SPNs and the Early Detection of Lung Cancer George Erbacher D.O., FAOCR Chair imaging/interventional radiology OSUMC Radiology residency program director

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SPNs and the Early
Detection of Lung CancerGeorge Erbacher D.O.,
FAOCRChair imaging/interventional radiology
OSUMCRadiology residency program director
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DEFINITION OF SOLITARY PULMONARY NODULE (SPN)

• Single round water density mass lt 3 cm
• Completely surrounded by lung parenchyma
• Incidental finding 0.2 CXRs, 1 CT

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MIMICS OF SPN

• Chest wall lesion
• Healing rib fracture
• AVN
• Abscess
• Pneumonia
• Immune-RA/Wegeners granulomatosis etc.

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MIMICS OF SPN

• Hematoma
• Lung infarct/atelecatasis
• Pleural plaque
• Bronchial atresia/Sequestration
• Inhaled FB
• MOST COMMON BENIGN GRANULOMA/HAMARTOMA

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PATIENT FEATURES INCREASING RISK OF MALIGNANCY

• SMOKING ESPECIALLY gt20 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.

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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) lt 15-20 benign
• Very fast and very slow growing lesions are
  likely benign-PREVIOUS COMPARISON IMAGES ARE
  CRITICAL

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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

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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.)

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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.
2003181(3)711-5.
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Survival

• 5 years 14
• 50 survive if diagnosed in early stage (small
  size IA 85 100 survival
• Only 15 diagnosed in early stage

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Tobacco Smoke

• Cigarette smoking is causally related to lung
  cancerthe 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

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CXR Screening Revisited

• Analysis of the 4 RCT from 20 years ago (Mayo,
  Czech, Sloan-Kettering, Johns-Hopkins)
• Czech Mayo studies found increase in mortality
  in screened vs. controls (6 increase in Mayo)
  however 29 MORE lung cancer in screening vs.
  controls

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CXR Screening Revisited

• Screened had 34 living _at_ 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

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Low Dose CT (LD CT)Screening vs. CXR

• RationaleLD 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

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LD CT Indication (ELCAP)

• gt 60 y.o.a.
• gt 10 pk/y smoker no previous cancer
• Medically fit to undergo thoracic surgery
• Baseline LD CT, then annuals

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ELCAP Technique Helical CT

• 140 kVp, 40 mA
• 21 Pitch, 10 mm slice thickness
• Scan entire lung in 1 breath hold _at_ end
  inspiration after hyperventilation
• Reconstruct images with bone algorithm in
  overlapping 5 mm increments
• Only lung windows (W1500, L-650) reviewed

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ELCAP Scoring

• 1-6 non-calcified nodules positive
• If no non-calcified nodules negative
• gt 6 non-calcified nodules, diffuse
  bronchiectasis, ground glass opacities or
  combinations diffuse disease

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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)

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ELCAP Benign Nodule

• Benign calcifications
• Smooth edges
• lt 20 mm size

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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
• lt 5mm F/U high res CT 3 mo, 6 mo, 12 mo, 24 mo
  no growth over 3 yrsbenign
• 6-10 mm bx, if not possible F/U per above
• gt 11mm bx

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Fleishner Recommendations do NOT apply to
patients

• lt35 Y.O.A. with low risk of lung cancer
• Who have fever/signs of infection

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Fleishner Nodule CT Reassessment Recommendations

• NONCONTRAST
• THIN COLLIMATION
• LIMITED COVERAGE-JUST REGION OF INTEREST
• LOW DOSE

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Nodule Enhancement and metabolism

• Cancer/Infection/inflammation- CT
• neovascularity- malignant nodules enhance gt 20
  Hounsfield Units (HU), benign lt 15 HU
• Cancer/Infection/inflammation- increased glucose
  turnover- PET- SUVmax lt 2.5 benign
• PET/CT HAS SENSITIVITY AND SPECIFICITY CLOSE TO
  90 FOR NODULES 10 MM OR GREATER DIAMETER

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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

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Caveats for PET/CTNO STANDARIZATION FROM ONE
MACHINE TO ANOTHER AND POOR STANDARDIZATION OFTEN
BETWEEN EXAMINATIONS ON THE SAME
MACHINE.EXPERIENCE OF TECHNOLOGISTS-RADIOLOGISTS
VARIES WIDELY
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Benign? NM in Lung Cancer
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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

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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

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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?

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Cost Effectiveness

• Radiographic F/U cost effective when probability
  of malignancy is low (lt0.14)
• 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 gt .90
• Over greatest range of probability .14 - .71 CT
  and PET/CT cost effective
• Rad Clinics N.A. May 2000 p. 521-522

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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

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Staging lung cancer

• Stage 1A-T1N0MO tumor lt 3cm with no positive
  nodes and no metastasis
• Stage 1B-T2N0M0- tumor gt 3cm, no nodes, no
  metastasis

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RFA in Pulmonary Applications
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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.
2003181(3)711-5.
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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

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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.
  2003181(3)711-5.

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Radiofrequency AblationNSC Lung Cancer
18 mo S/P RFA/XRT
3 cm RFA
3 mo S/P RFA/XRT
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KEYS

• Excellent HP
• 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

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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