Pulmonary nodules and CT screening: the past, present and future.
Ruparel M,Quaife S L,Navani N,Wardle J,Janes S M,Baldwin D R
Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.
Dual-energy snap-shot perfusion CT in suspect pulmonary nodules and masses and for lung cancer staging.
Sudarski Sonja,Hagelstein Claudia,Weis Meike,Schoenberg Stefan O,Apfaltrer Paul
European journal of radiology
Dual energy computed tomography (DECT) has proven its clinical usefulness for improved tissue characterization within the past years. In thoracic oncology, DECT can be used to differentiate between benign and malignant pulmonary nodules and masses. In patients with known lung cancer, DECT can add incremental functional information to staging scans, therapeutic response evaluation, as well as to the assessment of lung function. This review aims to give an overview on the current clinical utilities of DECT of the chest, its multiple post-processing applications and dose saving options. Furthermore, this review highlights promising applications of DECT that merit implementation in future clinical routine.
Subsolid pulmonary nodules: imaging evaluation and strategic management.
Godoy Myrna C B,Sabloff Bradley,Naidich David P
Current opinion in pulmonary medicine
PURPOSE OF REVIEW:Given the higher rate of malignancy of subsolid pulmonary nodules and the considerably lower growth rate of ground-glass nodules (GGNs), dedicated standardized guidelines for management of these nodules have been proposed, including long-term low-dose computed tomography (CT) follow-up (≥3 years). Physicians must be familiar with the strategic management of subsolid pulmonary nodules, and should be able to identify imaging features that suggest invasive adenocarcinoma requiring a more aggressive management. RECENT FINDINGS:Low-dose CT screening studies for early detection of lung cancer have increased our knowledge of pulmonary nodules, and in particular our understanding of the strong although imperfect correlation of the subsolid pulmonary nodules, including pure GGNs and part-solid nodules, with the spectrum of preinvasive to invasive lung adenocarcinoma. Serial CT imaging has shown stepwise progression in a subset of these nodules, characterized by increase in size and density of pure GGNs and development of a solid component, the latter usually indicating invasive adenocarcinoma. SUMMARY:There is close correlation between the CT features of subsolid nodules (SSNs) and the spectrum of lung adenocarcinoma. Standardized guidelines are suggested for management of SSNs.
Comparison of digital tomosynthesis and chest radiography for the detection of pulmonary nodules: systematic review and meta-analysis.
Kim Jun H,Lee Kyung H,Kim Kyoung-Tae,Kim Hyun J,Ahn Hyeong S,Kim Yeo J,Lee Ha Y,Jeon Yong S
The British journal of radiology
OBJECTIVE:To compare the diagnostic accuracy of digital tomosynthesis (DTS) with that of chest radiography for the detection of pulmonary nodules by meta-analysis. METHODS:A systematic literature search was performed to identify relevant original studies from 1 January 1 1976 to 31 August 31 2016. The quality of included studies was assessed by quality assessment of diagnostic accuracy studies-2. Per-patient data were used to calculate the sensitivity and specificity and per-lesion data were used to calculate the detection rate. Summary receiver-operating characteristic curves were drawn for pulmonary nodule detection. RESULTS:16 studies met the inclusion criteria. 1017 patients on a per-patient basis and 2159 lesions on a per-lesion basis from 16 eligible studies were evaluated. The pooled patient-based sensitivity of DTS was 0.85 [95% confidence interval (CI) 0.83-0.88] and the specificity was 0.95 (0.93-0.96). The pooled sensitivity and specificity of chest radiography were 0.47 (0.44-0.51) and 0.37 (0.34-0.40), respectively. The per-lesion detection rate was 2.90 (95% CI 2.63-3.19). CONCLUSION:DTS has higher diagnostic accuracy than chest radiography for detection of pulmonary nodules. Chest radiography has low sensitivity but similar specificity, comparable with that of DTS. Advances in knowledge: DTS has higher diagnostic accuracy than chest radiography for the detection of pulmonary nodules.
Models to Estimate the Probability of Malignancy in Patients with Pulmonary Nodules.
