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Chest imaging in up to 50-yo non symptomatic smokers
G Ferretti CHU Grenoble FRANCE
� CT acquisitions in people > 50 yo � Lung cancer screening studies � Early detection of pulmonary fibrosis � Screening for asbestosis
have increased our need to better understand the morphology of the lung in aging population and particularly in those who have smoking habits
Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010
Aging +/- cigarette smoking
� Abnormalities without clinical consequences ◦ “Wrinkles” within the lung
� Abnormalities with potentially severe evolution ◦ Lung nodules ◦ Emphysema ◦ Respiratory broncholitis ◦ NSIP/UIP pattern ◦ Chronic bronchitis ◦ Air trapping
“WRINKLES” WITHIN THE LUNG
Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010
55 yo patient GGO Opacity in the posterior lung ILD ? Re scan the patient in prone position
Increase pulmonary density in a 67yo patient suspected of PE due to incomplete inspiration and contrast injection Confusing pattern for ILD
Fibrosis adjacent to spinal osteophytes Localized GGO or reticular pattern near dorsal Osteophytes (right side >>> left side No evolution in time Not related to asbestose exposure Not indicative of early UIP
Otake S. AJR 2002;179:893–896.
Aging pattern of the lung (1)
� Bronchial dilatation (Richards DW Bull NYAM 1956)
� Enlargement of alveolar spaces : senile emphysema? (Janssens JP ERJ 1999)
84 yo woman asymptomatic
70 yo smoker man Thickening of bronchial walls
Localized fibrosis of lung parenchyma • Sub pleural reticulation in 60% of asymptomatic
subjects > 75 yo vs 0% < 55 yo
• Interlobular septal enlargement more frequent in older persons
Copley SJ Radiology 2009
Aging lung (2)
� Pulmonary cysts with thin walls in 25% of subjects > 75yo but absent in < 55yo ◦ These cysts are related to aging but not to
tobacco ◦ Their volume is limited
Copley SJ Radiology 2009
72 yo asymptoma+c female
ABNORMALITIES WITH POTENTIALLY SEVERE EVOLUTION
Emphysema
� the link between smoking and emphysema is well demonstrated ◦ Interstitial abnormalities used to be called
“dirty lung” on CXR ◦ Respiratory bronchiolitis / RB ILD has been
described more recently � Centrilobular GGO micronodules � Upper lung
Bronchiolite respiratoire
Pathologie tabagique : EXCES DE MACROPHAGES Bronchiolite respiratoire
– inflammation chronique bronchiolaire, macrophages tatoué
Bronchiolite respiratoire avec infiltration pulmonaire diffuse (RB-ILD)
– Extension dans l ’espace des anomalies TDM. Pneumopathie interstitielle desquamative (DIP))
5 years la2er
*Remy-‐Jardin et al, Radiology 1993, 186: 107-‐115 **Remy-‐Jardin et al, Radiology 1993, 186: 643-‐651 *** Remy-‐Jardin et al Radiology, 2002, 222: 261-‐70
65 yo patient 43 PY Asymptomatic ENT polyps CXR then CT
Tobacco and ILD
� Do smokers develop limited and progressive pulmonary fibrosis ? ◦ Remain controversial ◦ Experts supports that smoking is a direct
cause for developing UIP/NSIP
Cordier JF et Co8n V ERJ 2013
l 2007, 58 yo man chronic cough
l What do you see?
2007 2012
21 │
l 2012 , heterogeneous distribution of ILD l Reticulation l Honey combing l Bronchectasis l Sub pleural distribution
l UIP pattern
Raghu G AJRCCM 2011
692 heavy smokers from the Multicentric Italian Lung Detection (MILD) Four CT patterns were considered:
• usual interstitial pneumonia(UIP) • other chronic interstitial pneumonia (OCIP) • respiratory bronchiolitis (RB) • indeterminate
the evolution of ILD after 3 yrs was assessed UIP pattern in 0.3% OCIP pattern 3.8% progression three (25%) of 12 RB pattern in 15.7% indeterminate pattern in 3%
The lung of smokers in screening program for lung cancer
Sverzella+ N ERJ 2011
� Age, male sex and current smoking status were factors associated with the presence of OCIP and UIP pattern
� Thin-section CT features of ILD, probably representing smoking-related ILD, are not uncommonin a lung cancer screening population and should not be overlooked.
Sverzella+ N ERJ 2011
• 884 smokers from the NLST – ILD at base line – ILD were classified into
• nonfibrotic (ground-glass opacity, consolidation, mosaic attenuation), • fibrotic (GGO with reticular pattern, reticular pattern, honeycombing).
