SOLITARY PULMONARY NODULE.pptx

solitary pulmonary nodule

1. SOLITARY PULMONARY NODULE Dr Sabhilash sugathan

2. DEFINITION A single well or poorly defined rounded opacity less than or Equal to 3cm in diameter. Predominantly surrounded by lung parenchyma, does not touch the hilum or mediastinum There should be no related abnormalities in the thorax such as lymphadenopathy, pneumonia or atelectasis. Lesions larger than 3cm are called Pulmonary Masses ( are treated as malignancies until proven otherwise).

3. Frequency depends on Endemicity of granulomatous disease Whether we are looking at an AT RISK population

4. 90% are incidental findings Possible alert signal for lung cancer X ray pick up rate 0.09 — 2 % Ct scan : 8 – 51%

5. Nodule measurements and technical parameters for imaging Image Production In full inspiration Nodules are viewed and measured in thin slices(<1.5mm)using high spatial frequency algorithm in order to avoid partial volume averaging and to detect any fat or calcification Measurement usually in Axial Plane. Measurement should be in lung window.

6. Measurement and Description <3mm – Micronodules(No need to measure) 3-10mm measured for risk estimation. Average of short and long axis diameter, rounded to the nearest whole mm >10mm measured in both axis

7. On seeing a SPM Important to secure old films to see whether a nodule is new , old , stable or growing over time Look for definitely benign features Asses for the risk of Malignancy Follow up

8. MALIGNANT VS BENIGN

9. NODULE CHARACTERISTICS SIZE LOCATION CALCIFICATION GROWTH MORPHOLOGY ENHANCEMENT

10. BENIGN Shape and Edges Calcification Nodule with Macroscopic fat Peri fissural nodules Nodule with long term stability Small nodules in young patients

11. Shape and Edges Round , oval shaped nodules with smooth / sharp margin only 20% of nodules with a smooth, sharp margin are malignant.

12. 1. Calcification Diffuse Central Laminated Pop- corn

13. Metastases from mucinous adenocarcinoma, osteogenic sarcoma, or chondrosarcoma can show homogenous calcification, but a history of the primary tumor allows a correct diagnosis.

14. Tuberculoma . Amyloidosis Homogeneous calcification. Dense and uniform calcification

15. Dense central (bull’s-eye) calcification Histoplasmom Hamartoma

16. Concentric rings of calcium (“target” calcification) histoplasmoma

17. “popcorn” calcification hamartoma

18. 2. Nodule with macroscopic fat

19. Shape polygonal shape and a three-dimensional ratio > 1.78 was a sign of benignity A polygonal shape means that the lesion has multiple facets (multi-sided). A peripheral subpleural location was also a sign of benignity in this study. The three-dimensional ratio is measured by obtaining the maximal transverse dimension and dividing it by the maximal vertical dimension. A large three-dimensional ratio indicates that the lesion is relatively flat, which is a benign sign . Granulomas often are round Hamartomas &metastases - round, oval, or lobulated Scars or areas of atelectasis - linear or angular or elliptical in shape.

20. 3. Peri – fissural nodules Homogenous, smooth, solid, lentiform and triangular shaped nodules either within / 1 cm of fissure or pleural surface and measuring less than 10mm.

21. 4. Nodules with long term stability Solid nodules – 2 yrs. Sub solid nodules – 3yrs

22. Contrast enhancement Contrast enhancement less than 15 HU has a very high predictive value for benignity (99%). After a baseline scan, 4 consecutive scans at 1 minute interval are performed

23. Satellite Nodules Satellite nodules are small nodules seen adjacent to a larger nodule or mass. Satellites are most common with granulomatous diseases and infections such as TB In patients with sarcoidosis , the presence of satellite nodules has been termed the “ galaxy sign .” Tuberculosis. A right upper lobe nodule is associated with satellites ( arrows ).

