Master di II livello in PNEUMOLOGIA iNTERVENTISTICA Linee guida per la gestione dei noduli polmonari solidi e subsolidi Massimo Pistolesi Dipartimento di Medicina Sperimentale e Clinica Pneumologia e Fisiopatologia Toraco-Polmonare Noduli subsolidi e solidi: follow-up radiologico Linee guida attuali • Noduli solidi ≤ 8 mm • Noduli solidi > 8 mm • Noduli sub-solidi (ground glass o parzialmente solidi) Noduli subsolidi e solidi: follow-up radiologico Linee guida attuali • Noduli solidi ≤ 8 mm • Noduli solidi > 8 mm • Noduli sub-solidi (ground glass o parzialmente solidi) CT incidental nodules Fleischner Society guidelines 2005 2005 Articolo più frequentemente consultato online sulla rivista Radiology Raccomandazioni più citate per valutazione e trattamento di piccoli noduli diagnosticati alla TC CT incidental nodules Fleischner Society guidelines 2005 CT incidental nodules ACCP guidelines 2013 CT incidental nodules ACCP guidelines 2013 CT incidental nodules ACCP guidelines 2013 Probability of malignancy= ex/(1+ex) X= -6.8272 + (0.0391 x age) + (0.7917 x smoke) + (1.3388 x cancer) + (0.1274 x diameter) + (1.407 x spiculation) + (0.7838 x location) Herder GJ et al. Chest 2005 CT incidental nodules ACCP guidelines 2013 CT incidental nodules ACCP guidelines 2013 Noduli subsolidi e solidi: follow-up radiologico Linee guida attuali • Noduli solidi ≤ 8 mm • Noduli solidi > 8 mm • Noduli sub-solidi (ground glass o parzialmente solidi) CT incidental nodules ACCP guidelines 2013 Noduli polmonari incidentali alla TC:cosa fare. Linee guida attuali • Noduli solidi ≤ 8 mm • Noduli solidi > 8 mm • Noduli sub-solidi (ground glass o parzialmente solidi) CT incidental nodules Fleischner Society guidelines 2005 “The recommendations presented here are based on our current understanding of pulmonary nodules, and we expect that they will continue to evolve as more information becomes available.” CT incidental nodules Fleischner Society guidelines 2005 Since 1970 the relative frequency of adenocarcinoma has increased 8-fold to make it the predominant type of lung cancer. CT incidental nodules Subsolid-partly subsolid nodules Vazquez M et al. Lung Cancer 2009 338 patients with a diagnosis of adenocarcinoma in a low-dose CT screening program. 2011 new classification of lung adenocarcinoma WHO, 2004 Preinvasive lesions Atypical adenomatous hyperplasia Adenocarcinoma Mixed subtype (80%-90%) Acinar Papillary Bronchioloalveolar carcinoma Solid with mucin formation Variants 2011 CT incidental nodules Histologic classifications and CT AAH (premalignant) AIS MIA invasive adenocarcinoma invasive adenocarcinoma poorly differentiate papillary adenocarcinoma 2011 new classification of lung adenocarcinoma AAH AIS MIA Invasive Adenocarcinoma CT incidental nodules ACCP guidelines May 2013 Patel VK et al. Chest 2013 2011 new classification of lung adenocarcinoma AAH 2011 new classification of lung adenocarcinoma AIS 2011 new classification of lung adenocarcinoma MIA 2011 new classification of lung adenocarcinoma Invasive adenocarcinoma Micropapillary Lepidic Papillary Acinar Solid 2011 new classification of lung adenocarcinoma Invasive adenocarcinoma lepidic non-mucinous solid mucinous Micropapillary Lepidic Papillary Acinar Solid 2011 new classification of lung adenocarcinoma Russel PA et al. J Thorac Oncol 2011 CT incidental nodules Fleischner guidelines 2013 Radiology 2013 CT incidental nodules 1 2 3 4 5 6 Fleischner guidelines 2013 CT incidental nodules Fleischner guidelines 2013 Note - These guidelines assume meticulous evaluation with contiguous thin sections (1mm) reconstructed with narrow and/or mediastinal window to evaluate the solid component and wide and/or lung windows to evaluate the nonsolid component of nodules, if indicated. When electronic calipers are used, bidimensional measurements of both the solid and ground-glass components of lesions should be obtained as necessary. The use of a consistent low-dose technique is recommended, especially in cases for which prolonged followup is recommended, particularly in younger patients. With serial scans, always compare with the original baseline study to detect subtle indolent grow. CT incidental nodules Fleischner guidelines 2013 Recommendation 1. Solitary pure GGNs ≤5mm Solitary pure GGNs measuring 5 mm or less do not require follow-up surveillance CT examination. Rationale. Although many of these GGNs likely represent foci of atypical adenomatous hyperplasia (AAH), these lesions are typically stable or extremely indolent at follow-up over several years. CT incidental nodules Fleischner guidelines 2013 Recommendation 2. Solitary pure GGNs >5mm Solitary pure GGNs larger than 5 mm require an initial followup CT examination in 3 months to determine persistence, followed by yearly surveillance CT examination for a minimum of 3 years if persistent or unchanged. Rationale. Because most of these lesions prove either to be benign or to represent isolated foci of AAH, AIS, or MIA, close monitoring is appropriate to enable early detection of even subtle