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The Solitary Pulmonary The Solitary Pulmonary Nodule Nodule Suneel S. Kumar MD Suneel S. Kumar MD

The Solitary Pulmonary Nodule Suneel S. Kumar MD

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Page 1: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

Suneel S. Kumar MDSuneel S. Kumar MDSuneel S. Kumar MDSuneel S. Kumar MD

Page 2: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

““Coin lesion”Coin lesion” Defined as < 3 cmDefined as < 3 cm Completely surrounded by lung Completely surrounded by lung

parenchymaparenchyma Lesions > 3 cm called “masses” and Lesions > 3 cm called “masses” and

often malignantoften malignant

““Coin lesion”Coin lesion” Defined as < 3 cmDefined as < 3 cm Completely surrounded by lung Completely surrounded by lung

parenchymaparenchyma Lesions > 3 cm called “masses” and Lesions > 3 cm called “masses” and

often malignantoften malignant

Page 3: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

Incidence of cancer from 10 – 70%Incidence of cancer from 10 – 70% Found on 0.09 to 0.20 % of all CXRs Found on 0.09 to 0.20 % of all CXRs

(approximately 1 in 500)(approximately 1 in 500) 90% incidental findings90% incidental findings 150,000 SPNs found annually150,000 SPNs found annually Increased with incidental findings on Increased with incidental findings on

CTCT

Incidence of cancer from 10 – 70%Incidence of cancer from 10 – 70% Found on 0.09 to 0.20 % of all CXRs Found on 0.09 to 0.20 % of all CXRs

(approximately 1 in 500)(approximately 1 in 500) 90% incidental findings90% incidental findings 150,000 SPNs found annually150,000 SPNs found annually Increased with incidental findings on Increased with incidental findings on

CTCT

Page 4: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

Patients with best prognosis are stage Patients with best prognosis are stage IA (TIA (T11NN00MM00))

61 – 75% 5-year survival following 61 – 75% 5-year survival following surgical resectionsurgical resection

Approximately half of all lung cancers Approximately half of all lung cancers have extrapulmonary spread by time have extrapulmonary spread by time of diagnosisof diagnosis

5-year survival 10 – 15%5-year survival 10 – 15%

Patients with best prognosis are stage Patients with best prognosis are stage IA (TIA (T11NN00MM00))

61 – 75% 5-year survival following 61 – 75% 5-year survival following surgical resectionsurgical resection

Approximately half of all lung cancers Approximately half of all lung cancers have extrapulmonary spread by time have extrapulmonary spread by time of diagnosisof diagnosis

5-year survival 10 – 15%5-year survival 10 – 15%

Page 5: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

Most SPNs are benignMost SPNs are benign Primary malignancy found in about Primary malignancy found in about

35%35% Solitary metastases may account for Solitary metastases may account for

23%23%

Most SPNs are benignMost SPNs are benign Primary malignancy found in about Primary malignancy found in about

35%35% Solitary metastases may account for Solitary metastases may account for

23%23%

Page 6: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis NeoplasmNeoplasm InfectionInfection InflammationInflammation Vascular lesionVascular lesion Post-traumaticPost-traumatic Congenital Congenital Lung cystLung cyst Pulmonary infarctPulmonary infarct AmyloidosisAmyloidosis

NeoplasmNeoplasm InfectionInfection InflammationInflammation Vascular lesionVascular lesion Post-traumaticPost-traumatic Congenital Congenital Lung cystLung cyst Pulmonary infarctPulmonary infarct AmyloidosisAmyloidosis

Rheumatoid nodulesRheumatoid nodules Intrapulmonary Intrapulmonary

lymph nodeslymph nodes Plasma cell Plasma cell

granulomasgranulomas Sarcoidosis Sarcoidosis Mucoid impactionMucoid impaction HematomaHematoma Nipple shadowNipple shadow

Rheumatoid nodulesRheumatoid nodules Intrapulmonary Intrapulmonary

lymph nodeslymph nodes Plasma cell Plasma cell

granulomasgranulomas Sarcoidosis Sarcoidosis Mucoid impactionMucoid impaction HematomaHematoma Nipple shadowNipple shadow

Page 7: The Solitary Pulmonary Nodule Suneel S. Kumar MD

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

The Solitary Pulmonary The Solitary Pulmonary NoduleNodule

Since the SPN by definition is a Since the SPN by definition is a radiographic finding, radiological radiographic finding, radiological imaging is intrinsic to the diagnostic imaging is intrinsic to the diagnostic workupworkup

