Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
A Canadian Approach to Lung Cancer Screening: What every radiologist should know. May 28 – 30, 2015, Montréal, Québec Disclosure Statement: I have/had an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization, which could include: Speakers bureau: HIT Global, Intermune Subinvestigator on research sponsored by: Boehringer Ingelheim, CSL Behring, Grifols May 28 – 30, 2015, Montréal, Québec Lung cancer kills more Canadians than breast, colon and prostate cancers combined. 1% of cancer donations. 7% of cancer research funding. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2014. Toronto, ON: Canadian Cancer Society; 2014. Howlader N, et al. SEER Cancer Statistics Review, 1975-2011, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014. Faster and safer 14 Comparative average dose in mSv 12 10 8 6 4 2 0 abd pel CT CT chest LD CT chest CXR 50 000 randomized to CXR vs low dose CT 3 annual screens Age 55 to 74, > 30 pack years 20% reduction in lung cancer specific mortality. Screen 320 high risk smokers to prevent one death from lung cancer. Daria Manos US Preventative Services Task Force American Thoracic Society American College of Chest Physicians American Society of Clinical Oncology Cancer Care Ontario “YES! WE SHOULD SCREEN HIGH RISK PATIENTS!” Canadian Preventative Services Task Force – release date Fall 2015 Lung nodules are very common NLST data Positive screens True positive Positive screen False positive Problems with existing definition of positive screen Follow up Majority “positive CT” need nothing more than one additional surveillance CT. Problems with existing definition of positive screen Myth: Size is the most important predictor of malignancy. Change is more important than size. Nodules ≥ 10 mm: multiple important variables. Not all nodules ≥ 10mm need immediate work up. Problems with existing definition of positive screen CT too sophisticated a test to reduce to positive or negative results 13 months Lu-RADS 1 No nodule Lu-RADS 2 Benign nodule NEGATIVE INDETERMINATE Lu-RADS 3 Indeterminate (requires surveillance CT) Lu-RADS 4 4A – low risk 4B – likely low aggressive adenocarcinoma 4C – likely malignant POSITIVE Lu-RADS 5 Malignant by CT Lu-RADS 6 Tissue malignant LU-RADS • • Communicates level of concern. Groups nodules based on the best management. • • • • • • Recognizes not all worrisome nodules need same work up. Maintain safety but control work up costs. Reassurance that work up plan is appropriate. Identifies nodules for which negative PET/CT, bronchoscopy or biopsy would be discordant. Provides a roadmap for general radiologists. Provides a framework for comparable data. LU-RADS 1 – return to screening Direct participant to smoking cessation support. No nodule Explain limitations of screening. Describe and instruct re: concerning symptoms. LU-RADS 2 – return to screening • Small nodules • < 5mm LU-RADS 2 – return to screening • Small nodules • • Stable nodules • • • < 5mm Solid stable for 2 years Subsolid stable for 5 years Benign nodules • • • • • PFO Round atelectasis Benign calcification Hamartoma Specific benign tissue LU-RADS 2 – return to screening • Small nodules • • Stable nodules • • • < 5mm Solid stable for 2 years Subsolid stable for 5 years Benign nodules • • • • • PFO Round atelectasis Benign calcification Hamartoma Specific benign tissue No benefit follow up before next annual screen. Risk of lung cancer in next 2 years lower than prior to CT. One year Two years Three years 69 year old smoker Some of these nodules will be early cancer but overall no benefit for early follow up CT. Lu-RADS 1 No nodule Lu-RADS 2 Benign nodule Lu-RADS 3 Indeterminate (requires surveillance CT) Lu-RADS 4 4A – low risk 4B – likely low aggressive adenocarcinoma 4C – likely malignant Lu-RADS 5 Malignant by CT Lu-RADS 6 Tissue malignant LU-RADS 3 – Indeterminate recall for surveillance low dose CT 3 SMALL 3 LARGE LU-RADS 3 – Indeterminate recall for surveillance low dose CT 5-9 mm Not stable long enough to call benign 3 SMALL Too small for PET, biopsy, bronch Risk of cancer not high enough to justify work up. Patients assume all nodules are cancer. (Wiener. Chest 2013). Myth: 30-50% of lung nodules are malignant Journal of Nuclear Medicine 1999, Chest 2003, JTO 2011 http://www.brocku.ca/lung-cancer-risk-calculator For small solid nodules: Size is important but change is more important. LU-RADS 3 small (nodules 5-9 mm) After 2 years of stability classify as LU-RADS 2 (benign). Serial growth upstages. LU-RADS 3 – Indeterminate recall for surveillance low dose CT 3 LARGE ≥ 10 mm but CT or clinical features suggest inflammatory Follow in 4 to 12 weeks. LU-RADS 3 – requires surveillance CT Asymptomatic patients Follow up CTs LU-RADS 3 – requires surveillance CT Pneumonia 3 mos ago Follow up CTs ED last month 3 large: Requires surveillance Nodules ≥ 10 mm with clinical or CT features suggesting transient process possible even if patient asymptomatic. 