Management pathways for solitary pulmonary nodules

Intrathoracic Ewing's sarcoma in an adult masquerading as lung abscess

Intrathoracic extraskeletal Ewing's sarcoma (EES) is a relatively uncommon malignant tumour. Here, we present a scenario involving an adult man in his 20s with a large intrathoracic EES that manifested as a lung abscess. Preoperative diagnostic tests were inconclusive; hence, the patient underwent an exploratory thoracotomy for the excision of the mass. Histopathology revealed a small round blue cell tumour, and immunohistochemistry, along with fluorescence in situ hybridisation, confirmed the diagnosis of Ewing's sarcoma. Adjuvant chemoradiotherapy was recommended, but the patient did not comply. A year later, he presented with a recurrence of the intrathoracic mass and subsequently received adjuvant chemotherapy. Currently, he is in remission.

Management of ground-glass opacities and sub-solid pulmonary nodules: a surgeon's perspective

The regular use of high-resolution computed tomogram scans has led to an increase in the detection of asymptomatic ground-glass opacities and sub-solid nodules at an early stage. Different growth patterns of these lesions are making decision-making a real challenge. With growing experience and improving radiology interventions, management of these lesions is changing constantly. However, with variations in growth patterns and outcomes, immediate treatment options as well as follow-up surveillance and subsequent interventions can be confounding for the clinicians. This mini review describes algorithms for managing these ground-glass opacities (GGOs) and sub-solid nodules (SSNs) with a focus on the surgical options.

Minimally invasive interventions for biopsy of malignancy-suspected pulmonary nodules: a systematic review and meta-analysis

BACKGROUND

Imaging tests are important for diagnosis during the management of pulmonary nodules; however, biopsy is required to confirm the malignancy.

OBJECTIVES

To compare the effects of different techniques used for the biopsy of a pulmonary nodule.

DESIGN AND SETTING

Systematic review and meta-analysis were conducted using Cochrane methodology in São Paulo, São Paulo, Brazil.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) on minimally invasive techniques, including tomography-guided percutaneous biopsy (PERCUT), transbronchial biopsies with fluoroscopy (FLUOR), endobronchial ultrasound (EBUSR), and electromagnetic navigation (NAVIG). The primary outcomes were diagnostic yield, major adverse events, and need for another approach.

RESULTS

Seven RCTs were included (913 participants; 39.2% female, mean age: 59.28 years). Little to no increase was observed in PERCUT over FLUOR (P = 0.84), PERCUT over EBUSR (P = 0.32), and EBUSR over NAVIG (P = 0.17), whereas a slight increase was observed in NAVIG over FLUOR (P = 0.17); however, the evidence was uncertain. EBUSR may increase the diagnostic yield over FLUOR (P = 0.34). PERCUT showed little to no increase in all bronchoscopic techniques, with uncertain evidence (P = 0.02).

CONCLUSION

No biopsy method is definitively superior to others. The preferred approach must consider availability, accessibility, and cost, as safety and diagnostic yield do not differ. Further RCTs planned, conducted, and reported with methodological rigor and transparency are needed, and additional studies should assess cost and the correlation between nodule size and location, as well as their association with biopsy results.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO database, CRD42018092367 -https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=92367.

Qualitative (and Quantitative) Values of the Lung-RADS and Computed Tomography in Diagnosing Solitary Pulmonary Nodules

Background: Lung-RADS classification and CT signs can both help in the differential diagnosis of SPNs. The purpose of this study was to investigate the diagnostic value of these two methods and the combination of the two methods for solitary pulmonary nodules (SPNs). Methods: A total of 296 cases of SPNs were retrospectively analyzed. All the SPNs were classified according to the Lung-RADS grading version 1.1. The scores of each lesion were calculated according to their CT signs. Imaging features, such as the size and margin of the lesions, pleural traction, spiculation, lobulation, bronchial cutoff, air bronchogram, vacuoles, tumor vasculature, and cavity signs, were analyzed. The imaging results were compared with the pathology examination findings. Receiver operating characteristic (ROC) curves were applied to compare the values of the different methods in differentially diagnosing benign and malignant SPNs. Results: The sensitivity, specificity, and accuracy of Lung-RADS grading for diagnosing SPNs were 34.0%, 94.4%, and 47.6%, respectively. The area under the ROC curve (AUC) was 0.600 (p < 0.001). The sensitivity, specificity, and accuracy of the CT sign scores were 56.3%, 70.0%, and 60.5%, respectively, and the AUC was 0.657 (p < 0.001). The sensitivity, specificity, and accuracy of the combination of the two methods for diagnosing SPNs were 93.2%, 61.1%, and 83.5%, and the AUC was 0.777 (p < 0.001). Conclusion: The combination of Lung-RADS classification and CT signs significantly improved the differential diagnosis of SPNs.