Since the SPN by definition is a Since the SPN by definition is a radiographic finding, radiological radiographic finding, radiological imaging is intrinsic to the diagnostic imaging is intrinsic to the diagnostic workupworkup

Page 8: The Solitary Pulmonary Nodule Suneel S. Kumar MD

RadiologyRadiologyRadiologyRadiology

Failure to recognize lung cancer on CXR Failure to recognize lung cancer on CXR is one of most frequent causes of missed is one of most frequent causes of missed diagnosis in radiologydiagnosis in radiology

Rate of failure to diagnose ranges from Rate of failure to diagnose ranges from 25 – 90% in different studies with 25 – 90% in different studies with different designsdifferent designs

Error rate of 20 – 50% for radiological Error rate of 20 – 50% for radiological detection of lung cancer is generally detection of lung cancer is generally accepted*accepted*

Failure to recognize lung cancer on CXR Failure to recognize lung cancer on CXR is one of most frequent causes of missed is one of most frequent causes of missed diagnosis in radiologydiagnosis in radiology

Rate of failure to diagnose ranges from Rate of failure to diagnose ranges from 25 – 90% in different studies with 25 – 90% in different studies with different designsdifferent designs

Error rate of 20 – 50% for radiological Error rate of 20 – 50% for radiological detection of lung cancer is generally detection of lung cancer is generally accepted*accepted*

*Guiss, Cancer 1960;13:91-5*Guiss, Cancer 1960;13:91-5

Page 9: The Solitary Pulmonary Nodule Suneel S. Kumar MD

RadiologyRadiologyRadiologyRadiology

Study looked back at CXRs in 259 Study looked back at CXRs in 259 patients with proven NSCLC*patients with proven NSCLC*

Found 19% incidence of missed Found 19% incidence of missed diagnosisdiagnosis

Those missed had significantly Those missed had significantly smaller nodules (median diameter 16 smaller nodules (median diameter 16 mm), more superimposing structures, mm), more superimposing structures, and more indistinct bordersand more indistinct borders

Study looked back at CXRs in 259 Study looked back at CXRs in 259 patients with proven NSCLC*patients with proven NSCLC*

Found 19% incidence of missed Found 19% incidence of missed diagnosisdiagnosis

Those missed had significantly Those missed had significantly smaller nodules (median diameter 16 smaller nodules (median diameter 16 mm), more superimposing structures, mm), more superimposing structures, and more indistinct bordersand more indistinct borders

*Quekel, Chest 1999;115:720-32*Quekel, Chest 1999;115:720-32

Page 10: The Solitary Pulmonary Nodule Suneel S. Kumar MD

RadiologyRadiologyRadiologyRadiology

Time of delay in diagnosis was Time of delay in diagnosis was significant at 472 vs 29 dayssignificant at 472 vs 29 days

Resulted in 43% of lesions being Resulted in 43% of lesions being upstaged from Tupstaged from T11 to T to T22 during the during the delay period*delay period*

Time of delay in diagnosis was Time of delay in diagnosis was significant at 472 vs 29 dayssignificant at 472 vs 29 days

Resulted in 43% of lesions being Resulted in 43% of lesions being upstaged from Tupstaged from T11 to T to T22 during the during the delay period*delay period*

*Quekel, Chest 1999;115:720-32*Quekel, Chest 1999;115:720-32

Page 11: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins

Corona radiata signCorona radiata sign Fine linear strands Fine linear strands

extending 4-5 mm extending 4-5 mm outwardoutward

Spiculated on CXRsSpiculated on CXRs 84 – 90% are 84 – 90% are

malignantmalignant

Corona radiata signCorona radiata sign Fine linear strands Fine linear strands

extending 4-5 mm extending 4-5 mm outwardoutward

Spiculated on CXRsSpiculated on CXRs 84 – 90% are 84 – 90% are

malignantmalignant

Page 12: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins

Page 13: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins

Spiculated lipoid pneumonia

Spiculated lipoid pneumonia

Page 14: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins

Scalloped borderScalloped border Intermediate Intermediate

probability of probability of cancercancer

Smooth border Smooth border suggestive of suggestive of benign diagnosisbenign diagnosis

Scalloped borderScalloped border Intermediate Intermediate

probability of probability of cancercancer

Smooth border Smooth border suggestive of suggestive of benign diagnosisbenign diagnosis

Page 15: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Other CharacteristicsOther CharacteristicsOther CharacteristicsOther Characteristics