Choi Humberto K,Ghobrial Michael,Mazzone Peter J
Annals of the American Thoracic Society
Pulmonary nodules are a common clinical problem. The goals of their evaluation are to expedite the diagnosis and treatment of patients with malignant nodules and to minimize testing in patients with benign nodules. The approach to lung nodule evaluation is directed by the probability that the nodule is malignant. Estimation of the probability of malignancy can be performed subjectively with intuition and clinical experience or by using validated probability models that combine patient clinical characteristics with nodule imaging features to estimate a probability of malignancy. The accuracy and the generalizability of probability models depend on the clinical profile and the prevalence of malignancy in the population in which they were derived. In this article, we review available validated models to estimate the probability of malignancy in patients with pulmonary nodules and outline how they were derived, their limitations, and how they compare with each other and physician judgment. We conclude with a brief discussion of advances in probability models.
Advances in techniques for identifying small pulmonary nodules.
Since the introduction of video-assisted thoracoscopic surgery, the demand for its use in resecting small pulmonary nodules has increased. In parallel, the development of high-resolution computed tomography has led to an increase in the detection of the early lung cancers appearing as nodules with ground-glass opacity. Several techniques to resect these small lesions have been devised, the most familiar of which is the use of a computed tomography-guided percutaneous hook wire. We recently developed virtual-assisted lung mapping to achieve safer and more reliable resection of these lesions. Virtual-assisted lung mapping is carried out using three-dimensional computed tomography, bronchoscopy, and fluoroscopically guided navigation to mark the lung surface with dye. A prospective study showed that this technique was safe and had a high success rate. Multiple marking around the targeted lesion allows for a sufficient surgical margin at resection. We recently introduced an electromagnetic navigation bronchoscopy system to confirm the sites to be marked by virtual-assisted lung mapping in the operating room prior to video-assisted thoracoscopic surgery. We are now studying a method to enable minimally invasive, safe, and reliable resection of lesions located deep in the lung parenchyma.
Approach to multiple pulmonary nodules: a case report and review of literature.
Niknam Farshid,Chen Jiezhong,Napaki Sabar,Aghmesheh Morteza
Chest X-ray and CT examinations often find pulmonary nodules that could be malignant or benign. A case is presented and discussed here in order to improve diagnosis and management of pulmonary nodules. A 62-year-old lady was found to have multiple pulmonary nodules by X-ray when she complained of a cough and fever. This was confirmed by a CT scan. Fine needle aspiration (FNA) of one of the lung lesions reported scant atypical epithelial cells that stained positive for TTF-1 and cytokeratin 7, but negative for cytokeratin 20. Thus, it was suspicious for large cell carcinoma. A videothoracoscopic lung biopsy and histopathology were applied and showed a necrotic nodule with surrounding chronic inflammation and macrophage response, with no evidence of malignant cells. Atypical reactive pneumocytes at the periphery of the lesion (an old infarct) were probably equivalent to the atypical cells seen on cytology. This result changed the diagnosis of our patient from a malignant condition to a benign process. Thus, CT and FNA may give a false positive. A second pathological opinion is very useful for the right diagnosis and management, as shown in our case.
How should pulmonary nodules be optimally investigated and managed?
Callister Matthew E J,Baldwin David R
Lung cancer (Amsterdam, Netherlands)
Pulmonary nodules are a common incidental finding on CT and the inexorable rise in the use of CT (10% increase per year in the UK over the last decade) means that the frequency of their detection is likely to increase over coming years. This may be augmented further if CT screening is implemented. Management has previously been influenced by North American guidelines, with the most widely used resource to date being the Fleischner Society guidelines published in 2005. These predominantly focus on the timing of CT scans arranged to survey small pulmonary nodules (≤ 8 mm), and the guideline authors chose not to offer specific recommendations regarding larger nodules. More recently, the society published specific guidelines for sub-solid nodules, reflecting the different prognosis that this subtype of nodules confers. The American College of Chest Physicians have published two guidelines on pulmonary nodules-the latest was completed in 2012 and published in Chest the following year. However, the investigation and management of pulmonary nodules is a rapidly evolving subject largely driven by evidence from the large CT screening studies. In 2012, The British Thoracic Society (BTS) convened a guideline development group to address the topic of pulmonary nodule investigation and management, with publication of the guideline in July 2015. One third of the 359 references included in the guideline date from 2012 onwards, and many of the differences between the recommendations made and previous guideline recommendations reflect this recent evidence. This article reviews specific evidence considered in formulating the BTS guidelines, and summarises the main guideline recommendations.
