich D P et al. Radiology 2013;266:304-317
Rapid Enlargement of a GGO
Naidich D P et al. Radiology 2013;266:304-317
Recommendations for Subsolid Nodules
Nodule 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
Rationale
• Part solid nodules have a high likelihood of
malignancy
• Development of a solid component within a
pure GGO
Recommendations for Subsolid Nodules
Nodule 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
Initial CT at 3 months; If persistent, biopsy or
part solid or solid component surgical resection, especially for lesions with > 5mm
solid component
Multiple subsolid lesions with single
dominant focus.
Naidich D P et al. Radiology 2013;266:304-317
PET Scans
Erasmus, et al. Clinics in Chest Medicine 2008
PET Scans
• Sensitivity ~ 85%
• Specificity ~ 80%
• Less accurate for:
– Smaller lesions
– Subsolid nodlues
Establishing a Tissue Diagnosis
• Bronchoscopy vs. CT guided TTNA
Modality
Sensitivity
Traditional bronchoscopy (screen detected)
15%
Navigational bronchoscopy
70%
CT guided TTNA
90%
Establishing a Tissue Diagnosis
• Bronchoscopy vs. CT guided TTNA
Modality
Sensitivity
Traditional bronchoscopy (screen detected)
15%
Navigational bronchoscopy
70%
CT guided TTNA
90%
• Data based on case series
• Risks of CT guided TTNA
– Pneumothorax 15-27%
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
THANK YOU