Air bronchograms Air bronchograms and and pseudocavitation pseudocavitation more commonly more commonly malignantmalignant

Cavitation with Cavitation with thick (>15 mm vs thick (>15 mm vs < 5 mm) more < 5 mm) more often maligantoften maligant

Air bronchograms Air bronchograms and and pseudocavitation pseudocavitation more commonly more commonly malignantmalignant

Cavitation with Cavitation with thick (>15 mm vs thick (>15 mm vs < 5 mm) more < 5 mm) more often maligantoften maligant

Page 16: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Air BronchogramsAir BronchogramsAir BronchogramsAir Bronchograms

Page 17: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CalcificationCalcificationCalcificationCalcification

Suggests benign diagnosisSuggests benign diagnosis With CT the reference standard, CXR With CT the reference standard, CXR

has sensitivity 50%, specificity 87%, has sensitivity 50%, specificity 87%, and PPV 93% for identifying and PPV 93% for identifying calcificationcalcification

Suggests benign diagnosisSuggests benign diagnosis With CT the reference standard, CXR With CT the reference standard, CXR

has sensitivity 50%, specificity 87%, has sensitivity 50%, specificity 87%, and PPV 93% for identifying and PPV 93% for identifying calcificationcalcification

Page 18: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CalcificationCalcificationCalcificationCalcification

Laminated or Laminated or central pattern central pattern typical of typical of granulomagranuloma

Laminated or Laminated or central pattern central pattern typical of typical of granulomagranuloma

Page 19: The Solitary Pulmonary Nodule Suneel S. Kumar MD

HistoplasmomaHistoplasmomaHistoplasmomaHistoplasmoma

Page 20: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Popcorn CalcificationPopcorn CalcificationPopcorn CalcificationPopcorn Calcification

Classic “popcorn” Classic “popcorn” pattern often seen pattern often seen in hamartomasin hamartomas

HRCT can show fat HRCT can show fat and cartilage in and cartilage in half of caseshalf of cases

Classic “popcorn” Classic “popcorn” pattern often seen pattern often seen in hamartomasin hamartomas

HRCT can show fat HRCT can show fat and cartilage in and cartilage in half of caseshalf of cases

Page 21: The Solitary Pulmonary Nodule Suneel S. Kumar MD

HamartomaHamartomaHamartomaHamartoma

Page 22: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CalcificationCalcificationCalcificationCalcification

Stippled or Stippled or eccentric patternseccentric patterns

Have been Have been associated with associated with cancercancer

Stippled or Stippled or eccentric patternseccentric patterns

Have been Have been associated with associated with cancercancer

Page 23: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CalcificationCalcificationCalcificationCalcification

Page 24: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Rounded AtelectasisRounded AtelectasisRounded AtelectasisRounded Atelectasis

Page 25: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Rounded AtelectasisRounded AtelectasisRounded AtelectasisRounded Atelectasis

Page 26: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Growth RateGrowth RateGrowth RateGrowth Rate

Volume-doubling time for malignant Volume-doubling time for malignant bronchogenic tumors rarely < 1 bronchogenic tumors rarely < 1 month or > 1 yearmonth or > 1 year

If considered spherical, 30% increase If considered spherical, 30% increase in diameter represents a doubling of in diameter represents a doubling of volumevolume

Volume-doubling time for malignant Volume-doubling time for malignant bronchogenic tumors rarely < 1 bronchogenic tumors rarely < 1 month or > 1 yearmonth or > 1 year

If considered spherical, 30% increase If considered spherical, 30% increase in diameter represents a doubling of in diameter represents a doubling of volumevolume

Page 27: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Growth RateGrowth RateGrowth RateGrowth Rate

Traditionally, stability of SPN on CXR for 2 Traditionally, stability of SPN on CXR for 2 years suggested benign diseaseyears suggested benign disease

Bronchoalveolar cell carcinoma and Bronchoalveolar cell carcinoma and typical carcinoids occasionally appear typical carcinoids occasionally appear stable for more than 2 yearsstable for more than 2 years

Hamartomas often grow over timeHamartomas often grow over time Initial studies were retrospective and Initial studies were retrospective and

reviewed only cases which were resectedreviewed only cases which were resected

Traditionally, stability of SPN on CXR for 2 Traditionally, stability of SPN on CXR for 2 years suggested benign diseaseyears suggested benign disease

Bronchoalveolar cell carcinoma and Bronchoalveolar cell carcinoma and typical carcinoids occasionally appear typical carcinoids occasionally appear stable for more than 2 yearsstable for more than 2 years

