iskander al-githmi, md, frcsc, facs, fccp

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SURGICAL APPROACH TO THE MANAGEMENT OF SOLITARY PULMONARY NODULE (SPN). ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP. Division of Cardiothoracic Surgery. February 22, 2011. Solitary Pulmonary Nodule. SOLITARY PULMONARY NODULE. SPN On Chest Radiography would raise several questions. - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP
Page 2: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP
Page 3: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP
Page 4: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP
Page 5: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Solitary Pulmonary Nodule

Page 6: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Is the nodule benign or malignant?

Should it be investigated or observed?

Should it be surgically resected?

SOLITARY PULMONARY NODULE

SPN On Chest Radiography would raise several questions

Page 7: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

SOLITARY PULMONARY NODULE

~ 150,000 solitary pulmonary nodule (or coin lesions) are detected annually in the US and often discovered incidentally at CxR or CT

or 1-2 SPNs per 500 CxR

Definition : Single, round and discrete pulmonary opacity that measure <3 cm. in diameter, surrounded by normal lung tissue and not associated with adenopathy or atelectasis.

Page 8: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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)

Page 9: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Primary LesionsAdeno CA

Squamous Cell CALarge Cell CA

Small Cell CA

Lymphoma

Carcinoid

Metastatic LesionsBreast

Head and Neck

Melanoma

Colon

Kidney

Sarcoma

SOLITARY PULMONARY NODULE

Malignant causes of Solitary Pulmonary Nodules

Page 10: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Solitary Pulmonary Nodule

• “ Remember that exploratory incision should not be made a cloak for diagnostic incompetence” – Rutherford Morrison (1853-1939)

Page 11: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Age

History of Smoking

Presence of other malignancy

Size of lesion

Border characteristic of lesion

Calcification of Lesion

Growth rate of lesion

SOLITARY PULMONARY NODULE

Factors affecting the likelihood of malignancy

Page 12: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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/o

But have to be cautious in assuming that a SPN in a young person is benign.

SOLITARY PULMONARY NODULE

Patient Age

Page 13: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

History of smoking – strong association of cigarette smoking with primary lung CA

Previously 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 Factors

SOLITARY PULMONARY NODULE

Page 14: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Size of the Lesion :

- Small lesions tend to be benign

- Over 80% of lesion > 5cm. are malignant

SOLITARY PULMONARY NODULE

- In fact, 25-35% of SPN under 1 cm have been shown to be malignant

Page 15: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Growth Rate :

- A nodule that is stable for 2 years is almost always benign.

- Doubling time – a 25% increase in diameter

- Most malignancy doubling time: 30-465 days.

- Some like osteosarcoma or germ cell tumor can double faster.

SOLITARY PULMONARY NODULE

Page 16: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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

Page 17: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Diagnostic tools for evaluation of lung nodules: X-ray or CT scan

Bronchoscopy (including direct biopsy, needle biopsy and brushing and washing for cytology)

Percutaneous fine needle aspiration biopsy.

PET/CT Scan

Excisional Biopsy

- Video assisted

- Thoracotomy

SOLITARY PULMONARY NODULE

Page 18: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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

Page 19: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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

Page 20: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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 scan

• On spiral CT, a nodule was considered malignant with enhancement of >25 HU

• On PET/CT, nodules were considered malignant with Max. SUV >3.5

The sensitivity, specificity and accuracy were compared

Page 21: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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=0.011

Conclusion: PET/CT may be performed as 1st line test for SPN

JNM 2006;47(3)443-

Page 22: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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)

SOLITARY PULMONARY NODULE

Page 23: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Important decisions made by patient’s physician and by patient himself.

Often patient decides between follow-up or surgery

SOLITARY PULMONARY NODULE

Who makes surgical decision?

Page 24: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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

Page 25: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

The management options : include

- “wait and watch” strategy

or

- Immediate surgery

- Biopsy of the nodule based on which decision is taken.

SOLITARY PULMONARY NODULE

Page 26: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Solitary Pulmonary Nodule

“Action is not a substitute for judgment”

Page 27: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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

Page 28: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

- 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

Page 29: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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.

Decision

Observation was suggested when the likelihood of malignancy was <5% or the risk of surgery was high. (Am Rev Respir Dis 1988; 134(3)453)

Page 30: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

Approach to the Management of Solitary Pulmonary Nodules

SOLITARY PULMONARY NODULENew nodule identified on

standard CT scanning

Benign calcification pattern on CT or stability for 2 yr.

on arcival filmsYes

No further testing

NoRisk factors for surgery•Predicted postoperative FEV1 < 0.8 liter•VO2 max < 10-15 ml/kg/min

Does probability of cancerwarrant surgery, given the

Surgical risk?

No

Moderate probability of cancer(10-60%)

Additional testing•PET if nodule >1 cm in diameter•Contrast-enhanced CT, depending on institutional expertise•Transthoracic fine-needle aspiration biopsy if nodule is peripherally located* Bronchoscopy if air-bronchus sign present

Low probability of cancer(<10%)

Yes

Postive

tsts

Video-assisted thoracoscopicSurgery, examination of a

Frozen section, followed byLobectomy if nodule is malignant

Negative

tests

Serial high-resolution CT at3, 6, 9, 12, 18 and 24 mo.

Page 31: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

SOLITARY PULMONARY NODULE

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.

Conclusions:

Page 32: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

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.

SOLITARY PULMONARY NODULE

Conclusions:

Page 33: ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP

THANK YOU!