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
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
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
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%
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%
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
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
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
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
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
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
Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins
Patterns of MarginsPatterns of MarginsPatterns of MarginsPatterns of Margins
Spiculated lipoid pneumonia
Spiculated lipoid pneumonia
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
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
Air BronchogramsAir BronchogramsAir BronchogramsAir Bronchograms
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
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
HistoplasmomaHistoplasmomaHistoplasmomaHistoplasmoma
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
HamartomaHamartomaHamartomaHamartoma
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
CalcificationCalcificationCalcificationCalcification
Rounded AtelectasisRounded AtelectasisRounded AtelectasisRounded Atelectasis
Rounded AtelectasisRounded AtelectasisRounded AtelectasisRounded Atelectasis
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Gould, JAMA 2001;285:914-24
Gould, JAMA 2001;285:914-24
Gould, JAMA 2001;285:914-24
Gould, JAMA 2001;285:914-24
*Gould, JAMA 2001;285:914-24*Gould, JAMA 2001;285:914-24
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
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
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
PET ImagesPET ImagesPET ImagesPET Images
Pieterman, NEJM 2000;343:254-61
Pieterman, NEJM 2000;343:254-61
PET ImagesPET ImagesPET ImagesPET Images
Pieterman, NEJM 2000;343:254-61
Pieterman, NEJM 2000;343:254-61
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
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
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
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
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
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
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
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
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
Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy
Ost, NEJM 2003;348:2535-42Ost, NEJM 2003;348:2535-42
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
Diagnostic StrategyDiagnostic StrategyDiagnostic StrategyDiagnostic Strategy
Ost, NEJM 2003;348:2535-42Ost, NEJM 2003;348:2535-42