Hamartomas often grow over timeHamartomas often grow over time Initial studies were retrospective and Initial studies were retrospective and

reviewed only cases which were resectedreviewed only cases which were resected

Page 28: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Growth RateGrowth RateGrowth RateGrowth Rate

One study examined 156 solitary One study examined 156 solitary lesions 1 – 14 cm in sizelesions 1 – 14 cm in size

Previous CXR in 74Previous CXR in 74 Previously documented no growth in 26Previously documented no growth in 26 9 of these were malignant*9 of these were malignant* Absence of growth over 2 years on CXR Absence of growth over 2 years on CXR

has predictive value of 65% for benign has predictive value of 65% for benign lesionslesions

One study examined 156 solitary One study examined 156 solitary lesions 1 – 14 cm in sizelesions 1 – 14 cm in size

Previous CXR in 74Previous CXR in 74 Previously documented no growth in 26Previously documented no growth in 26 9 of these were malignant*9 of these were malignant* Absence of growth over 2 years on CXR Absence of growth over 2 years on CXR

has predictive value of 65% for benign has predictive value of 65% for benign lesionslesions

*Yankelevitz, Am J Roentgenol 1997;168:325-8*Yankelevitz, Am J Roentgenol 1997;168:325-8

Page 29: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Growth RateGrowth RateGrowth RateGrowth Rate

Use of stability predicated on Use of stability predicated on accurate measurement of growthaccurate measurement of growth

Thus, it is dependent on resolution of Thus, it is dependent on resolution of imaging techniqueimaging technique

Thin-section high-resolution CT has Thin-section high-resolution CT has better estimation of nodule size and better estimation of nodule size and growth characteristicsgrowth characteristics

Use of stability predicated on Use of stability predicated on accurate measurement of growthaccurate measurement of growth

Thus, it is dependent on resolution of Thus, it is dependent on resolution of imaging techniqueimaging technique

Thin-section high-resolution CT has Thin-section high-resolution CT has better estimation of nodule size and better estimation of nodule size and growth characteristicsgrowth characteristics

Page 30: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Growth RateGrowth RateGrowth RateGrowth Rate

Limit of detectable changes on CXR Limit of detectable changes on CXR estimated to be 3 – 5 mmestimated to be 3 – 5 mm

CT has resolution of 0.3 mmCT has resolution of 0.3 mm Reasonable to use two-year stability Reasonable to use two-year stability

on CT as a practical guidelineon CT as a practical guideline

Limit of detectable changes on CXR Limit of detectable changes on CXR estimated to be 3 – 5 mmestimated to be 3 – 5 mm

CT has resolution of 0.3 mmCT has resolution of 0.3 mm Reasonable to use two-year stability Reasonable to use two-year stability

on CT as a practical guidelineon CT as a practical guideline

Page 31: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Follow-UpFollow-UpFollow-UpFollow-Up

Optimal time not knownOptimal time not known Traditionally follow every three Traditionally follow every three

months for first year, then six months for first year, then six months the second yearmonths the second year

Provided CT is usedProvided CT is used

Optimal time not knownOptimal time not known Traditionally follow every three Traditionally follow every three

months for first year, then six months for first year, then six months the second yearmonths the second year

Provided CT is usedProvided CT is used

Page 32: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Nonsurgical ApproachesNonsurgical ApproachesNonsurgical ApproachesNonsurgical Approaches

CT DensitometryCT Densitometry Contrast-enhanced CTContrast-enhanced CT BronchoscopyBronchoscopy Transthoracic fine needle aspiration Transthoracic fine needle aspiration

biopsybiopsy Positron emission tomographyPositron emission tomography

CT DensitometryCT Densitometry Contrast-enhanced CTContrast-enhanced CT BronchoscopyBronchoscopy Transthoracic fine needle aspiration Transthoracic fine needle aspiration

biopsybiopsy Positron emission tomographyPositron emission tomography

Page 33: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CT DensitometryCT DensitometryCT DensitometryCT Densitometry

Involves measurement of attenuation Involves measurement of attenuation valuesvalues

Expressed in Hounsfield units, as Expressed in Hounsfield units, as compared to reference “phantom”compared to reference “phantom”

Usually higher for benign nodulesUsually higher for benign nodules Allows for identification of 35 – 55% of Allows for identification of 35 – 55% of

subsequently identified benign lesionssubsequently identified benign lesions

Involves measurement of attenuation Involves measurement of attenuation valuesvalues

