Diagnostisk tilnærming av solitær lunge knute. Kost. Overlege Bezzazi Høst 2013

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1 Diagnostisk tilnærming av solitær lunge knute Kost. Overlege Bezzazi Høst 2013

2 Del 1: Radiologisk karakteristika og bilde modalitet Definisjon: Solitær Pulmonal knute( SPN Solitary Pulmonal Nodul) er en radiografisk fortetning 3 cm i d. Med minst 2/3 deler av den er omgitt av lunge paranshym Ekskludert lymfe knutter, atelektase og pneumoni

3 SPN observeres i 0,09% til 7 % på et vannlig RTG thorax SPN prevalens ved CT varierer fra 8% til 51% Fra 1.1% opp til 12% malignitet

4 Etiologi Representerer en rekke sykdommer som varierer fra helt uskyldige tilstand som Hamartom og potensielt dødelig sykdom som lunge kreft. Kritisk viktig å utrede pasienten siden kirurgis behandling kan gi kurasjon ved tidlig lunge kreft.

5 Å unngå kirurgi og dermed evt. komplikasjon som måtte oppstå etter det ved benign SPN

6 Differensial diagnoser ved SPN Infectious TB (tuberculoma) Round pneumonia, organizing pneumonia Lung abscess Fungal: aspergillosis, blastomycosis, cryptococcosis, histoplasmosis, coccidioidomycosis Parasitic: amoebiasis, echinococcosis, Dirofi laria immitis (dog heartworm) Measles Nocardia Atypical mycobacteria Pneumocystis jiroveci Septic embolus Neoplastic Benign Hamartoma Chondroma Fibroma Lipoma Neural tumor (Schwannoma, neurofi broma) Sclerosing hemangioma Plasma cell granuloma Endometriosis Malignant Lung cancer Primary pulmonary carcinoid Solitary metastasis Teratoma Leiomyoma Vascular Arteriovenous malformation Pulmonary infarct Pulmonary artery aneurysm Pulmonary venous varix Hematoma Congenital Bronchogenic cyst Lung sequestration Bronchial atresia with mucoid impaction Infl ammatory Rheumatoid arthritis Granulomatosis with polyangiitis (Wegener) Microscopic polyangiitis Sarcoidosis Lymphatic Intrapulmonary or subpleural lymph node Lymphoma Outside lung fi elds Skin nodule Nipple shadows Rib fracture Pleural thickening, mass or fl uid (pseudotumor [ie, loculated fl uid]) Miscellaneous Rounded atelectasis Lipoid pneumonia Amyloidosis Mucoid impaction (mucocele) Infected bulla Pulmonary scar

7 Klinisk vurdering. Faktorer som øker malignitet mistanke - Alder - Røyk i sykehistorien - Gjennomgått Malign sykdom

8 Interessant at ofte presenterer SPN primær lunge cancer enn metastaser fra enn kreft ekstrapulmonalt Unntak er sarkomer, melanomer og testikkel karsinom Tilstedeværelse av forstørret lymfe knutte i mediastinum styrker mistanken om primær lunge cancer enn metastase Interstitial lunge sykdom som lunge fibrose, sklerodermi, asbestose øker malignitet suspekt

9 Table 2 Extrapulmonary Malignancy and Ratio of Primary vs Metastatic SPNs Extrapulmonary Malignancy Carcinomas of the head and neck Cancers of the bladder, breast, cervix, bile ducts, esophagus, ovary, prostate, or stomach Cancers of the salivary glands, adrenal gland, colon, parotid gland, kidney, thyroid gland, thymus, or uterus Melanoma, sarcoma, or testicular carcinoma Ratio of Malignant SPNs Representing Primary Lung Cancer vs Metastasis From the Extrapulmonary Malignancy 25:3 26:8 13:16 9:23

10 Radiografisk karakteristika CT-scan- det er anbefalt tynne snitt CT både lunge og mediastinum vindu Vekst rate - SPN fordoblingsvolum variere fra 20 til 400 dager. Flesteparten har en fordoblings rate på < 100 dager - volum fordobling over 400 dager styrker benignitet

11 Fordoblings rate under 20 dager indikerer rask vekst og indikerer en infeksiøs prosess/ komponent. Viktig å ha det for seg at volum av en Sfære er 4πr 3 =V og at en økning av knuttens diameter med 25% indikerer fordobling av volum. En knute med d.4 mm fordobles i volum ved d. På 5 mm

