Transcript Early Detection of Lung Cancer

SPNs and the
Early Detection of Lung Cancer
George Erbacher D.O., FAOCR
Chair imaging/interventional radiology
OSUMC
Radiology residency program director
DEFINITION OF SOLITARY
PULMONARY NODULE (SPN)

Single round water density mass < 3 cm
 Completely surrounded by lung
parenchyma
 Incidental finding 0.2% CXRs, 1% CT
MIMICS OF SPN

Chest wall lesion
 Healing rib fracture
 AVN
 Abscess
 Pneumonia
 Immune-RA/Wegeners granulomatosis etc.
MIMICS OF SPN

Hematoma
 Lung infarct/atelecatasis
 Pleural plaque
 Bronchial atresia/Sequestration
 Inhaled FB
 MOST COMMON: BENIGN
GRANULOMA/HAMARTOMA
PATIENT FEATURES
INCREASING RISK OF
MALIGNANCY

SMOKING ESPECIALLY >20 PK/YEAR
 Older age
 Personal history of malignancy
 First degree relative with lung cancer
 Asbestos/uranium/radon exposure
 Other workplace exposure- some aromatic
hydrocarbons, coal mines etc.
IMAGING FEATURES BENIGN
VS. MALIGNANT

Smaller less risk of malignancy
 Well defined borders tend to be benign
 If a cavity –thin walls-favor benign
 Popcorn like calcification –benign –
characteristic of hamartoma
 Density (HU) < 15-20 benign
 Very fast and very slow growing lesions are
likely benign-PREVIOUS COMPARISON
IMAGES ARE CRITICAL
Epidemiology Lung Cancer in
the World

Most frequently diagnosed cancer
(1.04M in 1990)
 Leading cause of cancer mortality
– 921K deaths

Most common cancer in males and #1 cause
of cancer death
Incidence Lung Cancer in U.S.

171,600 cases diagnosed in 1999 (94K M;
77.6K F)
 Leading cause of cancer death M & F
(158.9K)
 Kentucky highest mortality rate
– 67.9/100K (37% above avg.)

Utah lowest mortality rate
– 21.6/100K (56.4% below avg.)
U.S. Lung Cancer
“Lung cancer is the leading cause of cancer
mortality in the U.S. among both men and
women surpassing totals from breast, colon,
and ovarian cancers
combined.” [1]
1Dupuy,
DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with
brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
Survival

5 years – 14%

50% survive if diagnosed in early stage
(small size IA 85 – 100% survival

Only 15% diagnosed in early stage
Tobacco Smoke

“Cigarette smoking is causally related to lung
cancer…the magnitude of the effect far outweighs
all other factors.”

Is leading cause of avoidable mortality in US, w/
about 434K preventable deaths per year
 Cost to US economy $200 billion/year
US surgeon general
CXR Screening Revisited

Analysis of the 4 RCT from 20 years ago
(Mayo, Czech, Sloan-Kettering, JohnsHopkins)

Czech & Mayo studies found increase in
mortality in screened vs. controls (6%
increase in Mayo) however 29% MORE
lung cancer in screening vs. controls
CXR Screening Revisited

Screened had 34% living @ 5yrs vs. 15%
control (Sloan-Kettering, Johns-Hopkins
similar results)

“Analysis of the randomized trials strongly
suggests CXR screening is superior to no
screening whatsoever”
Low Dose CT (LD CT)
Screening vs. CXR

Rationale:LD CT greatly increases detection of
small non-calcified nodules and of lung cancer at
an earlier/more curable stage
 LD CT showed non-calcified nodules 3x more
commonly
 LD CT showed malig. tumors 4x more commonly
 LD CT showed stage 1 tumors 6x more commonly
LD CT Indication (ELCAP)

> 60 y.o.a.

> 10 pk/y smoker & no previous cancer

Medically fit to undergo thoracic surgery

Baseline LD CT, then annuals
ELCAP Technique – Helical CT

140 kVp, 40 mA
 2:1 Pitch, 10 mm slice thickness
 Scan entire lung in 1 breath hold @ end
inspiration after hyperventilation
 Reconstruct images with bone algorithm in
overlapping 5 mm increments
 Only lung windows (W1500, L-650)
reviewed
ELCAP Scoring

1-6 non-calcified nodules = positive

If no non-calcified nodules = negative

> 6 non-calcified nodules, diffuse
bronchiectasis, ground glass opacities or
combinations = diffuse disease
ELCAP Nodule Description

Size (L & W/2)
 Location (lobe & distance from pleura)
peripheral if w/in 2 cm costal margin
 Benign calcifications
 Shape (round, non-round)
 Edge (smooth, non-smooth)
ELCAP “Benign Nodule”

Benign calcifications

Smooth edges

< 20 mm size
Guideline for Diagnostic
Intervention ELCAP

Non-benign nodule on LD CT goes to
diagnostic CT w/ high resolution imaging of
abnormalities. If not benign per above
criteria:
– < 5mm : F/U high res CT 3 mo, 6 mo, 12 mo,
24 mo; no growth over 3 yrs=benign
– 6-10 mm : bx, if not possible F/U per above
– > 11mm : bx
Fleishner Recommendations do
NOT apply to patients:

