Top Banner
Pulmonary Nodules: When to worry, when to ‘chill’ Douglas Arenberg Associate Professor Pulmonary & Critical Care
31

Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Jul 03, 2020

Download

Documents

dariahiddleston
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Pulmonary Nodules: When to worry, when to ‘chill’

Douglas ArenbergAssociate Professor

Pulmonary & Critical Care

Page 2: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Disclosure• MDCH Grant Funds to improve

tobacco cessation service in the Michigan Medicine Health System

• Past paid service Consultant/Advisory panel member for Nucleix, a company developing lung cancer biomarkers

• I will not be discussing any specific products or medications relevant to either of these financial relationships

Page 3: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Objectives

• Recognize features of the patient and the nodule that predict a likelihood of malignancy

• Understand the indications for (and limitations of) lung nodule biopsy

Page 4: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Let’s start with an exercise

• Each of the next few slides has two nodules found on CT scans

• There are some differences between the nodules

• Select which one you think is more likely to be malignant (A or B), and (in your head) think of one or two words why you chose your answer

Page 5: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Which of these is more likely malignant?

A B

Page 6: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Which of these is more likely malignant?

A B

Page 7: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Which of these is more likely malignant?

• 65 year old man • 32 year old man

A B

Page 8: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Which of these is more likely malignant?

• 65 year old heavy smoker

• 64 year old non-smoker

A B

Page 9: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

What features did you use to guess which one was more likely to be cancer?

• Features about the nodule?– Size– Edge characteristics?

• Features about the patient?– Age– Social history

Page 10: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Google “Swensen SPN calculator”

http://www.chestx-ray.com/index.php/calculators/spn-calculatorSwensen et al. Archives of Internal Medicine 1997; 157:849-855.

http://www.chestx-ray.com/index.php/calculators/spn-calculator
Page 11: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Approach to the patient with a nodule

Definitely Benign

Definitely Malignant

Younger ageSmall

Smooth bordersFat or calcium

Non-smokerLower lobe

Negative PET

Older age LargeSpiculated bordersHeavy smokerUpper lobeFDG-avid on PET

Low probability IntermediateProbability

Highprobability

Page 12: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

What do we do with this “probability”?

Definitely Benign

Definitely Malignant

Low probability Intermediateprobability

Highprobability

Fleischner Zone

PET scan zone“Is this more or less likely to be cancer?

PET scan zone“This is cancer. What stage is it?

Page 13: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

PET scan: Correlates anatomic and metabolic data

FDG-PET

~95% sensitivity for malignancy

False negativesGround glassSmall lesions (<8-10 mesions close to the diaphragm

False + (15-20%)ANYTHING inflammatoryDon’t get PET in patients with recent symptoms of infection

Page 14: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

63 yo former smoker otherwise healthy with a 3.5 cm RML mass...what would you do next?

A.Biopsy the massB.PET scanC.Refer for surgical

resectionD.MediastinoscopyE.Trick question…take a

history

A case scenario

Page 15: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

63 yo former smoker otherwise healthy with a 3.5 cm RML mass...what would you do next?

E. Trick question…take a history

He presented with abrupt onset chest pain, fever, diaphoresis and productive cough

How soon would you repeat the CT?

Page 16: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

You’ve determined a pre-test probability of lung cancer

Now what?

Goal: Definitely Benign

Goal: Definitely Malignant

Younger ageSmall

Smooth bordersFat or calcium

Non-smokerLower lobe

Negative PET

Older age LargeSpiculated bordersHeavy smokerUpper lobeFDG-avid on PET

Low probability~5-15% or less

IntermediateProbability

HighProbability >60%

Page 17: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

You’ve determined a pre-test probability of lung cancer

Now what?

Goal: Definitely Benign

Goal: Definitely Malignant

Proof of benign:Take it outTime (radiographic observation)

Proof of Malignancy:Any tissue under the

microscope (Biopsy or resection)

Low probability~5-15% or less

IntermediateProbability

HighProbability >60%

Page 18: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

WHEN IS BIOPSY INDICATED?

#1. ANY TIME YOU NEED TO PROVE ITS CANCERCorollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence of absence

Page 19: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

When is it appropriate to biopsy a patient with a lung nodule?

• Biopsy is of no use in patients with a high risk of cancer who are good surgical candidates

• For this group, the “biopsy” is a surgical procedure

• Biopsy people who need a diagnosis to facilitate treatment

• Medically or anatomically unresectable

• Make sure biopsy yields an unequivocal stage

• Suspicion of Small cell lung cancer or metastasis

Page 20: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

When do we biopsy? What is a biopsy?

