6 Is the nodule benign or malignant? Is the nodule benign or malignant?Should it be investigated or observed?Should it be surgically resected?SOLITARY PULMONARY NODULESPN On Chest Radiography would raise several questions
7 SOLITARY PULMONARY NODULE ~ 150,000 solitary pulmonary nodule (or coin lesions) are detected annually in the US and often discovered incidentally at CxR or CTor 1-2 SPNs per 500 CxRDefinition :Single, round and discrete pulmonary opacity that measure <3 cm. in diameter, surrounded by normal lung tissue and not associated with adenopathy or atelectasis.
8 SOLITARY PULMONARY NODULE Major question benign or malignant.Although most solitary pulmonary nodules have benign cause, “healed granuloma” (TB or fungi), 30-40% of these nodules are malignant (range 3-80%)More recent studies generally show higher percentage of malignancy among resected nodules than do older studies, presumably related to improved diagnostic techniques (CT, PET)
9 Primary LesionsAdeno CASquamous Cell CALarge Cell CASmall Cell CALymphomaCarcinoidMetastatic LesionsBreastHead and NeckMelanomaColonKidneySarcomaSOLITARY PULMONARY NODULEMalignant causes of Solitary Pulmonary Nodules
10 Solitary Pulmonary Nodule “ Remember that exploratory incision should not be made a cloak for diagnostic incompetence” – Rutherford Morrison ( )
11 AgeHistory of SmokingPresence of other malignancySize of lesionBorder characteristic of lesionCalcification of LesionGrowth rate of lesionSOLITARY PULMONARY NODULEFactors affecting the likelihood of malignancy
12 The probability of a SPN being malignant rises with increasing patient age.A study of malignancy in 955 patients in 1983:- 65% > 50 y/o- 35% < 50 y/oBut have to be cautious in assuming that a SPN in a young person is benign.SOLITARY PULMONARY NODULEPatient Age
13 History of smoking – strong association of cigarette smoking with primary lung CAPreviously diagnosed malignancy increases the likelihood that SPN may represent metastatic disease.~ 10-30% of resected malignant pulmonary nodules are metastatic from extrathoracic malignancies.Underlying Risk FactorsSOLITARY PULMONARY NODULE
14 Size of the Lesion :- Small lesions tend to be benign- Over 80% of lesion > 5cm. are malignantSOLITARY PULMONARY NODULE-In fact, 25-35% of SPN under 1 cm have been shown to be malignant
15 Growth Rate :-A nodule that is stable for 2 years is almost always benign.Doubling time – a 25% increase in diameterMost malignancy doubling time: days.Some like osteosarcoma or germ cell tumor can double faster.SOLITARY PULMONARY NODULE
16 Calcification :-Calcium are present in > 50% of benign nodules.Benign calcification appears as laminated central or diffuse pattern.Calcium may present in 15% of malignant nodule, but usually eccentrically located.SOLITARY PULMONARY NODULE
17 Diagnostic tools for evaluation of lung nodules: X-ray or CT scanBronchoscopy (including direct biopsy, needle biopsy and brushing and washing for cytology)Percutaneous fine needle aspiration biopsy.PET/CT ScanExcisional Biopsy- Video assisted- ThoracotomySOLITARY PULMONARY NODULE
18 Percutaneous Needle Biopsy (PNB)-Reliable with reported sensitivity 64-97% for diagnosis malignancy.In benign disease, the accuracy varies between 50-80%.Relatively Safe with Pneumothorex complication rate 30% and 5-10% requiring chest tube drainage.There is no doubt that PNB reduce the number of patients require thoracotomy.SOLITARY PULMONARY NODULE
19 PET/CT Scan-The sensitivity of PET for diagnosing lung cancer approaches 95% with a specificity of over 85%.One study has demonstrated that for SPNs, a negative PET scan associated with only a 4.7% risk of malignancy.False-negative PET scan are usually associated with lesions < 1 cm. in size & in BAC.SOLITARY PULMONARY NODULE
20 Tissue characterization of SPN:Comparative study between helical CT and integrated PET/CT Methods: 119 Pt. with SPN-underwent both enhanced spiral CT and PET/CT scanOn spiral CT, a nodule was considered malignant with enhancement of >25 HUOn PET/CT, nodules were considered malignant with Max. SUV >3.5The sensitivity, specificity and accuracy were compared
21 Results: There were 79 malignant & 40 benign nodule Sensitivity, specificity and accuracy of enhanced CT were 81%, 93% & 85%Those on PET/CT were 96% e p=0.008, 88% e p=0.72 & accuracy 93% e p=0.011Conclusion: PET/CT may be performed as 1st line test for SPNJNM 2006;47(3)443-
22 SOLITARY PULMONARY NODULE Video-Assisted thoracic excisional biopsy-Safe and highly effective in diagnosing and often in treating solitary pulmonary nodule.But smaller lesion may be difficult to localize.Series from the Brigham and Women’s Hospital reported successful resection of lesions < 1 cm in diameter without any localization techniques. (N Engl J Med 1995, 52:515)
23 Important decisions made by patient’s physician and by patient himself.Often patient decides between follow-up or surgerySOLITARY PULMONARY NODULEWho makes surgical decision?