Management of Progressive Pulmonary Nodules Found during and outside of CT Lung Cancer Screening Studies.
Meyer Mathias,Vliegenthart Rozemarijn,Henzler Thomas,Buergy Daniel,Giordano Frank A,Kostrzewa Michael,Rathmann Nils,Brustugun Odd Terje,Crino Lucio,Dingemans Anne-Marie C,Dusmet Michael,Fennell Dean,Grunenwald Dominique,Huber Rudolf Maria,Moniuszko Marcin,Mornex Francoise,Papotti Mauro,Pilz Lothar,Senan Suresh,Syrigos Kostas,Pérol Maurice,Gray Jhanelle E,Schabel Christoph,van Meerbeeck Jan P,van Zandwijk Nico,Zhou Cai Cun,Manegold Christian,Voigt Wieland,Roessner Eric Dominic
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
Although the effectiveness of screening for lung cancer remains controversial, it is a fact that most lung cancers are diagnosed at an advanced stage outside of lung cancer screening programs. In 2013, the U.S. Preventive Services Task Force revised its lung cancer screening recommendation, now supporting lung cancer screening by low-dose computed tomography in patients at high risk. This is also endorsed by many major medical societies and advocacy group stakeholders, albeit with different eligibility criteria. In Europe, population-based lung cancer screening has so far not been recommended or implemented, as some important issues remain unresolved. Among them is the open question of how enlarging pulmonary nodules detected in lung cancer screening should be managed. This article comprises two parts: a review of the current lung cancer screening approaches and the potential therapeutic options for enlarging pulmonary nodules, followed by a meeting report including consensus statements of an interdisciplinary expert panel that discussed the potential of the different therapeutic options.
The Added Value of Computer-aided Detection of Small Pulmonary Nodules and Missed Lung Cancers.
Cai Jiali,Xu Dongming,Liu Shiyuan,Cham Matthew D
Journal of thoracic imaging
Lung cancer at its earliest stage is typically manifested on computed tomography as a pulmonary nodule, which could be detected by low-dose multidetector computed tomography technology and the use of thinner collimation. Within the last 2 decades, computer-aided detection (CAD) of pulmonary nodules has been developed to meet the increasing demand for lung cancer screening computed tomography with a larger set of images per scan. This review introduced the basic techniques and then summarized the up-to-date applications of CAD systems in clinical and research programs and in the low-dose lung cancer screening trials, especially in the detection of small pulmonary nodules and missed lung cancers. Many studies have already shown that the CAD systems could increase the sensitivity and reduce the false-positive rate in the diagnosis of pulmonary nodules, especially for the small and isolated nodules. Further improvements to the current CAD schemes are needed to detect nodules accurately, particularly for subsolid nodules.
Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It.
Slatore Christopher G,Wiener Renda Soylemez
Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo lung cancer screening, even more patients will be found to have a nodule. The vast majority of patients cannot benefit from the detection of a pulmonary nodule because most are benign. Accordingly, it is important to develop strategies to minimize harm, in particular the distress of a "near-cancer" diagnosis. In other settings, communication strategies are critical mediators of patient-centered outcomes for those with cancer and those at-risk of cancer. We conducted multiple studies to characterize the experience of patients with the diagnosis and evaluation of incidental pulmonary nodules, measure patient-centered outcomes for patients with pulmonary nodules, and determine the association of patient-clinician communication practices with those outcomes. We learned that a substantial proportion of patients experience distress and inadequate communication about pulmonary nodules and their evaluation, and yet many clinicians are unaware of the degree to which some patients are affected by the finding of a pulmonary nodule. The present review provides a comprehensive summary of our results and offers suggestions for how clinicians can best provide high-quality communication for their patients.
Management of pulmonary nodules according to the 2015 British Thoracic Society guidelines. Key messages for clinical practice.
