Chest imaging in up to 50-yo
non symptomatic smokers
G Ferretti
CHU Grenoble
FRANCE
—  CT

acquisitions in people > 50 yo
—  Lung cancer screening studies
—  Early detection of pulmonary fibrosis
—  Scr...
Aging +/- cigarette smoking
— 

Abnormalities without
clinical consequences
◦  “Wrinkles” within the lung

— 

Abnormali...
“WRINKLES” WITHIN THE
LUNG

Dalal PU Eur Radiol 2006
Hansell DM Radiology 2010
55 yo patient
GGO Opacity in the posterior
lung
ILD ?
Re scan the patient in prone
position
Increase pulmonary density in a 67yo patient
suspected of PE due to incomplete inspiration and
contrast injection
Confusin...
Fibrosis adjacent to spinal
osteophytes
Localized GGO or reticular pattern
near dorsal Osteophytes (right side >>> left si...
Aging pattern of the lung (1)
— 

Bronchial dilatation (Richards DW Bull NYAM 1956)

— 

Enlargement of alveolar spaces ...
84 yo woman asymptomatic
70 yo smoker man Thickening of bronchial walls
Localized fibrosis of lung parenchyma

•  Sub pleural reticulation in 60% of asymptomatic
subjects > 75 yo vs 0% < 55 yo
•...
Aging lung (2)
—  Pulmonary

cysts with thin walls in 25% of
subjects > 75yo but absent in < 55yo
◦  These cysts are rela...
72	
  yo	
  asymptoma+c	
  female	
  	
  	
  
ABNORMALITIES
WITH POTENTIALLY
SEVERE EVOLUTION
Emphysema
—  the

link between smoking and emphysema
is well demonstrated
◦  Interstitial abnormalities used to be called...
Bronchiolite respiratoire

Pathologie tabagique : EXCES DE MACROPHAGES
Bronchiolite respiratoire
–  inflammation chronique...
5	
  years	
  la2er	
  

*Remy-­‐Jardin	
  et	
  al,	
  Radiology	
  1993,	
  186:	
  107-­‐115	
  
**Remy-­‐Jardin	
  et	...
65 yo patient
43 PY
Asymptomatic
ENT polyps
CXR then CT
Tobacco and ILD
—  Do

smokers develop limited and
progressive pulmonary fibrosis ?
◦  Remain controversial
◦  Experts su...
2007

2012

l 

2007, 58 yo man chronic cough

l 

What do you see?

l 

2012 , heterogeneous
distribution of ILD
l  R...
The lung of smokers in screening program for
lung cancer
692 heavy smokers from the Multicentric Italian Lung Detection (M...
—  Age, male

sex and current smoking status
were factors associated with the presence
of OCIP and UIP pattern

—  Thin-...
The lung of smokers in screening program
for lung cancer
•  884 smokers from the NLST
–  ILD at base line
–  ILD were clas...
Air trapping
Need expiratory acquisitions
seen in patients with normal PFT
—  present in healthy asymptomatic nonsmoking
...
Asymptoma+c	
  smokers	
  
INSPIRATION	
  

EXPIRATION	
  

• 	
  82	
  asymptoma-c	
  persons	
  

• 	
  Air	
  trapping	...
Tobacco and lung cancer
—  Lung

cancer is the leading cause of
cancer-related deaths worldwide.
—  85% of lung cancer p...
Survival of untreated patients with lung cancer

Raz D Chest 2007
NLST showed a 20%
decrease in lungcancer-specific
mortality
The National Lung Screening Trial Research Team.
Reduced Lung-...
Guideline Recommendations
— 

US Preventive Service Task Force
Humphrey MM Ann Intern Med 2013

— 

The IASLC
Heidi R J ...
Eligibility
- aged between 55 and 74 years;
- at least 30 pack-year tobacco exposure;
- active smoker or quit during the l...
CT
CXR
3 types of nodules
Etiology
VDT
Prognostic
Action

•  Solid
•  Part-solid
•  Nonsolid
78.9%
1.1% cancer

4.3%
6.6% cancer
...
NLST	
  

NELSON	
  

1	
  
2	
  

NLST
(Baseline + rounds 1-2)	
  

NELSON
(Baseline + round 1)	
  

75 126

14 846

2	
 ...
Follow up of Pulmonary nodules
(Fleischner, Radiology 2005)

Guidelines adapted to solid nodules only
Specific guidelines ...
Positif test Nelson study

Negatif
CT at 3-4 months
GROWCAT C if
VDT < 400 days

Positif
V = 4.19 x R3
V x 2 when R x 1.26
Reich JM Eur J Radiol 2011 ;80

1039mm3 at baseline to1539 mm3 at
3 months. T1N0M0 adeno...
NLST vs. NELSON

Nair & Hansell Eur Radiol 2011; 21:2445–2454
Couraud S Annals Oncology 2012.
Couraud S Annals Oncology 2012.
Conclusion
—  HRCT

can demonstrate very early disease,
sometimes in people without symptoms or
PFT abnormalities.

