1. Pulmonary nodules discovered on CT scan of the chest
Pulmonary nodules discovered on CT scan of the chest. What if it is lung cancer?
Pavlo Sakhatskyy, MD

2. Outline CT screening has mortality benefit Workup of nodules 3-8 mm
Staging of lung cancer
Role of navigational bronchoscopy and endobronchial ultrasound in diagnosis and staging of lung cancer

3. From August 2002 through April 2004, study enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers. Participants were randomly assigned to undergo three annual screenings with either low-dose CT (26,722 participants) or single-view posteroanterior chest radiography (26,732). Data were collected on cases of lung cancer and deaths from lung cancer that occurred through December 31, 2009.

4. Eligible participants were between 55 and 74 years of age at the time of randomization, had a history of cigarette smoking of at least 30 pack-years, and, if former smokers, had quit within the previous 15 years. 

5. There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P=0.004). The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02).

6. Potential Benefits and Harms of Three Rounds of Annual Screening with Low Dose CT scan per 1000 screened
Benefits
Harms
4 fewer deaths from lung cancer
375 false positive results
1 fewer death from other cause
41 biopsies for benign nodule
10 surgeries

7. Efficacy of CT chest screening is comparable with colonoscopy or mammogram
Number needed to screen to save one life
Colonoscopy
CT scan of the chest
Mammogram
CT of the chest
Colonoscopy
Mammogram

8. Major organizations recommend lung cancer screening
American Academy of Family Physicians, 2013
American Association for Thoracic Surgery, 2012
American Cancer Society, 2012
American College of Chest Physicians, 2012
American Thoracic Society, 2012
American Society of Clinical Oncology, 2012
US Preventive Services Task Force, 2013
National Comprehensive Cancer Network, 2012

9. Implications of CT scan screening
Annual screening is at least as effective in preventing death from cancer as annual mammogram.
Among high risk smokers low dose CT prevents one of five deaths from lung cancer.
Lung cancer screening is not a single test. It is a process that involves annual testing and follow up
False positives occur in one of five examinations. Each examination is 20 times as likely to yield a false positive test as it is to reveal lung cancer.
Screening for lung cancer is not a substitute for smoking cessation.

10. Management algorithm for individuals with solid nodules <8 mm

11. Management algorithm for solid nodules 8-30 mm

12. Treatment options and outcomes are determined by stage

13. Size and location of the tumor determines T stage

14. Size and location of the tumor determines T stage

15. Mediastinal lymph nodes and N stage

16. Stage of lung cancer based on TNM
Mediastinal 7,4, 2
Contraletaral
Hilar 10-14

17. Lower paratracheal lymph nodes

19. Subcarinal and paraesophageal nodes

20. Hilar Lymph Nodes

21. Some mediastinal lymph can be biopsied with mediastinoscopy or endoscopy

22. Most of mediastinal lymph nodes can be evaluated with bronchoscopy

26. Invasive staging is significantly more specific and sensitive

27. Invasive staging is significantly more specific and sensitive
Positive predictive value
Negative predictive value
CT scan
58%
83%
PET-CT
75%
91%
Bronchoscopy with EBUS
100%

28. EBUS bronchoscopy has high sensitivity and negative predictive value

29. It easier to find a needle in haystack with magnet

30. VERAN navigational bronchoscopy
A same-day Inspiration/Expiration CT scan was performed using Veran’s CT protocol. The physician was unable to reach the nodule using Always-On Tip Tracked® serrated forceps and the 21ga needle due to lack of direct airway to the lesion. SPiN Xtend™ needle was navigated to the exit point set during the planning portion of the procedure. Trajectory of the needle was aligned following simulated guidance and biopsies were perfomed. Malignant cells were noted upon inspection of the first pass with the SPiN Xtend™ needle and additional samples were taken.
36 year-old female with a history of breast cancer was hospitalized after undergoing an attempted CT-guided biopsy. This CT-guided procedure resulted in a pneumothorax. 14mm nodule located in the Right Lower Lobe was PET positive and CT scans revealed that the nodule increased in size.

32. Indications for bronchoscopy
Uncertain differential that includes infection or sarcoidosis
Centrally located pulmonary nodule in high risk patient with emphysema
Mediastinal lymphadenopathy on PET-CT or CT scan of the chest
2-3 cm lung cancer in a surgical candidate 

33. Case presentation
63 yo smoker presented to the hospital with spontaneous pneumothorax
2 years prior the patient had screening chest CT that was reassuring
5 years prior he had early stage bladder cancer with recurrence 3 years later that was radically treated

34. CT scan of the chest
CT of the chest demonstrated 1.5 cm cavitary lesion in the left upper lobe and 1.5 cm solid nodule in the right upper lobe, there was no significant mediastinal lymphadenopathy

35. PET scan
There is a metabolically active mass in the left lung apex ~2 cm with SUV Max of 7.5, compatible with malignancy. Medial to this is a small pneumothorax. A left chest tube is noted and increased FDG uptake is seen at the left lateral chest wall .There is a very small left pleural effusion. There is a metabolically active nodule in the right upper lobe of the lung measuring 15 mm on image 68. SUV Max is 4.5 compatible with malignancy. 

36. Workup and treatment
CT guided biopsy of the left upper nodule demonstrated SQUAMOUS CELL CARCINOMA
The patient had EBUS with sampling of mediastinal lymph nodes at stations 11R, 10R,4R and 7 and navigational bronchoscopy with biopsies of the right upper lobe nodule that was negative for malignancy
CT guided biopsy was performed few weeks later, again with reassuring results BENIGN LUNG TISSUE WITH NECROTIZING GRANULOMATOUS INFLAMMATION.
The patient had stereotactic radiation to the left upper lobe nodule

37. Follow Up
Follow up CT scan of the chest 6 months later was reassuring but 12 months after treatment demonstrated mediastinal lymphadenopathy
The patient had bronchoscopy with EBUS and biopsy confirmed recurrent squamous cells cancer at station 4L

38. Conclusions
Screening for lung cancer with CT scan of the chest improves all-cause mortality
Small pulmonary nodules can be followed over time with serial CT scan of the chest
Pulmonary nodules over 8 mm may require PET CT scan, biopsy or surgery
EBUS bronchoscopy is preferred staging modality that dictates further therapy
Navigational bronchoscopy provides alternative biopsy method for centrally located lesions in patients with emphysema