Baldwin David R
Polskie Archiwum Medycyny Wewnetrznej
The British Thoracic Society guideline on the investigation and management of pulmonary nodules is based on a comprehensive and systematic review of the literature on pulmonary nodules. Recent evidence has suggested that significant changes to existing guidelines are necessary. The use of 2 malignancy prediction calculators to better characterize the risk of malignancy was firmly supported by evidence, as were the recommendations for a higher nodule size threshold for follow‑up (≥5 mm or ≥80 mm3) and a reduction of the follow‑up period to 1 year for solid pulmonary nodules. Although caution is required where there is a history of cancer, both of these recommendations will reduce the number of follow‑up computed tomographies, thereby improving cost‑effectiveness and pressure on imaging services. Recent evidence has also confirmed the superiority of volumetry as the preferred measurement method and clarified the management of nodules with extended volume‑doubling times. Acknowledging the good prognosis of subsolid nodules, there are recommendations for less aggressive options in their management. The guidelines recommend ordinal scale reporting for positron emission tomography-computed tomography to facilitate incorporation into risk models. There are recommendations on when biopsy is most helpful, the threshold for treatment without histological confirmation, and surgical and nonsurgical treatment. The guideline also provides evidence‑based recommendations about the information that people need and that should be provided for them. The complexity of managing pulmonary nodules is made more accessible by 4 management algorithms. In the real world, it is surprising how easy these are to follow and how they seem to follow an intuitive approach.
Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia.
Bai Chunxue,Choi Chang-Min,Chu Chung Ming,Anantham Devanand,Chung-Man Ho James,Khan Ali Zamir,Lee Jang-Ming,Li Shi Yue,Saenghirunvattana Sawang,Yim Anthony
BACKGROUND:American College of Chest Physicians (CHEST) clinical practice guidelines on the evaluation of pulmonary nodules may have low adoption among clinicians in Asian countries. Unique patient characteristics of Asian patients affect the diagnostic evaluation of pulmonary nodules. The objective of these clinical practice guidelines was to adapt those of CHEST to provide consensus-based recommendations relevant to practitioners in Asia. METHODS:A modified ADAPTE process was used by a multidisciplinary group of pulmonologists and thoracic surgeons in Asia. An initial panel meeting analyzed all CHEST recommendations to achieve consensus on recommendations and identify areas that required further investigation before consensus could be achieved. Revised recommendations were circulated to panel members for iterative review and redrafting to develop the final guidelines. RESULTS:Evaluation of pulmonary nodules in Asia broadly follows those of the CHEST guidelines with important caveats. Practitioners should be aware of the risk of lung cancer caused by high levels of indoor and outdoor air pollution, as well as the high incidence of adenocarcinoma in female nonsmokers. Furthermore, the high prevalence of granulomatous disease and other infectious causes of pulmonary nodules need to be considered. Therefore, diagnostic risk calculators developed in non-Asian patients may not be applicable. Overall, longer surveillance of nodules than those recommended by CHEST should be considered. CONCLUSIONS:TB in Asia favors lesser reliance on PET scanning and greater use of nonsurgical biopsy over surgical diagnosis or surveillance. Practitioners in Asia are encouraged to use these adapted consensus guidelines to facilitate consistent evaluation of pulmonary nodules.
[Features of excised pulmonary nodules in 100 patients].
Vega S Javier,Lazo P David,Undurraga M Felipe,Clavero R Jóse Miguel,Rodríguez D Patricio
Revista medica de Chile
BACKGROUND:Pulmonary nodules are common, and surgery is the only alternative that allows a diagnostic and therapeutic management in a single procedure. AIM:To report the epidemiological, radiological, surgical and pathological features of excised pulmonary nodules. MATERIAL AND METHODS:Review of medical records of patients in whom a pulmonary nodule was excised between 2014 and 2018. Those with incomplete data or without a pathological study were excluded from analysis. RESULTS:We retrieved 108 records and 8 had to be excluded, therefore 100 patients aged 34 to 82 years (57% females) were analyzed. Sixty percent had a history of smoking. Mean nodule size was 16 mm and the solid type was the most common (65%). Forty five percent of nodules had irregular margins and 55% were in the superior lobes. All patients operated by video-assisted thoracoscopic surgery and 40% underwent a lobectomy. Malignant lesions were observed in 87% of biopsies and a pulmonary adenocarcinoma was found in pathology in 40%. CONCLUSIONS:A multidisciplinary approach of pulmonary nodules, using adapted international guidelines, accomplishes an appropriate management, decreasing unnecessary surgical interventions.