—  T...
Thorax cardio chest imaging in up to 50 year old non symptomatic smoker g ferrettit
Thorax cardio chest imaging in up to 50 year old non symptomatic smoker g ferrettit
Thorax cardio chest imaging in up to 50 year old non symptomatic smoker g ferrettit
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Thorax cardio chest imaging in up to 50 year old non symptomatic smoker g ferrettit

  1. 1. Chest imaging in up to 50-yo non symptomatic smokers G Ferretti CHU Grenoble FRANCE
  2. 2. —  CT acquisitions in people > 50 yo —  Lung cancer screening studies —  Early detection of pulmonary fibrosis —  Screening for asbestosis have increased our need to better understand the morphology of the lung in aging population and particularly in those who have smoking habits Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010
  3. 3. Aging +/- cigarette smoking —  Abnormalities without clinical consequences ◦  “Wrinkles” within the lung —  Abnormalities with potentially severe evolution ◦  ◦  ◦  ◦  ◦  ◦  Lung nodules Emphysema Respiratory broncholitis NSIP/UIP pattern Chronic bronchitis Air trapping
  4. 4. “WRINKLES” WITHIN THE LUNG Dalal PU Eur Radiol 2006 Hansell DM Radiology 2010
  5. 5. 55 yo patient GGO Opacity in the posterior lung ILD ? Re scan the patient in prone position
  6. 6. Increase pulmonary density in a 67yo patient suspected of PE due to incomplete inspiration and contrast injection Confusing pattern for ILD
  7. 7. Fibrosis adjacent to spinal osteophytes Localized GGO or reticular pattern near dorsal Osteophytes (right side >>> left side No evolution in time Not related to asbestose exposure Not indicative of early UIP Otake S. AJR 2002;179:893–896.
  8. 8. Aging pattern of the lung (1) —  Bronchial dilatation (Richards DW Bull NYAM 1956) —  Enlargement of alveolar spaces : senile emphysema? (Janssens JP ERJ 1999)
  9. 9. 84 yo woman asymptomatic
  10. 10. 70 yo smoker man Thickening of bronchial walls
  11. 11. Localized fibrosis of lung parenchyma •  Sub pleural reticulation in 60% of asymptomatic subjects > 75 yo vs 0% < 55 yo •  Interlobular septal enlargement more frequent in older persons Copley SJ Radiology 2009
  12. 12. Aging lung (2) —  Pulmonary cysts with thin walls in 25% of subjects > 75yo but absent in < 55yo ◦  These cysts are related to aging but not to tobacco ◦  Their volume is limited Copley SJ Radiology 2009
  13. 13. 72  yo  asymptoma+c  female      
  14. 14. ABNORMALITIES WITH POTENTIALLY SEVERE EVOLUTION
  15. 15. Emphysema —  the link between smoking and emphysema is well demonstrated ◦  Interstitial abnormalities used to be called “dirty lung” on CXR ◦  Respiratory bronchiolitis / RB ILD has been described more recently –  Centrilobular GGO micronodules –  Upper lung
  16. 16. Bronchiolite respiratoire Pathologie tabagique : EXCES DE MACROPHAGES Bronchiolite respiratoire –  inflammation chronique bronchiolaire, macrophages tatoué Bronchiolite respiratoire avec infiltration pulmonaire diffuse (RB-ILD) –  Extension dans l ’espace des anomalies TDM. Pneumopathie interstitielle desquamative (DIP))
  17. 17. 5  years  la2er   *Remy-­‐Jardin  et  al,  Radiology  1993,  186:  107-­‐115   **Remy-­‐Jardin  et  al,  Radiology  1993,  186:  643-­‐651   ***  Remy-­‐Jardin  et  al  Radiology,  2002,  222:  261-­‐70  
  18. 18. 65 yo patient 43 PY Asymptomatic ENT polyps CXR then CT
  19. 19. Tobacco and ILD —  Do smokers develop limited and progressive pulmonary fibrosis ? ◦  Remain controversial ◦  Experts supports that smoking is a direct cause for developing UIP/NSIP Cordier  JF  et  Co8n  V  ERJ  2013  
  20. 20. 2007 2012 l  2007, 58 yo man chronic cough l  What do you see? l  2012 , heterogeneous distribution of ILD l  Reticulation l  Honey combing l  Bronchectasis l  Sub pleural distribution UIP pattern l  Raghu  G  AJRCCM  2011   21  │  
  21. 21. The lung of smokers in screening program for lung cancer 692 heavy smokers from the Multicentric Italian Lung Detection (MILD) Four CT patterns were considered: •  usual interstitial pneumonia(UIP) •  other chronic interstitial pneumonia (OCIP) •  respiratory bronchiolitis (RB) •  indeterminate the evolution of ILD after 3 yrs was assessed UIP pattern in 0.3% OCIP pattern 3.8% progression three (25%) of 12 RB pattern in 15.7% indeterminate pattern in 3% Sverzella+  N    ERJ  2011    
  22. 22. —  Age, male sex and current smoking status were factors associated with the presence of OCIP and UIP pattern —  Thin-section CT features of ILD, probably representing smoking-related ILD, are not uncommonin a lung cancer screening population and should not be overlooked. Sverzella+  N    ERJ  2011    