– the rate of progression of ILAs on 2-year follow-up • Résults
– prevalence of equivocal ILD: 11.5% – prevalence of ILD: 9.7%
• Fibrotic 2.1% Progression 37%, improved 0% • Non fibrotic 5.9% improved 49% • Mixed 1.7%
• The percentage of current smokers (P = .001) and mean number of cigarette pack-years (P = .001) were significantly higher in those with ILA than those without.
The lung of smokers in screening program for lung cancer
Jin GY Radiology 2013
Air trapping
Need expiratory acquisitions seen in patients with normal PFT � present in healthy asymptomatic nonsmoking
individuals (Verschakelen JA Eur Radiol 1998) � more frequent in cigarette smokers (Mastora I Radiology
2001)
� found in approximately 50% of asymptomatic subjects. The frequency of air trapping increased with age, and its severity increased with age and smoking (Lee KW Radiology 2000)
INSPIRATION EXPIRATION
Asymptoma+c smokers
• 82 asymptoma-c persons • Air trapping present in 50% • increased Frequency with age • increased Frequency in smokers (>10PA)
Lee et al Radiology 2000, 214: 831-‐36
Tobacco and lung cancer
� Lung cancer is the leading cause of cancer-related deaths worldwide.
� 85% of lung cancer patients are smokers � Most patients are diagnosed with
advanced-stage tumors, precluding curative-intent treatment.
Raz D Chest 2007
Survival of untreated patients with lung cancer
The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. N Eng J Med 2011; 365(5): 395–409.
NLST showed a 20% decrease in lung-cancer-specific
mortality
� US Preventive Service Task Force Humphrey MM Ann Intern Med 2013
� The IASLC Heidi R J Thorac Oncol. 2013
� The National Cancer Center Network Wood DE J Natl Compr Canc Netw 2012
� The American Society of Clinical Oncology, � The American Association of Chest Physician � The American Association for Thoracic Surgery,
Mirkin JN JAMA 2012
� French groups IFCT, SIT, GOLF S Couraud Ann Oncol 2013
Recommended individual screening for lung cancer
Guideline Recommendations
- aged between 55 and 74 years; - at least 30 pack-year tobacco exposure; - active smoker or quit during the last 15 years; - no serious progressive disease (history of cancer other than non-melanoma skin cancer or carcinoma in situ over the past 5 years1; severe co-morbidity, including respiratory insufficiency contraindicating invasive chest examination; prior hemoptysis; unexplained weight loss over 10% over the past 12 months); - no pulmonary infection over the 12 past weeks; - accepts repeated scans or additional investigations in the case of abnormal findings; - accepts considering help to quit smoking (active smokers).
Eligibility
CT CXR
3 types of nodules • Solid • Part-solid • Nonsolid
Etiology VDT Prognostic Action
15.8% 1.9% cancer
4.3% 6.6% cancer
78.9% 1.1% cancer
McWilliams A NEJM 2013
NLST
1
2
3
NELSON
1
2
3
N screening CT N posi-ve N Cancers % de cancer/scr Stade I
NLST 75 126
18 146 24.1%
649 3.6%
0.86% 61.6% (Baseline + rounds 1-2)
NELSON 14 846
324 2.2%
126 38.9%
0.85% 69.8% (Baseline + round 1)
N screening CT N posi-ve N Cancers
NLST 75 126
18 146 24.1%
649 3.6%
FP: 96.6% (Baseline + rounds 1-2)
NELSON 14 846
324 2.2%
126 38.9%
FP: 61.1% (Baseline + round 1)
Follow up of Pulmonary nodules (Fleischner, Radiology 2005)
Guidelines adapted to solid nodules only Specific guidelines for nGGO 2013
Positif test Nelson study
CT at 3-4 months GROWCAT C if VDT < 400 days
Positif
Negatif
1039mm3 at baseline to1539 mm3 at 3 months. T1N0M0 adenocarcinoma
A Marchiano Radiology 2009; 251
V = 4.19 x R3
V x 2 when R x 1.26
Reich JM Eur J Radiol 2011 ;80
Nair & Hansell Eur Radiol 2011; 21:2445–2454
NLST vs. NELSON
Couraud S Annals Oncology 2012.
Couraud S Annals Oncology 2012.
Conclusion � HRCT can demonstrate very early disease,
sometimes in people without symptoms or PFT abnormalities.
� The lung of asymptomatic smokers > 50yo may be affected by ◦ Non significant abnormalities mainly related to
aging ◦ Significant diseases that should be followed
� Smoking may have a premature aging effect on the lungs
Nyunoya T Am J Respir Crit Care Med 2009
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