Pulmonary nodule

Question 1

Fleischner Society Guidelines 2017
- When is it applicable?

Answer 1

Age >35
No known malignancy
Not immunocompromised
Not in lung cancer screening

Question 2

What does Fleischner Society Guidelines 2017 suggest for solid nodules?

Answer 2

for multiple, use the most suspicious nodule

• Divided into:
  1) single vs multiple
  2) low vs high risk
  3) nodule size <6mm, 6-8mm, >8mm

For single, low risk:
<6mm: no f/up
6-8mm: CT 6-12m then 18-24m
>8mm: CT 3m, or PET CT or Bx

For single, high risk:
<6m: CT at 12m
6-8mm: CT 6-12m then 18-24m
>8mm: CT 3m, or PET CT or Bx

For multiple, low risk
<6mm: no f/up
6-8mm: CT 3-6m, then 18-24m
>8mm: CT 3-6m, then 18-24m

For multiple, high risk
<6mm: Optional CT 12m
6-8mm: CT 3-6m, then 18-24m
>8: CT 3-6m, then 18-24mm

Question 3

What does Fleischner Society Guidelines 2017 suggest for sub-solid nodules?

Answer 3

• Divided into:
  1) Single vs multiple
  2) Ground glass (GGN) vs partly solid
  3) Nodules size: <6mm vs ≥6mm

For single, ground glass:
<6mm: no f/up
≥6mm: CT 6-12m, then 2y until 5y

For single, partly solid:
<6mm: no f/up
≥6mm: CT 3-6m, if solid remains <6mm –> annual CT for 5y

For multiple:
<6mm: CT 3-6m, then 2y and 4y if lesion is stable
≥6mm: 3-6m, next CT based on most suspicious nodule

Question 4

What about nodules found at incomplete CT?

Answer 4

<6mm: No follow up

6-8mm: f/up with complete chest CT to be determined by pt’s individual risk, and performed in 3-12m

> 8mm or suspicious features, complete chest CT ASAP

Question 5

What about perifissural nodule?

Answer 5

Usually it is intrapulmonary lymph node

Normal features:
Triangular or lentiform morphology
Smooth contours
Sharp margins

Abnormal features:
Round morphology
Irregular contour
Abnormal adjacent fissure (retracted, bowed, transgressed)

Abnormal features needs f/up

Question 6

What about nodule with cyst?

Answer 6

Benign cysts characteristics:
Thin regular walls (<2mm)

Abnormal features:
Microcysts in a pre-existing solid or subsolid nodule
Tumour arising from wall of preexisting cyst (endophytic or exophytic mural nodule)
Asymmetric wall thickening of a cystic lesion

Question 7

2015 BTS guidelines for the Ix & Mx of pulmonary nodules
- When is it applicable?

Answer 7

1) ≥18y
2) Current or previously treated malignancy either pulm or extrapulm
3) Nodules detected on routine, surveillance of previous Ca or screening for lung Ca
4) Single or multiple nodule, of different morphology

Question 8

Brock’s criteria

https://www.brit-thoracic.org.uk/quality-improvement/guidelines/pulmonary-nodules/pn-risk-calculator/

Answer 8

Multivariable model that estimate the risk of a pulmonary nodule is lung cancer

Predictors:
1) Old age
2) Sex
3) Emphysema
4) Nodule size
5) Upper lobe location
6) Part-solid nodule type
7) Nodule count
8) Spiculation

Question 9

Sensitivity of nodule Bx
Resource: 2015 BTS guideline

Answer 9

1) Bronch with fluoroscopy:
central (82%),
intermediate (61%),
peripheral (53%),
lesion <2cm in outer third of lung (14%)

2) Radial EBUS
Located nodules (89%),
biopsy yield (70%)
Able to detect smaller nodule <10mm

3) Ultrasound
Nodules ≤2cm diameter & in contact with pleura
First Bx yield low (39%), repeat attempt (49%)

4) CT-guided
High sensitivity (90.7%), specificity (93.9%), PPV (97.4%), NPV (79.9%)
Higher pneumothorax risk (15%)

5) Surgical resection
For risk >70%
Indicated if pt is surgically fit.
VATS preferable to open surgery
Lobectomy for nodules confirmed to be lung Ca preop, or after wedge resection and intra-op frozen section analysis
Sens: 100%

Question 10

Nodule features suggestive of malignancy

Answer 10

Patient factors:
- Old
- Smoker
- PHx of Ca/ TB

Nodule factors:
- Large size
- Growth rate doubling time 20-400d (if too fast suggestive of infection)
- Upper lobes
- Margin: irregular/ spiculated
- Nodule near fissure that is round in shape, with abnormal fissure (e.g. retracted, bowed or transgressed)
- Cystic nodule with thick irregular wall
- Nodule arising from pre-existing cyst
- PET CT uptake

Question 11

What does the Clinical practice guideline for evaluation of lung nodule published in 2013 (CHEST)
Adaptation to Asia been developed in 2016
says about lung nodule?

Answer 11

Divided into:
1) Solid vs non-solid (part solid nodule PSN/ pure ground glass nodule PGGN)
2) Size >8mm vs ≤8mm
3) High vs low risk

Question 12

What are the pulmonary nodule risk calculation models?

Answer 12

1) Brock model
2) Herder model
3) Volume doubling time

Question 13

Herder model

https://www.brit-thoracic.org.uk/quality-improvement/guidelines/pulmonary-nodules/pn-risk-calculator/

Answer 13

A) Pt characteristics:
Age
Current/former smoker
Previous Hx of extrathoracic cancer

B) Nodule characteristics:
Nodule size
Nodule in upper lobe
Spiculation
PET CT findings (FDG uptake): None/ Faint/ Moderate/ Intense