Presentation by Kenneth Neigut, MD at the Longboat Key Central FL Cancer Institute Annual Seminar. Overview: 1. Review lung cancer screening updates. 2. Management of smal lung nodules detected on CT. 3. The role and limitations of using PET/CT for staging. Key Stats: 160,000 lung cancer deaths occur in the USA every year. 85% of these deaths occur in those with a strong smoking history. Lung CA is the number one cancer killer. Insurance companies will be required to cover the $300-$400 screening under a mandate in the federal health law.

1. CURRENT TOPICS IN LUNG
CANCER IMAGING
Kenneth M. Neigut, M.D.

2. Overview
 Review lung cancer screening updates.
 Management of small lung nodules detected
on CT.
 The role and limitations of using PET/CT for
staging.

3. Lung cancer screening.

4. ACR position on CT lung
cancer screening.
 “Today’s USPSTF draft recommendation
marks a dramatic shift in views towards
diagnosing and treating lung cancer.”
 “Expanded use of lung cancer screening in
high risk patients is a landmark step in the
battle to defeat this terrible disease.”
Paul Ellenbogen MD, FACR, chair of the
American College of Radiology Board of
Chancellors

7. NLST
 53,454 current or former heavy smokers from
33 sites across US.
 Half received low-dose CT, half PA chest x-
ray (randomized trial).
 Three annual screenings were performed.
 Study began in 2002.
 Final results published in NEJM 8/4/2011.

10. NLST
 24% of all CT screens = positive
 96% of positive studies = false positives
 36% of all CTs = false positive
 39% (CT) participants = at least one positive
study
 False negative = “missed rate”= estimated to
be between 0-20%.

11. False Positive

12. Risk
 Radiation Dose
-- CXR = 0.08 mSv
-- Mammo = 0.07 mSv
-- CT: Chest = 7 mSv; 3 phase hepatic = 30 mSv
-- NLST Low dose CT = 1.4 mSv
 Non-Medical
-- Yearly Background = 3-5 mSv
-- Chicago = 3 mSv; Denver = 6 mSv (1.5 mSv/ 3 mos.)
-- Ramsar, Iran = 100-280 mSv; airplane 10 hours = 0.04 mSv
www.nrc.gov; www.world-nuclear.org

13. New ultrafast CAT scan:

14. USPSTF Recommendations:
 Screen high-risk patients (55-79 years old
with a 30 pack year or greater history of
smoking and continue to smoke or quit fewer
than 15 years ago).
 Annual lung cancer screening.
 Find tumors early, when they are most
treatable.
 Benefits outweigh risks.

15. Facts:
 160,000 lung cancer deaths occur in the
United States every year.
 85% of these deaths occur in those with a
strong smoking history.
 Lung cancer is the number one cancer killer.
 Insurance companies will be required to cover
the $300-400 screening under a mandate in
the federal health law.

16. Downside of screening:
 Overdiagnosis
 Excess radiation exposure
 Lung biopsies for growths that turn out not to
be cancer.

17. Screening:
 USPSTF estimates that screening 287,000
high risk patients would prevent 521 cancer
deaths but cause an additional 24 cancer
deaths from excess radiation exposure.
 Some advocate broader screening criteria,
applying to those who smoke less but have
other risk factors such as a family history of
lung cancer or exposure to asbestos or other
carcinogens.

19. Fleischner - Nodule

20. Fleischner - not used when
cancer history

21. Subsolid nodules
 Ground glass (subsolid) nodules are less
dense than solid nodules and the surrounding
pulmonary vasculature and do not obscure
the lung parenchyma.
 Can be purely ground-glass in appearance or
can have mixed solid and ground-glass
components.
 Dilemma: morphologic characteristics of a
ground-glass nodule are less well described.

22. Fleischner – Subsolid (GGO)

23. GGO turns solid - cancer

25. PET/CT: Limitations
 False positive
Infections
Inflammation – alveolitis
Tumor necrosis
 False negative
Bronchioloalveolar cell carcinoma
Small size (detection unreliable if <7mm nodule).

26. PET/CT Staging: N3 (mets to
contralateral nodes).

27. Summary
 Lung cancer screening with low dose CT will
allow earlier lung cancer detection and save
lives.
 Fleischner guidelines for lung nodule follow
up now include subsolid nodules.
 Be aware of the limitations of PET/CT.

29. End