12 Figure 1. Solitary pulmonary nodule (SPN) doubling time. A 4-mm nodule can double in size over a period of time but the diameter will increase only approximately 1 mm to 5 mm, which may not be reliably detected on the CT scan. However, an increase in a bigger mass is very well appreciated by just looking at the diameter on the CT scan

13 Hava skal man måle diameter eller volum? Ingen konsensus per dags dato, volum beregning er bedre en diameter måling ved lesjoner < 1 cm og fortrekker ved solide lesjoner Generelt en solid Lesjon stabil i volum over 2 år dvs vekst rate over 730 dager betraktes som benigns unntak sakte voksende adenocarcinomer særlig de som presenterer seg som Mat glass knute

14 Størrelse

15 lokalisasjon Det er rapportert flere case med maligne apikale SPN. Dette er mulig grunnet høy konsentrasjon av inhalerte karsinogener fra røyk havner apikalt

16 Margin / Kant / kant Kjennetegn *Smooth Suggests a benign lesion. However, may be malignant in up to one-third of cases. *Lobulated Suggests uneven growth; a PPV of 80% for malignancy. 45,49 Up to 25% of benign lesions, such as hamartomas, can have lobulated margins. *Spiculated A spiculated margin (the so-called corona radiata sign) is highly predictive of malignancy, with a PPV of 88% to 94%. A few exceptions of benign SPNs that could have spiculated margins include lipoid pneumonia, focal atelectasis, tuberculoma, and progressive massive fi brosis. *Ragged Suggests growth pattern along the alveolar wall; lepidic pattern of adenocarcinoma. *Tentacle orpolygonal Seen in fi brosis, alveolar infi ltration, and collapsed alveoli. 49 *Halo SPN surrounded by a halo of ground glass attenuation, also called the CT halo sign. Seen in aspergillosis, Kaposi sarcoma, granulomatosis with polyangiitis (Wegener), and metastatic angiosarcoma. 55,56 Adenocarcinoma in situ (previously known as bronchoalveolar carcinoma) can also produce a halo, due to its lepidic growth. *Notches SPN with notches or concavity in the margin is seen in some SPNs with tumor growth. These notches are frequently found in adenocarcinomas with overt invasion and are associated with poor prognosis

17 Figure 3. SPN with a smooth border. A SPN with smooth borders may suggest benign etiology, although up to one-third of these lesions can be malignant. See Figure 1 legend for expansion of abbreviation

18 Figure 4. SPN with lobulated margin suggests uneven growth and likely is malignant with a positive predictive value of 80%. Up to 25% of benign lesions such as hamartomas can have lobulated margins. See Figure 1 legend for expansion of abbreviation

19 Figure 5. SPN with spiculated margin (corona radiata sign). This is highly predictive of malignancy with a positive predictive value of 88% to 94%. Lipoid pneumonia, focal atelectasis, tuberculoma, and progressive massive fibrosis can have spiculated margins. See Figure 1 legend for expansion of abbreviation

20 Figure 6. SPN with ragged margin suggests a growth pattern along the alveolar wall, as seen in adenocarcinoma with lepidic growth pattern. See Figure 1 legend for expansion of abbreviation

21 Figure 7. SPN with polygonal margins, usually suggestive of a benign etiology. Such a pattern is seen in fibrosis, focal atelectasis, and alveolar infiltration

22 Figure 8. SPN with surrounding halo and ground glass attenuation. This is seen in aspergillosis, Kaposi sarcoma, granulomatosis with polyangiitis (Wegener), and metastatic angiosarcoma. Adenocarcinoma can produce a halo due to lepidic growth

23 Forkalkning og attenuation Spesifikk mønster av forkalkning innen SPN( diffus; Central( okse øye) laminer elle konsentrisk elle poppkorn kan være benign Attenuation verdi > 200 HU( Hounsfield unites) i en SPN indikerer forklakning Vanlig RTG ikke sensitiv med 50% sensitivitet og 87% spesifisitet anbefales derfor CT

24 Table 4 Patterns of Calcifi cation in SPNs Pattern ofcalcifi cation Laminated and concentric Dense central core Diffuse and solid Popcorn Punctate Eccentric Etiology Usually benign Usually benign Usually benign Hamartoma Malignant lesions: scar arcinoma, typical and atypical arcinoids, large-cell neuroendocrinecarcinoma and colon metastasis, ovary,breast, thyroid, and osteogenic tumors. Due to necrosis within the malignant nodule or engulfment of adjacent granuloma

25 Figure 9. SPN with diffuse calcifi cation as seen on (left) mediastinal windows and (right) lung windows,usually suggest benign etiology