Surgical “biopsy”

Page 21: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Don’t let this happen to you…

FEV1 2.40 (73% of predicted), FVC 3.88 (93% of predicted)DLCO 14.5 (72% of predicted)

Page 22: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

What is wrong with this picture?…

Page 23: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Serial CT Observation

Diagnostic testing (PET) or biopsy Surgery or invasive staging

Biomarkers with high NPV

Benign imaging features

Safer surgery/Better outcomes?

Higher surgical risk or poorer outcomes

High patient anxiety, safer biopsy techniques, Positive PET

What do we do with this “probability”?Is there a single answer?

Page 24: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

When to chill? When there is evidence of benignity**

• Characteristics of benign nodules

– CT is more sensitive for detection of Ca++

– Detection of fat suggests a benign cause

– Important for non-radiologists to recall patterns that are NOT predictive of benign behavior

**How to you pronounce this?

Page 25: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

How do you prove a nodule is benign?What tools do we have?

• Calcium or fat • Time

• Cold hard steel

Page 26: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Characteristics of benign nodules: Perifissural nodules

de Hoop B et al. Radiology 2012;265:611-616Pulmonary Perifissural Nodules on CT Scans: Rapid Growth Is Not a Predictor of Malignancy. ©2012 by Radiological Society of North America

Page 27: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Journal of Thoracic Oncology 2013 8, 309-314

Not all GGOs are created equally

How good are we at identifying solid components?

How long should these be followed?

2006 2010

Page 28: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

How Long Should Small Lung Lesions of Ground-Glass Opacity be Followed?

108 total non-solid lesions from 61 subjects followed for a median period of 4.2 years

82 of the followed lesions were recorded as “pure GGO”

Of these 82, 18 grew during observation

Journal of Thoracic Oncology 2013 8, 309-314

Page 29: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

‘Disarming’ language

• Nodules are common• The VAST majority, even in people

at very high risk for cancer, are benign

• “Lung freckles”• Patient education materials…

Page 30: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

http://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

Page 31: Pulmonary Nodules: When to worry, when to ‘chill’...ANY TIME YOU NEED TO PROVE ITS CANCER Corollary: Biopsy cannot prove you don’t have cacer. Absence of evidence is not evidence

Take Home Points

• Nodule and patient features can be used to estimate the probability of malignancy

• This probability can determine the next step(s)• Long term follow up, PET scan, Surgery,

etc., • The PET scan has a very high NPV in the right

scenario• Benign features of nodules should allow

conservative management


Related Documents
ATTORNEY DISCIPLINE – ATTORNEY MISCONDUCT – PETITION … · ATTORNEY DISCIPLINE – ATTORNEY MISCONDUCT – PETITION DISMISSED There being not sufficient evidence to prove that

ATTORNEY DISCIPLINE – ATTORNEY MISCONDUCT – PETITION...

Category: Documents
AJ 104 Chapter 3 Types of Evidence. 1. Relevant Evidence Any evidence that tends to prove or disprove any disputed fact in the case. Relevant evidence.

AJ 104 Chapter 3 Types of Evidence. 1. Relevant Evidence Any...

Category: Documents
Strategies for Teaching Argumentative Writing 4 of 17 Explain Evidence: How should we read or interpret the evidence you are providing us? How does this evidence prove the point you

Strategies for Teaching Argumentative Writing 4 of 17...

Category: Documents
LEARNING GOALS Prove a point using evidence when writing.

LEARNING GOALS Prove a point using evidence when writing.

Category: Documents
Outline Explain the development Back up the information Prove it with details Provide evidence.

Outline Explain the development Back up the information...

Category: Documents
Claims are debatable or controversial statements/assertions you hope to prove Evidence and Reasons Claim.

Claims are debatable or controversial statements/assertions....

Category: Documents
€¦  · Web viewGrade 7: Prove It With Evidence From Our Past. Double Entry Journal 4. Grade 7: Prove It With Evidence From Our Past. Fairforest. Middle School . Examples of Student

€¦  · Web viewGrade 7: Prove It With Evidence From Our...

Category: Documents
There Is Such a Thing as a Mobile Context… and There Is Evidence to Prove it

There Is Such a Thing as a Mobile Context… and There Is...

Category: Design
evidence and prove of milad in bangla for the first time in history

evidence and prove of milad in bangla for the first time in....

Category: Documents
Writing about need What evidence can you use to prove there is a need for your project?

Writing about need What evidence can you use to prove there....

Category: Documents
Prove It Launch Webinar Transcript - Stacey BarrEvidence is the central word in my work, and certainly evidence- based leadership is the central theme in my book, Prove It! To me,

Prove It Launch Webinar Transcript - Stacey BarrEvidence is....

Category: Documents
1 EVIDENCE The Pursuit of Truth. 2 “Evidence is that which tends to prove/disprove a fact in issue.” “Evidence is any kind of proof offered to persuade.

1 EVIDENCE The Pursuit of Truth. 2 “Evidence is that which...

Category: Documents