73 year old 50+ pack year current smoker One year earlier 6 months later 3 months later Up to 50% of ground glass opacities in asymptomatic patients resolve on follow up. LU-RADS 3L: Possibly transient: What CT features suggest “possibly transient?” Baseline Subsolid Ill-defined gg halo air bronchograms Clinical features New large nodules POSITIVE CT Lu-RADS 4 4A risk 4A– low – low risk 4B – likely low aggressive adenocarcinoma 4C – likely malignant POSITIVE – but low risk 4A LOW RISK Nodule ≥ 10mm with benign but not definitive CT features. Hamartoma without fat Non-calcified granuloma ? round atelectasis, not definitive POSITIVE – but low risk 4A LOW RISK Any relevant priors? PET –good NPV here Nodule ≥ 10mm with Core biopsy benign but not definitive Serial CT CT features. Hamartoma without fat Non-calcified granuloma ? round atelectasis, not definitive Discussion POSITIVE – but low risk POSITIVE CT Lu-RADS 4 4A – low risk 4B – likely likelylow lowaggressive aggressive adenocarcinoma adenocarcinoma 4C – likely malignant LU-RADS 4: worrisome 4B LIKELY AIS or MIA Non transient Subsolid ≥ 10 mm No solid or ≤ 5mm solid portion Consider risks of surgery, wishes of patient Surgical biopsy vs monitor with CT Limitations of PET, bronch, perc biopsy GG neoplasm may grow very slowly. Will the competing cause of death be more important? 2 years 4 years 1 year 5 years 7 years 6 years 5 years Focal ground glass opacity can progress to invasive adenocarcinoma. 11 years Beware of growth: Persistent + growth = near 100% neoplastic* * Chang. Chest. 2013 Growth can be missed 8 years Beware increase in density 8 years 9.5 years 10 years Was the NLST long enough to evaluate these lesions? • How to manage? • • Biopsy? To faciltate non surgical treatment PET? • • • • • New GGO: Marked FDG uptake in GGO more likely to be inflammatory AIS by definition does not metastasize Mild FDG uptake in persistent GGO strongly predictive of neoplasm Useful to plan surgery when multiple lesions present Treatment for subsolid neoplasm • Screening studies criticized for overtreatment of indolent disease. • • • Consider competing causes of death. In situ disease in lung is difficult to resect • • Was the NLST long enough to determine this? Compared to breast, cervix, colon. No uniform approach Resect all persistent GGO? vs. Resect when solid portion develops Approach to GG neoplasm • • • • GG neoplasm common incidental finding Persistent GG - high likelihood of in situ neoplasm. GGO neoplasm unlikely invasive or metastatic but can develop into invasive disease with mets. Treatment decisions: • • • Need to reflect size and change of nodule Comorbidity and competing causes of death Wishes of patient POSITIVE CT Lu-RADS 4 4A – low risk 4B – likely low aggressive adenocarcinoma 4C likely malignant 4C– – likely malignant CT: Likely malignant Worrisome change 21 months CT: Likely malignant Worrisome baseline Malignant rate depends on local rate of granulomatous infection. CT: Likely malignant Negative PET bronch perc biopsy is discordant and should prompt team discussion. Do we need a new paradigm? CT shows SPN Biopsy, bronchoscopy, PET Treat Serial CT Clinical assessent +/-Biopsy +/-Bronch +/-PET Cancer likely Work up Biopsy/PET treat Cancer unlikely surveillance treat New approach • • • Not every worrisome nodule detected by CT requires the same work up. For some nodules negative work up will be reassuring, for other nodules it will not be. In addition to distinguishing benign from malignant nodules, CT can also help predict nodule aggression. Last words • • Screening CT for lung cancer has arrived in Canada. Will grow exponentially in next 10 years. Screening CT presents challenges to radiologists, including legal concerns. • • • Subtle slow growth in subsolid neoplasm. Overcalling new or inflammatory nodules. Use serial CT, clinical evaluation, PET, biopsy and brochoscopy as team players not a hierarchy. Last words • Our behaviour as radiologists in these initial stages has the power to make or break screening. THANK YOU! [email protected]