26 Figure 10. SPN with central calcifi cation usually suggestive of a benign etiology. It should be noted that it is quite uncommon to come across a truly central calcifi ed nodule

27 Figure 11. SPN with laminated calcifi cation, usually suggestive of a benign etiology

28 Figure 12. SPN with popcorn calcifi cation. It is suggestive of a benign etiology such as hamartoma

29 Fett Attenuation verdi mellom 40 og 120 HU indikerer fett holdig knute som ses opp til 60 % av hamartomer. Sjeldne årsaker til fett attenuation inkluderer lipoid pneumoni og metastaser fra liposarkom( nesten alltid solid utsende) og fra nyre celle carcinom

30 Figure 13. An attenuation value between 2 40 and Hounsfi eld units suggests presence of fat in a SPN. Fat is present in up to 60% of hamartomas

31 Kavitasjon Kavitasjon ses ved nekrose av malign SPN sop ved late epitel carcinom, som ved benign SPN slik lunge abscess, granulomatøse infeksjon, vaskulitt, tidlig langerhans cell histocytose og pulmonar infarkt. Kavitets vegg < 5 mm peker mot benign etiologi, men urigulær tykkere vegg > 15 mm ses ved malignitet

32 Figure 14. SPN with cavitation is seen in necrotic malignant SPNs such as squamous cell carcinoma. It may also be seen in benign SPNs such as abscesses, infectious granulomas, vasculitides, lymphoid interstitial pneumonia, early Langerhans-cell histiocytosis, and pulmonary infarction.

33 Figure 15. SPN with bubbly lucencies. Bubbly lucencies can be seen in adenocarcinoma in situ (previously known as bronchoalveolar carcinoma), pulmonary lymphoma, sarcoidosis, round pneumonia, and organizing pneumonia.

34 Mat glass knutter Pulmonale knutter kan klassifiseres ved CT som solide eller subsolide Solide knutter dekker lunge parenchym mens subsolide matt glass fortetninger karakteriseres med økt attenuation og gjennom det kan ses lunge parenchym

35 Matt glass knutter er som regel multiple og skiller seg fra solitær pulmonale knutter og har derfor en annen tilnærming.

36 Figure 17. Ground glass opacity (GGO) in a SPN. GGOs are defi ned as focal nodular areas of increased lung attenuation through which normal parenchymal structures such as airways, vessels, and interlobular septa are visible

37 PET-CT FDG-PET sensitivitet oppgis 96% mens spesifitet 79% og nøyaktighet 91% Knutter 1 cm sensitivitetten minker ved knuttet <8 mm PET-CT øker spesifitet og har en PPV 72% men NPV 90% Maligne celler er metabols aktive og derfor har en høyt FDG opptakk

38 Oppgis i SUV verdi med et cuttoff på > 2,5 Høy falsk neg. Ved matt glass knutter Dual time point FDG-PET bedrer sensitivitet men grunnet sprik i data fra forskjellige studier er dett ikke blitt rutine.

39 Figure 19. Combined PET-CT scan showing 18 F-2-deoxy-2-fl uoro- d -glucose-avid SPN. Malignant cells are more metabolically active and import glucose more avidly than other tissues.

40 del 2 Pretest sansynlighet og algoritme

41 Table 1 Calculation of Probability of Malignancy Source/Reference Factors Taken Into Consideration todetermine the Probabi Malignancy Swensen et al Gould et al Age 2. Smoking (ever vs never and pack-y) 3. Hemoptysis 4. History of prior malignancy 5. Nodule diameter 6. Location 7. Edge characteristics 8. Growth rate 9. Cavity wall thickness 10. Calcifi cation 11. Contrast enhancement on CT scan. 15 HU 12. PET scan 1. Age 2. Smoking history (ever vs never) 3. History of previous malignancy. 5 y ago 4. Presence of spiculation 5. Upper lobe location 1. Age 2. Smoking history (ever vs never) 3. Nodule diameter 4. Time since quitting sm

42 Praktisk klinisk tilnærming.

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45 Konklusjon SPN er fortetning under 3 cm omgitt av lunge vev Betraktes maligne d.v.s. T1N0M0 inntil det motsatt er bevist Skal utredes.

46 SPN < 8 mm skal følges opp etter Fleischner kriterier SPN > 8 med mer skal til PET-CT evt/ biopsy PET-CT kan være fals negativ. Ikke alle lunge tumors lyser ved PET

47 skylder cle.aspx?articleid= Chest Mar;143(3): doi: /chest