interval change. CT incidental nodules Fleischner guidelines 2013 Minimal increase of size of adenocarcinoma 36 months follow-up 20 months follow-up CT incidental nodules April 2004 Fleischner guidelines 2013 August 2011 CT incidental nodules Fleischner guidelines 2013 6-months evolution of mucinous adenocarcinoma CT incidental nodules Fleischner guidelines 2013 3-months evolution of adenocarcinoma CT incidental nodules Fleischner guidelines 2013 Additional remarks • • • Follow-up examinations should include contiguous 1 mm thick sections. • PET/CT is of limited value in pure GGNs (sensitivity 33-37%), potentially misleading, and therefore not recommended. Currently, there is no indication for an initial course of antibiotics. Percutaneous transthoracic needle byopsy is not routinely recommended for pure GGNs (diagnostic yield 35%). CT incidental nodules Fleischner guidelines 2013 Recommendation 3. Solitary part-solid nodules Initial follow-up at three months to confirm persistence. If persistent and solid component <5 mm, then yearly surveillance CT for a minimum of 3 years. If persistent and solid component ≥5 then biopsy or surgical resection. Rationale. Unlike pure GGNs, numerous studies have documented that part-solid GGNs have a sufficiently greater likelihood of being malignant and thus warrant an aggressive diagnostic approach. CT incidental nodules Fleischner guidelines 2013 Additional remarks • For part-solid GGNs measuring 8–10 mm, further evaluation with PET/CT is advisable. • Transbronchial needle biopsy is not recommended for part-solid nodules unless surgery is not considered a viable alternative. • In cases for which surgical resection is considered appropriate, limited video-assisted thoracoscopic surgical wedge or segmental resections may be considered in place of a standard lobectomy. CT incidental nodules Fleischner guidelines 2013 Recommendation 4. Multiple subsolid nodules (pure GGNs ≤5mm) Obtain CT follow-up at 2 and 4 years. Consider alternate diagnoses for multiple extremely small ground-glass lesions, including respiratory bronchiolitis in smokers. CT incidental nodules Fleischner guidelines 2013 Recommendation 5. Multiple subsolid nodules (pure GGNs >5mm without a dominant lesion) Initial follow-up CT examination in 3 months to determine persistence, followed by yearly surveillance CT examination for a minimum of 3 years if persistent or unchanged. Rationale. Same considerations proposed in Recommendation 2 for Solitary pure GGNs 5>mm. CT incidental nodules Fleischner guidelines 2013 Recommendation 6. Multiple subsolid nodules (dominant nodule with part-solid or solid component) Initial follow-up CT at 3 months to confirm persistence. If persistent, byopsy or surgical resection is recommended, especially for lesions with >5 mm solid component. Rationale. Same considerations proposed in Recommendation 3 for Solitary part-solid nodules Stage IA invasive lepidic adenoca at histologic examination of specimen from wedge resection after three months CT follow-up persistence. CT incidental nodules Fleischner guidelines 2013 4-years follow-up CT incidental nodules ACCP & Fleischner guidelines 2013 Noduli polmonari incidentali alla TC:cosa fare. Linee guida attuali • Noduli solidi ≤ 8 mm • Noduli solidi > 8 mm • Noduli sub-solidi (ground glass o parzialmente solidi) CT incidental nodules Noduli solidi ≤ 8 mm Noduli solidi > 8 mm Noduli sub-solidi (ground glass o parzialmente solidi) Fleischner and ACCP/ATS guidelines CT incidental nodules Fleischner and ACCP/ATS guidelines List of 5 recommendations in pulmonary care of the Task Force of the ACCP and the ATS as part of the Choosing Wisely campaign. ACCP Annual Meeting 2013 Chicago (CHEST 2014) 1. Don't perform computed tomography (CT) surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines. 2. Don't routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension). 3. For patients recently discharged on supplemental home oxygen after hospitalization for an acute illness, don't renew the prescription without assessing the patient for ongoing hypoxemia. 4. Don't perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay. 5. Don't perform CT screening for lung cancer among patients at low risk for lung cancer. CT incidental nodules Atypical Adenomatous Hyperplasia Adenocarcinoma in situ Categories of neoplasia Minimally Invasive Adenocarcinoma Invasive Adenocarcinoma Courtesy of JR Galvin CT incidental nodules Normal Lung Continuous spectrum of neoplasia Atypical Adenomatous Hyperplasia Adenocarcinoma in situ Invasive Adenocarcinoma Courtesy of JR Galvin CT incidental nodules 1 Fleischner guidelines 2013 CT incidental nodules Fleischner guidelines 2013 2 20 months follow-up Stage IA lepidic invasive adenoca CT incidental nodules Fleischner guidelines 2013 3 invasive adenoca CT incidental nodules 4 Fleischner guidelines 2013 CT incidental nodules 5 Fleischner guidelines 2013 CT incidental nodules Fleischner guidelines 2013 6 4-years follow-up
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