24 Decision may be influenced by numerous factors including the probability that the nodule is malignant, risks of surgery, accuracy of biopsy technique and fear that delay in surgical resection may forfeit the possibility of cure.In addition, surgeon confidence and experience are important in decision making.SOLITARY PULMONARY NODULE
25 The management options : include-“wait and watch” strategyorImmediate surgeryBiopsy of the nodule based on which decision is taken.SOLITARY PULMONARY NODULE
26 Solitary Pulmonary Nodule “Action is not a substitute for judgment”
27 Wait and watch strategy-There are no studies demonstrating a decrease in survival when patient is kept under observation for few months to assess the growth of the nodule.Observation is advisable when the risk of malignancy is low, the risk of surgery is high or the patient refused further invasive procedures.SOLITARY PULMONARY NODULE
28 -The proponents of immediate surgery argue that if surgery is delayed, it allows time for the growth of the nodule and therapy reduce the chance of a 5 year survival.Cummings et. al. (proposed the use of decision analysis based on the probability that the nodule is malignant using Bayes Theorem and four variables I.e. age, history of smoking, diameter of the nodule and prevalence of malignancy. The average of life expectancy in years of various strategies was then compared.SOLITARY PULMONARY NODULE
29 SOLITARY PULMONARY NODULE In patients with calculated probability of malignancy greater than 75-80%, early surgery appeared slightly superior to the needle biopsy.In patients with probability of malignancy less than 75-80%, needle biopsy was slightly superior to immediate surgery.DecisionObservation was suggested when the likelihood of malignancy was <5% or the risk of surgery was high. (Am Rev Respir Dis 1988; 134(3)453)
30 SOLITARY PULMONARY NODULE Approach to the Management of Solitary Pulmonary NodulesSOLITARY PULMONARY NODULENew nodule identified onstandard CT scanningBenign calcification patternon CT or stability for 2 yr.on arcival filmsYesNo further testingNoRisk factors for surgeryPredicted postoperativeFEV1 < 0.8 literVO2 max < ml/kg/minDoes probability of cancerwarrant surgery, given theSurgical risk?Moderate probability of cancer(10-60%)Additional testingPET if nodule >1 cm in diameterContrast-enhanced CT, dependingon institutional expertiseTransthoracic fine-needle aspirationbiopsy if nodule is peripherally located* Bronchoscopy if air-bronchus sign presentLow probability of cancer(<10%)PostivetstsVideo-assisted thoracoscopicSurgery, examination of aFrozen section, followed byLobectomy if nodule is malignantNegative testsSerial high-resolution CT at3, 6, 9, 12, 18 and 24 mo.
31 SOLITARY PULMONARY NODULE Conclusions:There is no one way to manage the indeterminate nodule, but the diagnosis require a suitable clinical evaluation. The judicious application of diagnostic methods that based on the medicine evidence based, will improve the quality of the medical attention.Excisional biopsy may be attractive for the surgeon because it provides a definite diagnosis and place the surgeon in a win position.
32 SOLITARY PULMONARY NODULE Conclusions:It is important to assess and respect the patient’s anxiety and fears. Most importantly, surgeons must personally oversee the follow-up and be willing to change their opinion, as new evidence is available.It is my bias that these nodules are best managed by thoracic surgeons who must have confidence that the algorithm followed in observing some patients, will not alter the ultimate outcome, even if the nodule should subsequently prove malignant.