<35 Y.O.A. with low risk of lung cancer
 Who have fever/signs of infection
Fleishner Nodule CT
Reassessment
Recommendations

NONCONTRAST
 THIN COLLIMATION
 LIMITED COVERAGE-JUST REGION
OF INTEREST
 LOW DOSE
Nodule Enhancement and
metabolism


Cancer/Infection/inflammation- CT
neovascularity- malignant nodules enhance > 20
Hounsfield Units (HU), benign < 15 HU
Cancer/Infection/inflammation- increased glucose
turnover- PET- SUVmax < 2.5 benign
 PET/CT HAS SENSITIVITY AND
SPECIFICITY CLOSE TO 90% FOR NODULES
10 MM OR GREATER DIAMETER
PET/CT vs. Helical dynamic CT
for SPN

PET/CT
MORE SENSITIVE (96% vs. 81%) and
MORE ACCURATE (93% vs. 85%) than
helical dynamic CT
Caveats for PET/CT:
NO STANDARIZATION FROM
ONE MACHINE TO ANOTHER
AND POOR STANDARDIZATION
OFTEN BETWEEN
EXAMINATIONS ON THE SAME
MACHINE.
EXPERIENCE OF
TECHNOLOGISTSRADIOLOGISTS VARIES
WIDELY
Benign? NM in Lung Cancer
Role of PET in Lung Cancer
Improves staging by ruling out
mediastinal/distant disease
 Useful in evaluating response to therapy
 Useful in early detection recurrent disease

Rad Clinics N.A. May 2000 p. 523
False Positive and Caveats
PET/CT

Active necrotizing granulomas and some
chronic inflammatory conditions are +
 ANY PROCESS THAT HAS INCREASED
UPTAKE OF GLUCOSE IS PET
POSITIVE
What to do with Indeterminant
CT W/U of SPN

Serial radiographic F/U?

CT alone to decide to surgerize or not?

PET/CT

Surgery for pts w/ + or indeterminant CT?
Cost Effectiveness





Radiographic F/U cost effective when probability
of malignancy is low (<0.14)
CT alone F/U cost effective when probability of
malignancy is high (.71 - .91)
Surgery alone is most cost effective when
probability of malignancy is very high > .90
Over greatest range of probability .14 - .71 CT and
PET/CT cost effective
Rad Clinics N.A. May 2000 p. 521-522
PRINCIPLES OF IMAGING IN
ONCOLOGY

Imaging justified only if results will change therapy with
patient benefit
 “Where there is an issue get tissue”-biopsy when imaging is
inconclusive (imaging guided?)
 Positive studies are more valuable/reliable than negative
studies
 The diagnostic plan should progress logically from least to
most invasive studies
 Accurate assessment of initial disease extent is vital to
selecting and sequencing appropriate treatment
Staging lung cancer

Stage 1A-T1N0MO= tumor < 3cm with no
positive nodes and no metastasis
 Stage 1B-T2N0M0- tumor > 3cm, no nodes,
no metastasis
RFA in Pulmonary Applications
Lung

25% of patients are candidates for lung resection. [1]

RT and chemotherapy together have a combined 5 year
survival rate of 5%. [1]

RF ablation can potentially provide direct
cytoreduction, which could make RT and
chemotherapy more effective. [1]
1Dupuy,
DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment
with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
Lung Cancer

Assessment of malignancy has required invasive
diagnostic methods
– Needle biopsy (10% sampling error; 15%
pneumothorax)
– Bronchoscopy (low sensitivity; occ. pneumothorax
– Mediastinoscopy (surgical procedure; limited to
anterior mediastinum)
– Thoracotomy (open surgery; 1-3% mortality)

FDG-PET expensive and not widely available
Lung Cancer
“The overall 5-year survival rate for all
stages combined is only 15%.” [1]
“Radiofrequency ablation of lung tumors may be
a promising option for nonsurgical candidates
given the suboptimal outcomes with current
treatment options.” [1]
1Dupuy, DE. Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment
with brachytherapy. Am J Roentgenol. 2003;181(3):711-5.
Radiofrequency Ablation
NSC Lung Cancer
3 cm RFA
3 mo S/P
RFA/XRT
18 mo S/P
RFA/XRT
KEYS

Excellent H&P
 Find Comparisons
 Send the above to your radiologist then call and
discuss the case-have the radiologist lay out the
work up as local resources dictate what will be
done
 IF PATIENT CANDIDATE FOR TREATMENT
TISSUE DIAGNOSIS IS NEEDED
We at Diagnostic Imaging
Associates are happy to help
FOR TULSA REFERRAL AREA CALL 918 599
5050/5094 TO TALK TO RADIOLOGIST
FOR OUTSIDE TULSA REFERRAL AREA
CALL CHRISTA -918 599 5031 and ask for
radiologist at site nearest you
Thank You