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Home , Lung nodule

What To Do With Small Nodules Hanh Vu Nghiem, M.D Oakland University William Beaumont School of Medicine

I do not have any relevant financial relationships with any commercial interests Small Pulmonary Nodules

• Definition of small pulmonary nodules – Size criteria ? 2 cm, 1.5 cm, 1.0 cm – The size criteria for small pulmonary nodules continues to evolve with improved imaging techniques and technological advances – Smaller nodules are more frequently detected Small Pulmonary Nodules

• The demand to sample small pulmonary nodules less than 1 cm has increased

• In patients with known , determining the etiology of small pulmonary nodules changes the stage, treatment, and prognosis. CT guided of pulmonary nodules • Reported accuracies of CT guided biopsy range from 64% to 93% (FNA). – For smaller nodules (<1.5 cm), diagnostic accuracies decrease to 74% to 79%. • Reported major complications: – ranges from 16% to 66% – Pneumothorax requiring thoracostomy tube ranges from 4% to 35%. What To Do With Small Lung Nodules? • We biopsy them when requested

• What are our accuracy and safety ?

• We conducted a retrospective study to evaluate the accuracy and safety of CT guided core biopsy of small lung nodules. Retrospective Study • Retrospective study over a two year period from 1-1-2008 to 12-31-2009 • Total of 620 CT guided lung mass during this period • Of these, 77 (12%) biopsies had average size of 10 mm or less Retrospective Study

• 77/620 lung biopsies with average size < 10mm • 65/77: core biopsies only • 12/77: core and FNA, or FNA only • 65 lung nodules with core biopsies only were included in the study group Retrospective Study

• 65 biopsies in 62 patients with average age 69 at a single institution • 2 patients with 2 Bx of 2 different nodules and 1 patients with repeat Bx of same nodule • 8 different radiologists performing lung biopsies Materials and Methods • Nodules were measured retrospectively in standard lung window using the average of the two maximal orthogonal diameters • 65 lung nodules with mean diameter of <10 mm – size range: 6.5 to 10 mm – average size: 8.7 mm Materials and Methods

65 nodules: Location and indication • Location: – Lobes: 39 upper, 22 lower, 4 middle – 35 parenchyma, 28 sub-pleural ( within 1cm of pleura), 2 sub-pleural and para-diaphragmatic Materials and Methods

• Indication: – 42 nodules (65%) in patients with hx of prior malignancy – 23 nodules (35%) in patients with no hx of prior malignancy • 18/23 single pulmonary nodules • 5/23 multiple pulmonary nodules 9.7 mm (1.01 x 0.93cm)

Retrospective Measurement of Parenchyma Lesion Lesion at the Time of Biopsy 8.8 mm (10.2 x 7.5)

Sub-pleural Lesion 10mm (10.6 x 9.5)

Sub-pleural and Para-diaphragmatic Lesion Materials and Methods

• 65 lung nodule biopsies • 63/65: 19 G introducers/ 20G core needle BX • 2/65 : 17 G introducers/ 18 G core needle BX • Number of passes made: 2 to 5 passes • No “on-site” pathology available Materials and Methods

• Pathology results from biopsy – Positive results: positive for malignancy or highly suspicious for malignancy – Negative results: Negative for malignancy or nondiagnostic Materials and Methods

• Data analysis: Definition • True Positive: – Surgical confirmation of malignancy – Histologic findings compatible with patient’s known primary malignancy – Patient had subsequent clinical course consistent with malignancy Materials and Methods

• False Positive: – No evidence of malignancy at surgical resection – Nodule regression at follow up CT in the absence of therapy Materials and Methods

• True Negative: – Regression or no lesion growth on subsequent f/u CT (> 12 months) – No tumor identified during examination of surgical specimen • False Negative: – Lesion growth found on subsequent f/u CT – Surgical confirmation of malignancy Results • 65 nodules – 44 True malignant: • SCCA 9, BAC 2, Mets 16, Adeno CA 15, Adenoid cystic CA 1, Non small cell CA 1 – 21 True benign: • 10, BOOP 1, fibrosis/ chronic inflammation 2, 1, eosinophilic granuloma 1, histiocytosis 1 • 2 nodules resolved on follow up studies. • 3 nodules stable over 1 yr f/u in a patient without malignancy. Study Results

• Biopsy results: 65 nodules – Malignant: 36 – Benign: 18 – Nondiagnostic 11 – Diagnostic accuracy 83% Study Results

• Final Diagnoses: 65 nodules – True Positive 37 – True Negative 21 – False Negative 7 – False Positive 0 – Sensitivity for malignancy 84% – Specificity for malignancy 100% CT Guided Lung Bx: Published Literature Li et al: AJR 167:105-109, 1996 Accuracy and sensitivity for CT guided bx of nodules <15mm: 74% and 72% Hur et al: AJR 192: 629-634, 2009 Accuracy and sensitivity for CT guided bx of nodules < 10mm: 80% and 67% Study Results Complications: • 20/65 (31%) pneumothorax ( Up to 42% reported rate in published literature) • 11/20 PTX (55% of PTX cases or 17% of all biopsies) requiring and hospital admission • 9/20 PTX did not require chest tube, other treatments or hospital admission Comparison

77 biopsies of < 10 mm nodules 65 biopsies of < 10 mm nodules 65 cores, 8 FNA, 4 FNA+core 65 cores Diag. Accuracy 81% Diag. Accuracy 83% Sens. for Malign 80% Sens. for Malign 84% Spec. for Malign 100% Spec. for Malign 100% PTX 30% PTX 31% PTX w chest tube 14% PTX w chest tube 17%

3/8 FNA (38% of FNA) w PTX Study Conclusion

• CT guided biopsy is a useful diagnostic technique for small (< 10 mm) lung nodules with a sensitivity of 84 % and a diagnostic accuracy of 83 % in the diagnosis of malignancy • Complication rate of CT guided core biopsy of small lung nodules, mostly pneumothorax, is acceptable (31%) • Core Bx does not increase risk of PTX compared to FNA The End Thank You