Expressed in Hounsfield units, as Expressed in Hounsfield units, as compared to reference “phantom”compared to reference “phantom”

Usually higher for benign nodulesUsually higher for benign nodules Allows for identification of 35 – 55% of Allows for identification of 35 – 55% of

subsequently identified benign lesionssubsequently identified benign lesions

Page 34: The Solitary Pulmonary Nodule Suneel S. Kumar MD

CT DensitometryCT DensitometryCT DensitometryCT Densitometry

One large, multicenter trial, only 1 of One large, multicenter trial, only 1 of 66 nodules identified as benign later 66 nodules identified as benign later found to be malignant*found to be malignant*

Cutoff used was 264 Hounsfield unitsCutoff used was 264 Hounsfield units More conventional cutoff is 185, More conventional cutoff is 185,

which yielded a higher false negative which yielded a higher false negative raterate

One large, multicenter trial, only 1 of One large, multicenter trial, only 1 of 66 nodules identified as benign later 66 nodules identified as benign later found to be malignant*found to be malignant*

Cutoff used was 264 Hounsfield unitsCutoff used was 264 Hounsfield units More conventional cutoff is 185, More conventional cutoff is 185,

which yielded a higher false negative which yielded a higher false negative raterate

*Zerhouni, Radiology 1986;160:319-27*Zerhouni, Radiology 1986;160:319-27

Page 35: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Contrast-Enhanced CTContrast-Enhanced CTContrast-Enhanced CTContrast-Enhanced CT

Degree on enhancement on spiral CT after Degree on enhancement on spiral CT after injection of contrastinjection of contrast

One study used an increase in attenuation One study used an increase in attenuation of 20 Hounsfield units as threshold for of 20 Hounsfield units as threshold for malignant lesionsmalignant lesions

Sensitivity 95-100%, specificity 70-93%*Sensitivity 95-100%, specificity 70-93%* Awaits further validationAwaits further validation Local expertise varies, and not widely usedLocal expertise varies, and not widely used

Degree on enhancement on spiral CT after Degree on enhancement on spiral CT after injection of contrastinjection of contrast

One study used an increase in attenuation One study used an increase in attenuation of 20 Hounsfield units as threshold for of 20 Hounsfield units as threshold for malignant lesionsmalignant lesions

Sensitivity 95-100%, specificity 70-93%*Sensitivity 95-100%, specificity 70-93%* Awaits further validationAwaits further validation Local expertise varies, and not widely usedLocal expertise varies, and not widely used

*Zhang, Radiology 1997;205:471-8*Zhang, Radiology 1997;205:471-8

Page 36: The Solitary Pulmonary Nodule Suneel S. Kumar MD

BronchoscopyBronchoscopyBronchoscopyBronchoscopy

Useful for lesions at least 2 cmUseful for lesions at least 2 cm Diagnostic yield varies in literature Diagnostic yield varies in literature

from 20 – 80%, depending on size of from 20 – 80%, depending on size of nodule and patient populationnodule and patient population

Yield depends on nodule size and Yield depends on nodule size and proximity to bronchial treeproximity to bronchial tree

Useful for lesions at least 2 cmUseful for lesions at least 2 cm Diagnostic yield varies in literature Diagnostic yield varies in literature

from 20 – 80%, depending on size of from 20 – 80%, depending on size of nodule and patient populationnodule and patient population

Yield depends on nodule size and Yield depends on nodule size and proximity to bronchial treeproximity to bronchial tree

Page 37: The Solitary Pulmonary Nodule Suneel S. Kumar MD

BronchoscopyBronchoscopyBronchoscopyBronchoscopy

Yield 10% for < 1.5 cm, and 40 – Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm60% for > 2 – 3 cm

70% yield when CT reveals a 70% yield when CT reveals a bronchus leading to lesion bronchus leading to lesion

Yield 10% for < 1.5 cm, and 40 – Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3 cm60% for > 2 – 3 cm

70% yield when CT reveals a 70% yield when CT reveals a bronchus leading to lesion bronchus leading to lesion

Page 38: The Solitary Pulmonary Nodule Suneel S. Kumar MD

BronchoscopyBronchoscopyBronchoscopyBronchoscopy

Relatively low riskRelatively low risk Overall complication rate 5%Overall complication rate 5% 3% risk of pneumothorax3% risk of pneumothorax 1% risk of hemorrhage1% risk of hemorrhage 0.24% risk of death0.24% risk of death