Incidental chest findings on coronary CT angiography: a pictorial essay and management proposal

Many health systems have been using coronary CT angiography (CCTA) as a first-line examination for ischaemic heart disease patients in various countries. The rising number of CCTA examinations has led to a significant increase in the number of reported incidental extracardiac findings, mainly in the chest. Pulmonary nodules are the most common incidental findings on CCTA scans, as there is a substantial overlap of risk factors between the population seeking to exclude ischaemic heart disease and those at risk of developing lung cancer (i.e., advanced age and smoking habits). However, most incidental findings are clinically insignificant and actively pursuing them could be cost-prohibitive and submit the patient to unnecessary and potentially harmful examinations. Furthermore, there is little consensus regarding when to report or actively exclude these findings and how to manage them, that is, when to trigger an alert or to immediately refer the patient to a pulmonologist, a thoracic surgeon or a multidisciplinary team. This pictorial essay discusses the current literature on this topic and is illustrated with a review of CCTA scans. We also propose a checklist organised by organ and system, recommending actions to raise awareness of pulmonologists, thoracic surgeons, cardiologists and radiologists regarding the most significant and actionable incidental findings on CCTA scans.

The screening role of a biomarker panel in BALF among patients with cancer-suspected pulmonary nodules less than 8 mm

BACKGROUND

It is intractable to differentiate the malignancy from benignancy of cancer-suspected pulmonary nodules less than 8 mm.

METHODS

The patients with small pulmonary nodules less than 8 mm which were suspected to be primary lung cancer underwent bronchoscopy and bronchoalveolar lavage. The level of vascular endothelial growth factor (VEGF), transforming growth factor-beta (TGF-β) and hepatocyte growth factor (HGF) in bronchoalveolar lavage fluid (BALF) were assayed. Then, all patients underwent histopathological examination by means of surgical resection of nodules to determine their benignancy or malignancy. The nodules' benignancy and malignancy suggested by the biomarker panel consisted of VEGF, TGF-β and HGF in BALF were validated by the histopathological results to determine their screening efficiency.

RESULTS

Among 405 patients with pulmonary nodules less than 8 mm, 252 and 153 were predicted to be malignant and benignant, respectively, by using the biomarker panel in BALF. Finally, 180 (71.4%) of 252 and 114 (74.5%) of 153 were validated to be truly malignant and benignant, respectively, according to the histopathological results. In a receiver operating characteristic curve analysis of screening efficiency for pulmonary nodules less than 8 mm, the results demonstrated that the AUC [0.807 (0.658-0.882)] of the biomarker panel in BALF was higher compared with that [0.605 (0.433-0.738)] of the biomarker panel in blood (P = .001).

CONCLUSIONS

For patients with cancer-suspected pulmonary nodules less 8 mm, a biomarker panel of VEGF, TGF-β and HGF in BALF demonstrated more eligible screening efficiency for the preliminary differentiation of malignancy from benignancy, by contrast with their level in blood as well as PET/CT.

Use of PET/CT to aid clinical decision-making in cases of solitary pulmonary nodule: a probabilistic approach

Objective

To determine the frequency with which ¹⁸F-FDG-PET/CT findings change the probability of malignancy classification of solitary pulmonary nodules.

Materials and Methods

This was a retrospective analysis of all ¹⁸F-FDG-PET/CT examinations performed for the investigation of a solitary pulmonary nodule between May 2016 and May 2017. We reviewed medical records and PET/CT images to collect the data necessary to calculate the pre-test probability of malignancy using the Swensen model and the Herder model. The probability of malignancy was classified as low if < 5%, intermediate if 5-65%, and high if > 65%. Cases classified as intermediate in the Swensen model were reclassified by the Herder model.

Results

We reviewed the records for 33 patients, of whom 17 (51.5%) were male. The mean age was 68.63 ± 12.20 years. According to the Swensen model, the probability of malignancy was intermediate in 23 cases (69.7%). Among those, the application of the Herder model resulted in the probability of malignancy being reclassified as low in 6 (26.1%) and as high in 8 (34.8%).