  23. 23. The lung of smokers in screening program for lung cancer •  884 smokers from the NLST –  ILD at base line –  ILD were classified into •  nonfibrotic (ground-glass opacity, consolidation, mosaic attenuation), •  fibrotic (GGO with reticular pattern, reticular pattern, honeycombing). –  the rate of progression of ILAs on 2-year follow-up •  Résults –  prevalence of equivocal ILD: 11.5% –  prevalence of ILD: 9.7% •  Fibrotic 2.1% •  Non fibrotic •  Mixed Progression 37%, improved 0% 5.9% improved 49% 1.7% •  The percentage of current smokers (P = .001) and mean number of cigarette pack-years (P = .001) were significantly higher in those with ILA than those without. Jin  GY  Radiology  2013    
  24. 24. Air trapping Need expiratory acquisitions seen in patients with normal PFT —  present in healthy asymptomatic nonsmoking individuals (Verschakelen JA Eur Radiol 1998) —  more frequent in cigarette smokers (Mastora I Radiology 2001) —  found in approximately 50% of asymptomatic subjects. The frequency of air trapping increased with age, and its severity increased with age and smoking (Lee KW Radiology 2000)
  25. 25. Asymptoma+c  smokers   INSPIRATION   EXPIRATION   •   82  asymptoma-c  persons   •   Air  trapping  present  in  50%   •   increased  Frequency  with  age   •   increased  Frequency  in  smokers  (>10PA)     Lee  et  al  Radiology  2000,  214:  831-­‐36  
  26. 26. Tobacco and lung cancer —  Lung cancer is the leading cause of cancer-related deaths worldwide. —  85% of lung cancer patients are smokers —  Most patients are diagnosed with advanced-stage tumors, precluding curative-intent treatment.
  27. 27. Survival of untreated patients with lung cancer Raz D Chest 2007
  28. 28. NLST showed a 20% decrease in lungcancer-specific mortality The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. N Eng J Med 2011; 365(5): 395–409.
  29. 29. Guideline Recommendations —  US Preventive Service Task Force Humphrey MM Ann Intern Med 2013 —  The IASLC Heidi R J Thorac Oncol. 2013 —  The National Cancer Center Network Wood DE J Natl Compr Canc Netw 2012 —  —  —  The American Society of Clinical Oncology, The American Association of Chest Physician The American Association for Thoracic Surgery, Mirkin JN JAMA 2012 —  French groups IFCT, SIT, GOLF S Couraud Ann Oncol 2013 Recommended individual screening for lung cancer
  30. 30. Eligibility - aged between 55 and 74 years; - at least 30 pack-year tobacco exposure; - active smoker or quit during the last 15 years; - no serious progressive disease (history of cancer other than nonmelanoma skin cancer or carcinoma in situ over the past 5 years1; severe co-morbidity, including respiratory insufficiency contraindicating invasive chest examination; prior hemoptysis; unexplained weight loss over 10% over the past 12 months); - no pulmonary infection over the 12 past weeks; - accepts repeated scans or additional investigations in the case of abnormal findings; - accepts considering help to quit smoking (active smokers).
  31. 31. CT CXR
  32. 32. 3 types of nodules Etiology VDT Prognostic Action •  Solid •  Part-solid •  Nonsolid 78.9% 1.1% cancer 4.3% 6.6% cancer 15.8% 1.9% cancer McWilliams A NEJM 2013
  33. 33. NLST   NELSON   1   2   NLST (Baseline + rounds 1-2)   NELSON (Baseline + round 1)   75 126 14 846 2   3    N  screening  CT   1   3              N  posi-ve              N  Cancers   %  de  cancer/scr     18 146 24.1% 324 2.2% Stade  I   649 649 3.6% 3.6% 0.86% 61.6% 126 126 38.9% 38.9% 0.85% 69.8% FP: 96.6% FP: 61.1%
  34. 34. Follow up of Pulmonary nodules (Fleischner, Radiology 2005) Guidelines adapted to solid nodules only Specific guidelines for nGGO 2013
  35. 35. Positif test Nelson study Negatif CT at 3-4 months GROWCAT C if VDT < 400 days Positif
  36. 36. V = 4.19 x R3 V x 2 when R x 1.26 Reich JM Eur J Radiol 2011 ;80 1039mm3 at baseline to1539 mm3 at 3 months. T1N0M0 adenocarcinoma A Marchiano Radiology 2009; 251
  37. 37. NLST vs. NELSON Nair & Hansell Eur Radiol 2011; 21:2445–2454
  38. 38. Couraud S Annals Oncology 2012.
  39. 39. Couraud S Annals Oncology 2012.
  40. 40. Conclusion —  HRCT can demonstrate very early disease, sometimes in people without symptoms or PFT abnormalities. —  The lung of asymptomatic smokers > 50yo may be affected by ◦  Non significant abnormalities mainly related to aging ◦  Significant diseases that should be followed —  Smoking the lungs may have a premature aging effect on Nyunoya T Am J Respir Crit Care Med 2009

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