Relatively low riskRelatively low risk Overall complication rate 5%Overall complication rate 5% 3% risk of pneumothorax3% risk of pneumothorax 1% risk of hemorrhage1% risk of hemorrhage 0.24% risk of death0.24% risk of death

Page 39: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Transthoracic FNATransthoracic FNATransthoracic FNATransthoracic FNA

Diagnostic yield up to 95% in Diagnostic yield up to 95% in peripheral lesionsperipheral lesions

Higher complication rateHigher complication rate 30% pneumothorax30% pneumothorax About 5% of these require chest tubeAbout 5% of these require chest tube

Diagnostic yield up to 95% in Diagnostic yield up to 95% in peripheral lesionsperipheral lesions

Higher complication rateHigher complication rate 30% pneumothorax30% pneumothorax About 5% of these require chest tubeAbout 5% of these require chest tube

Page 40: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Uptake of 18-flurodeoxyglucose used Uptake of 18-flurodeoxyglucose used to measure glucose metabolismto measure glucose metabolism

Taken up by cells in glycolysis but is Taken up by cells in glycolysis but is bound within cells and cannot enter bound within cells and cannot enter normal glycolytic pathwaynormal glycolytic pathway

Most tumors have greater uptake of Most tumors have greater uptake of FDG than normal tissueFDG than normal tissue

Due to increased metabolic activityDue to increased metabolic activity

Uptake of 18-flurodeoxyglucose used Uptake of 18-flurodeoxyglucose used to measure glucose metabolismto measure glucose metabolism

Taken up by cells in glycolysis but is Taken up by cells in glycolysis but is bound within cells and cannot enter bound within cells and cannot enter normal glycolytic pathwaynormal glycolytic pathway

Most tumors have greater uptake of Most tumors have greater uptake of FDG than normal tissueFDG than normal tissue

Due to increased metabolic activityDue to increased metabolic activity

Page 41: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Sensitivity for identifying a Sensitivity for identifying a malignancy is 96.8% and specificity malignancy is 96.8% and specificity 77.8%*77.8%*

False negatives can occurFalse negatives can occur Notable in association with Notable in association with

bronchoalveolar carcinoma, bronchoalveolar carcinoma, carcinoids, and tumors < 1 cm in carcinoids, and tumors < 1 cm in diameterdiameter

Sensitivity for identifying a Sensitivity for identifying a malignancy is 96.8% and specificity malignancy is 96.8% and specificity 77.8%*77.8%*

False negatives can occurFalse negatives can occur Notable in association with Notable in association with

bronchoalveolar carcinoma, bronchoalveolar carcinoma, carcinoids, and tumors < 1 cm in carcinoids, and tumors < 1 cm in diameterdiameter

*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24

Page 42: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

For 450 nodules reviewed in a meta-For 450 nodules reviewed in a meta-analysis, mean sensitivity was 93.9% analysis, mean sensitivity was 93.9% and specificity 85.8%and specificity 85.8%

Median sensitivity 98% and Median sensitivity 98% and specificity 83.3%*specificity 83.3%*

For 450 nodules reviewed in a meta-For 450 nodules reviewed in a meta-analysis, mean sensitivity was 93.9% analysis, mean sensitivity was 93.9% and specificity 85.8%and specificity 85.8%

Median sensitivity 98% and Median sensitivity 98% and specificity 83.3%*specificity 83.3%*

*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24

Page 43: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Gould, JAMA 2001;285:914-24

Gould, JAMA 2001;285:914-24

Page 44: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Gould, JAMA 2001;285:914-24

Gould, JAMA 2001;285:914-24

Page 45: The Solitary Pulmonary Nodule Suneel S. Kumar MD

*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24

Page 46: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

For diagnosis of benign nodules, For diagnosis of benign nodules, sensitivity 96% and specificity 88% sensitivity 96% and specificity 88% with 94% accuracywith 94% accuracy

False positives usually in association False positives usually in association with infectious or inflammatory with infectious or inflammatory processesprocesses

For diagnosis of benign nodules, For diagnosis of benign nodules, sensitivity 96% and specificity 88% sensitivity 96% and specificity 88% with 94% accuracywith 94% accuracy

False positives usually in association False positives usually in association with infectious or inflammatory with infectious or inflammatory processesprocesses

Page 47: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Resolution is currently 7 – 8 mmResolution is currently 7 – 8 mm Imaging of nodules < 1 cm unreliableImaging of nodules < 1 cm unreliable

