UNIVERSITA` DEGLI STUDI DI FIRENZE FACOLTA` DI MEDICINA E

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UNIVERSITA` DEGLI STUDI DI FIRENZE FACOLTA` DI MEDICINA E
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