Management of an incidentally discovered pulmonary nodule

Effect of slab thickness on the CT detection of pulmonary nodules: use of sliding thin-slab maximum intensity projection and volume rendering

OBJECTIVE

The objective of this study was to evaluate the detection rates of pulmonary nodules on CT as a function of slab thickness using sliding thin-slab maximum intensity projection (MIP) and volume rendering (VR).

SUBJECTS AND METHODS

Eighty-eight oncology patients (33 women, 55 men; mean age, 59 years; age range, 18-81 years) who routinely underwent chest CT examinations were prospectively included. Two radiologists independently evaluated each CT examination for the presence of pulmonary nodules using MIP and VR, with each image reconstructed using three different slab thicknesses (5, 8, 11 mm). The standard of reference was the maximum number of detected nodules, which were classified by localization and size, judged to be true-positives by a consensus panel. Interreader agreement was assessed by kappa value on a nodule-by-nodule basis. Sensitivities for both reconstruction techniques and for the three slab thicknesses were calculated using the proportion procedure for survey data with the patient as the primary sample unit and were compared using the Wilcoxon's signed rank test with Bonferroni correction for both readers separately.

RESULTS

One thousand fifty-eight true-positive nodules were detected. Interreader agreement was fair to moderate. Sensitivity for pulmonary nodules was superior for 8-mm MIP (reader 1, 84%; reader 2, 81%) and was significantly better than the sensitivities of all other tested techniques for both readers (p < 0.001 each) independent of nodule localization and size (except for one reader's analysis of 8-mm MIP versus 11-mm MIP for nodules > 8 mm). A higher sensitivity was achieved using MIP than VR.

CONCLUSION

MIP with a slab thickness of 8 mm is superior in the detection of pulmonary nodules to all other tested techniques.

Does the availability of positron emission tomography modify diagnostic strategies for solitary pulmonary nodules? An observational study in France

Background

Previous studies showed that at the individual level, positron emission tomography (PET) has some benefits for patients and physicians in terms of cancer management and staging. We aimed to describe the benefits of (PET) in the management of solitary pulmonary nodules (SPNs) in a population level, in terms of the number of diagnostic and invasive tests performed, time to diagnosis and factors determining PET utilization.

Methods

In an observational study, we examined reports of computed tomography (CT) performed and mentioning "spherical lesion", "nodule" or synonymous terms. We found 11,515 reports in a before-PET period, 2002–2003, and 20,075 in an after-PET period, 2004–2005. Patients were followed through their physician, who was responsible for diagnostic management.

Results

We had complete data for 112 patients (73.7%) with new cases of SPN in the before-PET period and 250 (81.4%) in the after-PET period. Patients did not differ in mean age (64.9 vs. 64.8 years). The before-PET patients underwent a mean of 4 tests as compared with 3 tests for the after-PET patients (p = 0.08). Patients in the before-PET period had to wait 41.4 days, on average, before receiving a diagnosis as compared with 24.0 days, on average, for patients in the after-PET period who did not undergo PET (p < 0.001). In the after-PET period, 11% of patients underwent PET during the diagnostic process. A spiculated nodule was more likely to determine prescription for PET (p < 0.001). Multivariate analysis revealed that patients in both periods underwent fewer tests when PET was prescribed by general practitioners (p < 0.001) and if the nodule was not spiculated (p < 0.001). The proportion of unnecessary invasive approaches prescribed (47% vs. 49%) did not differ between the groups.

Conclusion

In our study, 1 year after the availability of PET, the technology was not the first choice for diagnostic management of SPN. Even though we observed a tendency for reduced number of tests and mean time to diagnosis with PET, these phenomena did not fully relate to PET availability in health communities. In addition, the availability of PET in the management of SPN diagnosis did not reduce the overall rate of unnecessary invasive approaches.

Initial findings and progression of lung adenocarcinoma on serial computed tomography scans

OBJECTIVE

To study the initial findings of lung adenocarcinoma revealed by computed tomography (CT) scanning and observe tumor progression and elucidate appropriate follow-up schedule of tumor diagnosis via CT findings of suspected lung adenocarcinoma.

METHOD

We studied 59 patients who had undergone CT scanning twice or more at intervals of 3 months or longer before surgery. We evaluated the initial CT findings as well as all subsequent changes. The rate of tumor growth was estimated by tumor volume doubling time, using the original method of Schwartz. The histological classifications were evaluated according to the criteria of Noguchi et al (Cancer 1995;75:2844-2852).

RESULT

The initial appearances of lung adenocarcinoma were divided into 4 types: (1) ground-glass opacity-like lesions, (2) bubble-like appearance, (3) small nodules, and (4) scar-like lesions. Ground-glass opacity-like lesions tended to increase in size over the years, with solid parts appearing in some lesions during follow-up examinations. Bubble-like appearance displayed characteristic CT findings and tended to increase over the years from the time of initial diagnosis, and we therefore tended to consider them as old inflammatory lesions. Small nodules tended to increase in size over the months more rapidly than in other types. Scar-like lesions tended to exist mainly in the lungs already damaged by lung fibrosis and/or emphysema and therefore were difficult to detect on initial CT scans.

CONCLUSION

We categorized 4 types of initial findings of lung adenocarcinomas detected by CT. We determined that each type of lesion had its own unique characteristic growth patterns and required varying follow-up periods.

Neodymium:yttrium-aluminium-garnet laser for excision of pulmonary nodules: an institutional review

Eighty patients amongst 850 undergoing pulmonary surgery with the use of neodymium:yttrium-aluminium-garnet (Nd:YAG) laser had a solitary pulmonary nodule (< or = 50 mm) on chest radiography, which was confirmed or suspected pre-operatively to be primary lung cancer. All patients had a mini-thoracotomy to expose the lesion. They then had Nd:YAG laser to excise the nodule locally. There was no hospital mortality. Six patients had non-fatal post-operative complications. Pathologically, 46 patients had primary lung cancer and ten had secondary lung cancer. Twenty-four others had benign lesions. Mean hospital stay was 5.5 days. Post-operative reduction of forced vital capacity (FVC) and forced expiratory volume in one second (FEV(1)) was 14% and 13% (mean), respectively. Thirty-seven patients with primary lung cancer were followed up for between 12 months and 60 months. Mean survival time of these patients was 39 months (s.d. 13 months). It was concluded that Nd:YAG laser for pulmonary nodular lesions should be considered for a selected group of patients unsuitable for standard resection.