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Approach to the Solitary Pulmonary Nodule

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Title: Approach to the Solitary Pulmonary Nodule


1
Approach to the Solitary Pulmonary Nodule
  • Hrach Ike Kasaryan

2
Introduction
  • It is estimated that 150,000 patients per year in
    the US present their physicians with a Solitary
    Pulmonary Nodule (SPN)
  • 90 of these are found incidentally by
    radiographic studies done for totally unrelated
    diagnostic work ups
  • With the advancement in technology and methods in
    CT scanning this number is increasing

3
Definition
  • SPN is an intraparenchymal lung lesion that is
    lt 3 cm in diameter and is NOT associated with
    atelectasis or adenopathy
  • Lesions greater the 3 cm are defined as MASSES

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Why is it concerning?
  • SPN are concerning for what they could represent
  • The absolute 1 concern is if the SPN is the
    harbinger of a malignancy
  • What is more critical is the fact that the
    earlier you diagnose the malignancy the better
    the survival rate will be

11
Why is it concerning
  • Chest. 1997 Jun111(6)1486-7
  • Patients with the best prognosis are those found
    to have stage IA (T1N0M0) disease.
  • These patients have a 61 to 75 5-year survival
    following surgical resection
  • Radiol Clin North Am 2000 3819  
  • Unfortunately they showed that almost 50 of
    patients have extrathoracic spread by the time of
    diagnosis
  • these patients only had a 15 5 year survival

12
Why is it concerning?
  • With these numbers in mind, it is absolutely
    critical to give the SPN the attention it
    deserves
  • If it is not worked up properly we will
    effectively push our patients who do carry a
    malignancy with in the SPN from the 75 survival
    into the 15 survival
  • That is just unacceptable

13
Differential Diagnosis
It is important to note that the majority of SPN
are of a benign etiology
14
SO now you have a patient in your office with an
SPN on CXR or CT what do you do?
15
Postgrad Med 2003114(2)29-35
16
Assessing Growth
  • There are three categories to place the patient
    in assessing growth
  • No change in two years / or Growth Rate of benign
    nature
  • Indeterminate because of no old studies
  • Growth Rate of possible malignancy

17
No change in two years
  • Radiologic stability is the best predictor of a
    benign etiology.
  • Since the 1950s it has been well established
    that if the SPN has not grown in 2 years it is
    benign. (JAMA 1958 166210215 )
  • If you have old radiographs and can show no
    change in two years, no further work up is needed

18
Benign vs. Malignant Doubling Time
  • The time it takes for the apparent volume to
    double is referred to as the doubling time
  • one doubling in volume is equivalent to the
    nodule diameter increasing by only 26 to 28
  • Benign nodules representing acute inflammatory
    changes have a doubling time of less than 20 days
  • In contrast, stable granulomas and hamartomas may
    enlarge slowly and have a doubling time of more
    than 500 days

Semin Ultrasound CT MR 200021(2)97-115
19
Benign vs. Malignant Doubling Time
  • If the SPN has a doubling time of lt20 days or
    gt500 days the patient is in the clear and can be
    followed
  • If however the SPN doubling time falls in between
    20 and 500 days the SPN must be assumed malignant
    until proven otherwise and surgical intervention
    is now recommended.

Postgrad Med 1997101(3)145-50
20
Malignant Doubling Time
  • With the numbers crunch, biopsy in this case is
    not worth the risks because a malignant diagnosis
    would not change resection therapy
  • So in this case, surgical resection is highly
    recommended
  • If the patient is reluctant or the risk of
    surgery is really high and you would like to be
    sure of diagnosis before going to the OR, than
    biopsy can be undertaken.

21
Postgrad Med 2003114(2)29-35
22
Indeterminate Growth Rate
  • This is where the real dilemma is created and
    every radiological and clinical clue must be
    taken into consideration to make a decision.
  • First step is to look at all patterns of the SPN
    and determine if a typically benign or malignant
    pattern can be found

23
Spiral CT with IV contrast Enhancement (SCTIE)
  • SCTIE the imaging modality of choice for the SPN
    and should be obtained on all newly diagnosed
    SPNs
  • A number of benign etiologies for SPNs have a
    characteristic appearance on CT

24
Fat
  • Fat on CT can be diagnosed benign hamartoma with
    confidence

25
Solid or Central Calcification
  • A solid calcified SPN is found in association
    with prior granulomatous infection, most commonly
    histoplasmosis or tuberculosis

26
Popcorn Calcification
  • Popcorn calcification or Chondroid Calcification
    pattern typical of hamartomas

27
Speckled or Punctate Calcification
  • Speckled or Punctate calcifications represent
    malignant calcification and should not be taken
    as benign