Conclusion

¹⁸F-FDG-PET/CT was able to modify the probability of malignancy classification of a solitary pulmonary nodule in more than 50% of the cases evaluated.

Integrated, Multidisciplinary Management of Pulmonary Nodules Can Streamline Care and Improve Adherence to Recommendations

Every year millions of pulmonary nodules are discovered incidentally and through lung cancer screening programs. Management of these nodules is often suboptimal, with low follow-up rates and poor provider understanding of management approaches. There is an emerging body of literature about how to optimize management of pulmonary nodules. The Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) at Massachusetts General Hospital was founded in 2012 to manage pulmonary nodules via a multidisciplinary approach with optimized support staff. Recommendations from clinic providers and treatment details were recorded for all patients seen at the PNLCSC. Adherence to recommendations and outcomes were also tracked and reviewed. From October 2012 to September 2019, 1,136 patients were seen at the PNLCSC, each for a mean of 1.8 appointments (range, 1-10). A total of 356 procedures were recommended by the clinic and 271 patients were referred for surgery and/or radiation. The majority of interventions (74%) were recommended at the initial PNLCSC appointment. In total, 211 patients (19%) evaluated at the PNLCSC had pathologically confirmed pulmonary malignancies or were treated empirically with radiation. Among patients followed by the clinic, the adherence rate to clinic recommendations was 95%. This study shows how a multidisciplinary approach to pulmonary nodule management can streamline care and optimize follow-up. The PNLCSC provides a template that can be replicated in other health systems. It also provides an example of how multidisciplinary approaches can be applied to other complex conditions. IMPLICATIONS FOR PRACTICE: This work demonstrates how an integrated, multidisciplinary approach to management of pulmonary nodules can streamline patient care and improve adherence to provider recommendations. This approach has the potential to improve patient outcomes and reduce health care costs.

Volumetric assessment of solid pulmonary nodules on ultralow-dose CT: a phantom study

Background

To reduce the radiation exposure from chest computed tomography (CT), ultralow-dose CT (ULDCT) protocols performed at sub-millisievert levels were previously tested for the evaluation of pulmonary nodules (PNs). The purpose of our study was to investigate the effect of ULDCT and iterative image reconstruction on volumetric measurements of solid PNs.

Methods

CT datasets of an anthropomorphic chest phantom containing solid microspheres were obtained with a third-generation dual-source CT at standard dose, 1/8th, 1/20th and 1/70th of standard dose [CT volume dose index (CTDI_vol): 0.03-2.03 mGy]. Semi-automated volumetric measurements were performed on CT datasets reconstructed with filtered back projection (FBP) and advanced modelled iterative reconstruction (ADMIRE), at strength level 3 and 5. Absolute percentage error (APE) evaluated measurement accuracy related to the effective volume. Scan repetition differences were evaluated using Bland-Altman analysis. Two-way analysis of variance (ANOVA) assessed influence of different scan parameters on APE. Proportional differences (PDs) tested the effect of dose settings and reconstruction algorithms on volumetric measurements, as compared to the standard protocol (standard dose-FBP).

Results

Bland-Altman analysis revealed small mean interscan differences of APE with narrow limits of agreement (-0.1%±4.3% to -0.3%±3.8%). Dose settings (P<0.001), reconstruction algorithms (P<0.001), nodule diameters (P<0.001) and nodule density (P=0.011) had statistically significant influence on APE. Post-hoc Bonferroni tests showed slightly higher APE when scanning with 1/70th of standard dose [mean difference: 3.4%, 95% confidence interval (CI): 2.5-4.3%; P<0.001], and for image reconstruction with ADMIRE5 (mean difference: 1.8%, 95% CI: 1.0-2.5%; P<0.001). No significant differences for scanning with 1/20th of standard dose (P=0.42), and image reconstruction with ADMIRE3 (P=0.19) were found. Scanning with 1/70th of standard dose and image reconstruction with FBP showed the widest range of PDs (-16.8% to 23.4%) compared to standard dose-FBP.

Conclusions

Our phantom study showed no significant difference between nodule volume measurements on standard dose CT (CTDI_vol: 2 mGy) and ULDCT with 1/20th of standard dose (CTDI_vol: 0.10 mGy).