Resolution is currently 7 – 8 mmResolution is currently 7 – 8 mm Imaging of nodules < 1 cm unreliableImaging of nodules < 1 cm unreliable

Page 48: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

May provide staging informationMay provide staging information Up to 14% of patients otherwise Up to 14% of patients otherwise

eligible for surgery have occult extra eligible for surgery have occult extra thoracic disease on whole-body PETthoracic disease on whole-body PET

May provide staging informationMay provide staging information Up to 14% of patients otherwise Up to 14% of patients otherwise

eligible for surgery have occult extra eligible for surgery have occult extra thoracic disease on whole-body PETthoracic disease on whole-body PET

Page 49: The Solitary Pulmonary Nodule Suneel S. Kumar MD

PET ImagesPET ImagesPET ImagesPET Images

Pieterman, NEJM 2000;343:254-61

Pieterman, NEJM 2000;343:254-61

Page 50: The Solitary Pulmonary Nodule Suneel S. Kumar MD

PET ImagesPET ImagesPET ImagesPET Images

Pieterman, NEJM 2000;343:254-61

Pieterman, NEJM 2000;343:254-61

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Page 55: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Integrated PET and CTIntegrated PET and CTIntegrated PET and CTIntegrated PET and CT

Lardinos, NEJM 2003;348:2500-7

Lardinos, NEJM 2003;348:2500-7

Page 56: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Integrated PET and CTIntegrated PET and CTIntegrated PET and CTIntegrated PET and CT

Lardinos, NEJM 2003;348:2500-7

Lardinos, NEJM 2003;348:2500-7

Page 57: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Decision-analysis model constructed to Decision-analysis model constructed to assess cost effectiveness showed assess cost effectiveness showed strategy of CT combined with PET for strategy of CT combined with PET for staging was often superior to staging was often superior to conventional approachesconventional approaches

Reduced number of surgeries by 15%Reduced number of surgeries by 15% Estimated cost savings per patient Estimated cost savings per patient

ranged from $91 to $2,200 per patient*ranged from $91 to $2,200 per patient*

Decision-analysis model constructed to Decision-analysis model constructed to assess cost effectiveness showed assess cost effectiveness showed strategy of CT combined with PET for strategy of CT combined with PET for staging was often superior to staging was often superior to conventional approachesconventional approaches

Reduced number of surgeries by 15%Reduced number of surgeries by 15% Estimated cost savings per patient Estimated cost savings per patient

ranged from $91 to $2,200 per patient*ranged from $91 to $2,200 per patient*

*Gambhir, J Clin Oncol 1998;16:2113-25*Gambhir, J Clin Oncol 1998;16:2113-25

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Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

More expensive than other imaging More expensive than other imaging modalitiesmodalities

Medicare reimbursement of $1,912 Medicare reimbursement of $1,912 compared to chest CT ($276) or compared to chest CT ($276) or transthoracic needle aspiration transthoracic needle aspiration ($560)*($560)*

More expensive than other imaging More expensive than other imaging modalitiesmodalities

Medicare reimbursement of $1,912 Medicare reimbursement of $1,912 compared to chest CT ($276) or compared to chest CT ($276) or transthoracic needle aspiration transthoracic needle aspiration ($560)*($560)*

*http://cms.hhs.gov, Dec 2002*http://cms.hhs.gov, Dec 2002

Page 59: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Question of using PET dependent on Question of using PET dependent on when clinical decision making will be when clinical decision making will be changed by its findingschanged by its findings

Low-risk patients (pretest probability of Low-risk patients (pretest probability of malignancy 20%) have posttest malignancy 20%) have posttest likelihood of malignancy with negative likelihood of malignancy with negative PET of 1%*PET of 1%*

Would support observation in this Would support observation in this population with serial CT scanspopulation with serial CT scans

Question of using PET dependent on Question of using PET dependent on when clinical decision making will be when clinical decision making will be changed by its findingschanged by its findings

Low-risk patients (pretest probability of Low-risk patients (pretest probability of malignancy 20%) have posttest malignancy 20%) have posttest likelihood of malignancy with negative likelihood of malignancy with negative PET of 1%*PET of 1%*

Would support observation in this Would support observation in this population with serial CT scanspopulation with serial CT scans

*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24

Page 60: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

High-risk patients (pretest probability High-risk patients (pretest probability of malignancy 80%) with negative of malignancy 80%) with negative PET still have 14% posttest likelihood PET still have 14% posttest likelihood of malignancy*of malignancy*