28
Eccentric Calcification
  • Eccentric Calcification is also a sign of
    malignant potential

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Radiological Findings
  • If you have definitive findings suggestive of
    benign pattern than no further work up is needed.
  • If still no answer after SCTIE or other
    radiologic finding further work up is needed

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Postgrad Med 2003114(2)29-35
32
No Specific Pattern Found
  • With no specific finding, all risk factors must
    be taken into account.
  • Trying to milk the SPN for as much information
    you can may help stratify the risk in the patient

33
Size
  • Size of the SPN can also help out at this point
    to help make a decision
  • In general, smaller nodules are more likely to be
    benign and larger lesions
  • 80 of benign SPNs are less than 2 cm in diameter
  • However, small size is not necessarily reliable
    evidence of benignity because 15 of malignant
    nodules are less than 1 cm in diameter
    approximately 42 are less than 2 cm in diameter

Radiographics 2043, 2000
34
Cavitation
  • Although cavitation can occur in necrotic
    malignant SPNs, inflammatory lesions can also
    cavitate.
  • The thickness of the cavity wall can be helpful
    in distinguishing benign from malignant lesions.
  • Cavities with a greatest wall thickness less
    than 5 mm are almost always benign
  • whereas most of those with a maximal wall
    thickness greater than 15 mm are malignant

35
Cavitation
This is an example of a thick walled cavity which
came back as squamous cell carcinoma.
36
Margins
  • Smooth, well-defined margins most often indicate
    a benign nodule
  • However 21 of malignant nodules have a smooth
    well-defined margin
  • a lobulated margin may reflect uneven growth of a
    SPN and can indicate malignancy
  • although 25 of benign nodules, particularly
    hamartomas, are lobulated

Radiology 179469, 1991  
37
Indeterminate SPN
  • After milking the SPN for all its characteristics
    it is now important to milk the patient for all
    relevant information
  • Key points include smoking history symptoms
    comorbid conditions (particularly severe
    emphysema) history and type of prior malignancy
    prior infections and environmental exposures.

38
N Engl J Med 3482535-2542
39
Odds Ratios
Odds Ratio
Odds Ratio
  • Age 20-29 0.05 x
  • 30-39 0.24
  • 40-49 0.94
  • 50-59 1.90
  • 60-69 2.64
  • Nonsmoker 0.15
  • lt 30 pk-yrs 0.74
  • 30-39 pk-yrs 2
  • gt40 pk-yrs 3.7
  • Hemoptysis, absent 1
  • Hemoptysis, present 5.08
  • No prev malig 1
  • Prev Malig 4.95

Radiology 1993 186405-413
40
Postgrad Med 2003114(2)29-35
41
Clinical Decision
  • Now after evaluating the entire clinical picture
    and clinically identifiable risks its time to
    determine where they fall into Low, Moderate or
    High risk

42
Low risk indeterminate SPN
  • 30 year old male, never smoked, nodule is lt1cm
    with no previous studies, no environmental
    exposure, found on CT not seen on CXR and no
    specific pattern found
  • Can follow for two years
  • OH DOC, I FORGOT TO TELL YOU I HAVE SARCOID!!

43
Moderate Risk
  • Now you have a patient who isnt clearly low risk.
    Maybe older age, questionable smoke or
    environmental history but not quite screaming
    high risk, what to do?
  • PET SCAN is now recommended

44
PET SCAN
  • Positron emission tomography (PET) with
    18-fluorodeoxyglucose (FDG) has proven to be an
    excellent mode of tumor imaging
  • Increased activity is demonstrated in cells with
    high metabolic rates, as is seen in tumors and
    areas of inflammation
  • It can also tell us about if any metastatic
    disease is present thus altering treatment
  • However the spatial resolution of PET is
    currently 7 to 8 mm, and so the imaging of SPNs lt
    1 cm is unreliable
  • 1,912 !!!!

45
Pet Scan
  • Gould et al performed a meta-analysis of the
    literature on pulmonary nodules and masses and
    PET scanning and found an overall sensitivity of
    96.8 and specificity of 77.8 for detecting
    malignancy.
  • PET scans also have a 96 sensitivity and 88
    specificity with 94 accuracy in the diagnosis of
    benign nodules

JAMA 2001 285914924  
46
Pet Scan
  • So depending on the PET Scan result you can base
    your treatment
  • If PET is positive than you can refer the patient
    to CT Surgery for resection options
  • If PET is negative than can follow

47
High Risk Patient
  • 68 year old male, 100 pack years of smoking, used
    to work with asbestos, and coughing up blood
  • RIGHT TO THE OR for resection.

48
Conclusion
  • The main point is to make sure you give the SPN
    the respect it deserves.
  • With timely diagnosis we can effectively prevent
    morbidity and mortality for our patients
  • There is just no excuse for a patient to die
    because we did not work up the patient in a
    timely fashion.

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