24. 5. Small nodules in young patients Small < 8mm Young <35yrs

25. History of risk factors

26. Radiological predictors of malignancy Size Spiculation Upper lobe location Asymmetrical calcification Cavitation Sub solid appearance

27. SIZE <4mm –1% 4-7mm—3-7% 8-10mm—15% >20mm—40% The likelihood of malignancy for a solid nodule seen on CT in patients being screened for lung cancer is directly related to its size (Table 9.2).Richard Webb

28. SPICULATION Corona radiata sign  - highly associated with malignancy –Spiculation due to desmoplastic reaction around tumor 90% of nodules with an irregular or spiculated edge are malignant. only 20% of nodules with a smooth, sharp margin are malignant. Malignancies that tend to have a sharp and smooth edge include metastases and carcinoid tumors Two pleural tails (arrows)

29. Pleural tail sign It is a thin linear opacity seen extending from the edge of a lung nodule to the pleural surface , seen in association with spiculation . As with spiculation , most often is associated with adenocarcinoma ; uncommonly indicates the presence of a large cell carcinoma pleural tail sign also can be seen in association with benign lung nodules, which are associated with fibrosis, including various granulomatous diseases . The presence of a spiculated contour is more suggestive of malignancy than a pleural tail.

30. Upper lobe location right upper lobe is most commonly involved metastatic tumor presenting as an SPN subpleural or outer third of the lung in the lower lobes.

31. CAVITATION <4mm - benign 4 – 16 mm – intermediate >16mm – malignant( thick,nodular wall ) most commonly in patients with adenocarcinoma and squamous cell carcinoma

32. MALIGNANT CALCIFICATION Eccentric calcification in anadenocarcinoma Speckled calcification in Carcinoid tumor

33. Air Bronchogram sign commonly seen in malignant pulmonary nodules. most commonly seen in BAC (bronchoalveolar cell carcinoma) and adenocarcinoma. airbronchogram seen as a linear lucency (broad arrow) and as a more cystic lucency (small arrow) due to the fact that the bronchus is seen en face.

34. Doubling time the time required for a lesion to double in volume, is used to measure the growth rate. For easy reference, a 26% increase in nodule diameter is one doubling, a doubling of diameter means that three volume doublings have occurred. Doubling times ranging from 1 month to 200 days encompass most cancers.(1 to 16 months) 30 days for small cell carcinoma 100 days for squamous cell and large cell carcinomas 180 days for invasive adenocarcinoma

35. SUB - SOLID NODULE

36. Halo sign in invasive aspergillosis Halo sign in adenocarcinoma

37. Halo sign A halo of GGO surrounding a soft tissue density lung nodule. It is commonly present in leukemic patients with angioinvasive aspergillosis , but also can be seen in patients with other infections, inflammatory and vascular abnormalities, and in some tumors, particularly adenocarcinoma . In patients with invasive aspergillosis , the halo sign represents hemorrhage ; in patients with carcinoma , it reflects the presence of lepidic spread of tumor .

38. Chance of malignancy Solid –7% Part solid –63% Ground glass nodule—17%

39. Pure GGN

40. Differential diagnosis of sub solid nodules Hemorrhage Infection Organizing pneumonia Focal fibrosis

41. Adeno carcinomas of lung –30-35% of primary lung tumours and the subset bronchoalveolar carcinoma commonly present as SSN The term BAC is now replaced by its histological subtypes which has characteristic CT finding

42. AAH(Atypical adenomatous hyperplasia) CT findings : <5mm Ground Glass opacities

43. AIS (Adenocarcinoma InSitu ) >5mm diameter CT findings : ground glass opacities with small solid components

44. MIA(Minimally invasive Adenocarcinoma) CT findings : part solid nodule – ground glass with <5mm solid components

45. Invasive Adenocarcinoma (non mucinous or mucinous) CT findings: part solid with >=5 mm or solid

46. Follow up of solid nodules ( Fleishchner Society guidelines) Low risk group <6mm –no follow up 6-8mm—CT at 6- 12months High risk group <6mm –optional CT after 12 months , consider CT at 18-24 6-8mm—CT at 6 - 12 months ----follow at 18 - 24months

47. Nodule >8mm All Cases – CT at 3months , PET CT followed by CT guided biopsy/ Excision biopsy

48. Follow up of SSN( Fleishchner Society guidelines) Recommendation 1 : GGN <6mm – no followup Recommendation 2 : GGN>6mm – follow up after 3 months, then yearly followup for 5 yrs Recommendation 3 : PSN –considered malignant if it remains stable at 3 months and if increases in size. if solid component <6mm likely to be AIS or MIA(follow R2) if solid component >6mm biopsy if not a surgical candidate

49. Lung-RADS Lung-RADS  ( Lung Imaging Reporting and Data System ), is a classification proposed to aid with findings in  low-dose CT screening exams for lung cancer . The goal of the classification system is to standardize follow-up and management decisions. The system is similar to the   Fleischner criteria  but designed for the subset of patients intended for low-dose screening studies.