Those with high risk of malignancy Those with high risk of malignancy should have tissue diagnosisshould have tissue diagnosis

High-risk patients (pretest probability High-risk patients (pretest probability of malignancy 80%) with negative of malignancy 80%) with negative PET still have 14% posttest likelihood PET still have 14% posttest likelihood of malignancy*of malignancy*

Those with high risk of malignancy Those with high risk of malignancy should have tissue diagnosisshould have tissue diagnosis

*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24

Page 61: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

No indication for PET:No indication for PET: Negative lymph nodes on CT if operative Negative lymph nodes on CT if operative

intervention definitely planned or if it intervention definitely planned or if it will otherwise not change managementwill otherwise not change management

Known malignancy who has a Known malignancy who has a questionable pulmonary metastasis vs questionable pulmonary metastasis vs primary lung cancerprimary lung cancer

No indication for PET:No indication for PET: Negative lymph nodes on CT if operative Negative lymph nodes on CT if operative

intervention definitely planned or if it intervention definitely planned or if it will otherwise not change managementwill otherwise not change management

Known malignancy who has a Known malignancy who has a questionable pulmonary metastasis vs questionable pulmonary metastasis vs primary lung cancerprimary lung cancer

Page 62: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Positron Emission Positron Emission TomographyTomography

Positron Emission Positron Emission TomographyTomography

Some gamma cameras can now have Some gamma cameras can now have PET capability added to themPET capability added to them

Question if these modified gamma Question if these modified gamma cameras have same ability to detect cameras have same ability to detect malignant processes as specific PET malignant processes as specific PET equipment equipment

Requires further studyRequires further study

Some gamma cameras can now have Some gamma cameras can now have PET capability added to themPET capability added to them

Question if these modified gamma Question if these modified gamma cameras have same ability to detect cameras have same ability to detect malignant processes as specific PET malignant processes as specific PET equipment equipment

Requires further studyRequires further study

Page 63: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy

Pretest probability of cancer Pretest probability of cancer determines most cost-effective determines most cost-effective strategystrategy

Low (< 12%): radiographic follow-upLow (< 12%): radiographic follow-up Intermediate (12 – 69%): CT and PETIntermediate (12 – 69%): CT and PET High (> 69 – 90%): CT followed by High (> 69 – 90%): CT followed by

biopsy or surgerybiopsy or surgery Very high (> 90%): surgery*Very high (> 90%): surgery*

Pretest probability of cancer Pretest probability of cancer determines most cost-effective determines most cost-effective strategystrategy

Low (< 12%): radiographic follow-upLow (< 12%): radiographic follow-up Intermediate (12 – 69%): CT and PETIntermediate (12 – 69%): CT and PET High (> 69 – 90%): CT followed by High (> 69 – 90%): CT followed by

biopsy or surgerybiopsy or surgery Very high (> 90%): surgery*Very high (> 90%): surgery*

*Gambhir, J Clin Oncol 1998;16:2113-25*Gambhir, J Clin Oncol 1998;16:2113-25

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Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy

Ost, NEJM 2003;348:2535-42Ost, NEJM 2003;348:2535-42

Page 65: The Solitary Pulmonary Nodule Suneel S. Kumar MD

Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy

Determining probability of cancer Determining probability of cancer remains an inexact scienceremains an inexact science

Multivariate model incorporating age, Multivariate model incorporating age, cigarette-smoking status, history of cigarette-smoking status, history of cancer, diameter of nodule, presence cancer, diameter of nodule, presence of spiculation, and location of nodule of spiculation, and location of nodule proven similar to expert physician proven similar to expert physician judgment in predicting cancer*judgment in predicting cancer*

Determining probability of cancer Determining probability of cancer remains an inexact scienceremains an inexact science

Multivariate model incorporating age, Multivariate model incorporating age, cigarette-smoking status, history of cigarette-smoking status, history of cancer, diameter of nodule, presence cancer, diameter of nodule, presence of spiculation, and location of nodule of spiculation, and location of nodule proven similar to expert physician proven similar to expert physician judgment in predicting cancer*judgment in predicting cancer*

*Swenson, Arch Intern Med 1997;157:849-55*Swenson, Arch Intern Med 1997;157:849-55

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Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy

Ost, NEJM 2003;348:2535-42Ost, NEJM 2003;348:2535-42

Page 67: The Solitary Pulmonary Nodule Suneel S. Kumar MD
Page 68: The Solitary Pulmonary Nodule Suneel S. Kumar MD