50. Practical points nodule measurement should be in lung windows to calculate nodule mean diameter, measure both the long and short axis to one decimal point, and report mean nodule diameter to one decimal point. [previously recommended rounding to nearest whole number version 1.0.] only a single measurement is necessary for round nodules "growth" is an increase in size of ≥1.5 mm assignment of a Lung-RADS status is based on the most suspicious nodule category 4B management is based on multiple factors including overall patient status and patient preference solid nodules with smooth margins, an oval, lentiform or triangular shape, and maximum diameter less than 10 mm ( perifissural nodules) should be classified as category 2. (version 1.1 addition) for category x, the Lung-RADS is rendered as "Lung-RADS category x" or "Lung-RADS x".

51. Category 0 (Incomplete) prior CT studies were performed, but are not available for comparison lungs are incompletely imaged Recommended follow-up Category 0: comparison with prior studies before assignment of Lung-RADS classification

52. Category 1 (negative, <1% chance of malignancy) no lung nodules lung nodule(s) with specific findings favoring benign nodule(s) complete calcification central calcification popcorn calcification calcification in concentric rings fat-containing nodules Recommended follow-up continue annual screening with LDCT

53. Category 2 (benign appearance or behavior, <1% chance of malignancy) solid nodule(s) <6 mm at baseline new nodule <4 mm <10 mm  perifissural nodules with characteristic (solid nodules with smooth margins, an oval, lentiform or triangular shape) appearance (version 1.1 addition) subsolid nodule(s) <6 mm on baseline screening ground glass nodule(s) <30 mm (version 1.1 change previously 20 mm) ≥30 mm and unchanged or slowly growing (version 1.1 change previously 20 mm) category 3 or 4 nodules that are unchanged for ≥3 months Recommended follow-up continue annual screening with LDCT

54. Category 3 (probably benign, 1-2% chance of malignancy) solid nodule(s) ≥6 mm to <8 mm at baseline new nodule 4 mm to <6 mm subsolid nodule(s) ≥6 mm total diameter with solid component <6 mm new <6 mm total diameter ground glass nodule(s) ≥30 mm on baseline CT or new (version 1.1 change previously 20 mm) Recommended follow-up 6-month follow-up with LDCT

55. Category 4A (suspicious, 5-15% chance of malignancy) (version 1.1 change previously suspicious) solid nodule(s) ≥8 mm to <15 mm at baseline growing nodule(s) <8 mm new nodule 6 mm to <8 mm subsolid nodule(s) ≥6 mm total diameter with solid component ≥6 mm to <8 mm new or growing <4 mm solid component endobronchial nodule Recommended follow-up 3-month follow-up with LDCT PET-CT may be used if there is a ≥8 mm solid component

56. Category 4B (very suspicious, >15% chance of malignancy) solid nodule(s) ≥ 15 mm at baseline new or growing, and ≥8 mm subsolid nodule(s) solid component ≥8 mm new or growing ≥4 mm solid component for new large nodules that develop on an annual repeat screening CT, a 1 month LDCT may be recommended to address potentially infectious or inflammatory conditions. (version 1.1 addition) Recommended follow-up

57. Category 4X (very suspicious, >15% chance of malignancy) ategory 3 or 4 nodules with additional features or imaging findings that increase the suspicion of malignancy includes: spiculation ground glass nodule(s) that double in size in 1 year enlarged regional lymph nodes for new large nodules that develop on an annual repeat screening CT, a 1 month LDCT may be recommended to address potentially infectious or inflammatory conditions. (version 1.1 addition) Recommended follow-up

58. Recommended follow-up chest CT with or without contrast, as appropriate PET-CT and/or tissue sampling depending on the probability of malignancy and comorbidities (PET-CT if solid component ≥8 mm) for new large nodules that develop on an annual repeat screening CT, a 1 month LDCT may be recommended to address potentially infectious or inflammatory conditions. (version 1.1 addition)

59. Modified categories [X] S  (e.g. "3S") if there is a clinically significant or potentially significant non-lung cancer finding (version 1.1 removal): [X] C  (e.g. "3C") for a patient with a prior diagnosis of lung cancer who returns to screening Recommended follow-up

60. THANK YOU.

61. Feeding Vessel Sign The “ feeding vessel sign ” is present if a small pulmonary artery is seen leading directly to a nodule. This appearance is most common with metastasis, infarct, and AVM . It is less common with primary lung carcinomas or benign lesions such as granuloma. If present, it should suggest the possibility of a vascular abnormality, but is nonspecific