This document provides guidelines for the management of small pulmonary nodules detected on CT scans. It summarizes recent studies showing that the majority of small nodules, especially those under 5mm, detected on CT scans in smokers are benign. Existing guidelines requiring 2 years of follow-up CTs for any indeterminate nodule are costly and expose patients to unnecessary radiation. The guidelines propose new recommendations for follow-up and management of small pulmonary nodules based on size, characteristics, and a patient's risk profile.
Adjuvant Radiation Therapy in Early Cervical Cancer - EvidencesDr. Malhar Patel
Radiation therapy is one of the main line of management of carcinoma cervix.
This presentation is regarding evidences of adjuvant radiation therapy (post operative) in case of early carcinoma cervix.
CyberKnife: A New Option In the Treatment of Lung CancerKue Lee
This document summarizes the development and use of stereotactic body radiotherapy (SBRT) for early stage non-small cell lung cancer (NSCLC). It discusses how conventional radiation therapy had poor outcomes, but SBRT allows higher, more effective radiation doses to be delivered safely. Phase II data showed SBRT achieved high local control and 3-year survival rates for inoperable early stage NSCLC. Emerging data also suggests SBRT may be comparable to surgery for operable NSCLC, though more research is still needed to determine the optimal treatment approach. Overall, SBRT has significantly improved outcomes for early stage NSCLC compared to previous radiation techniques.
Evaluating Lung Nodules in an Endemic Region for CoccidioidomycosisKue Lee
This document summarizes a talk on evaluating lung nodules in a region where coccidioidomycosis is endemic. It discusses challenges in applying national guidelines locally. Radiological characteristics and clinical risk factors are used to evaluate nodules. A calculator was developed using these factors that better differentiates between coccidioidomycosis and lung cancer in nodules. Ongoing work includes refining the calculator, evaluating new tests like PCR for coccidioidomycosis, creating a tissue database, and assessing the impact of a lung nodule clinic.
This document discusses treatment options for oropharyngeal tumors, specifically comparing surgery versus radiotherapy. It notes that upfront surgery has the potential to provide pathological staging to help determine adjuvant treatment needs and tailor treatment intensity. Surgery, particularly transoral laser microsurgery (TORS), may achieve acceptable oncologic outcomes comparable to chemoradiotherapy while providing better long-term swallowing and speech outcomes. However, the optimal treatment for oropharyngeal tumors remains an ongoing debate, as chemoradiotherapy also has strong outcomes data, and treatment must be personalized based on tumor characteristics and patient factors.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
The document discusses stage III non-small cell lung cancer (NSCLC), noting its heterogeneity in presentation, risk factors, and treatment approaches. Stage III NSCLC encompasses locally advanced tumors with varying degrees of lymph node involvement. Effective treatment requires a multidisciplinary team and individualized treatment plans based on tumor characteristics and patient health. While surgery can potentially cure some stage III NSCLC, many patients require pre-operative or post-operative chemotherapy and radiation therapy to improve outcomes.
Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014Työterveyslaitos
This document discusses health surveillance of asbestos-exposed workers. It summarizes various asbestos-related diseases such as asbestosis, pleural plaques, and mesothelioma. It notes that CT scans have found more early-stage lung cancers in asbestos workers but have not reduced mortality. Biomarkers and microRNAs show promise as screening tools but require more research. Lung function tests and smoking cessation also remain important aspects of health surveillance for these workers. Overall, the benefits of screening must be weighed against the risks of repeated radiation exposure and invasive follow-up procedures.
Adjuvant Radiation Therapy in Early Cervical Cancer - EvidencesDr. Malhar Patel
Radiation therapy is one of the main line of management of carcinoma cervix.
This presentation is regarding evidences of adjuvant radiation therapy (post operative) in case of early carcinoma cervix.
CyberKnife: A New Option In the Treatment of Lung CancerKue Lee
This document summarizes the development and use of stereotactic body radiotherapy (SBRT) for early stage non-small cell lung cancer (NSCLC). It discusses how conventional radiation therapy had poor outcomes, but SBRT allows higher, more effective radiation doses to be delivered safely. Phase II data showed SBRT achieved high local control and 3-year survival rates for inoperable early stage NSCLC. Emerging data also suggests SBRT may be comparable to surgery for operable NSCLC, though more research is still needed to determine the optimal treatment approach. Overall, SBRT has significantly improved outcomes for early stage NSCLC compared to previous radiation techniques.
Evaluating Lung Nodules in an Endemic Region for CoccidioidomycosisKue Lee
This document summarizes a talk on evaluating lung nodules in a region where coccidioidomycosis is endemic. It discusses challenges in applying national guidelines locally. Radiological characteristics and clinical risk factors are used to evaluate nodules. A calculator was developed using these factors that better differentiates between coccidioidomycosis and lung cancer in nodules. Ongoing work includes refining the calculator, evaluating new tests like PCR for coccidioidomycosis, creating a tissue database, and assessing the impact of a lung nodule clinic.
This document discusses treatment options for oropharyngeal tumors, specifically comparing surgery versus radiotherapy. It notes that upfront surgery has the potential to provide pathological staging to help determine adjuvant treatment needs and tailor treatment intensity. Surgery, particularly transoral laser microsurgery (TORS), may achieve acceptable oncologic outcomes comparable to chemoradiotherapy while providing better long-term swallowing and speech outcomes. However, the optimal treatment for oropharyngeal tumors remains an ongoing debate, as chemoradiotherapy also has strong outcomes data, and treatment must be personalized based on tumor characteristics and patient factors.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
The document discusses stage III non-small cell lung cancer (NSCLC), noting its heterogeneity in presentation, risk factors, and treatment approaches. Stage III NSCLC encompasses locally advanced tumors with varying degrees of lymph node involvement. Effective treatment requires a multidisciplinary team and individualized treatment plans based on tumor characteristics and patient health. While surgery can potentially cure some stage III NSCLC, many patients require pre-operative or post-operative chemotherapy and radiation therapy to improve outcomes.
Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014Työterveyslaitos
This document discusses health surveillance of asbestos-exposed workers. It summarizes various asbestos-related diseases such as asbestosis, pleural plaques, and mesothelioma. It notes that CT scans have found more early-stage lung cancers in asbestos workers but have not reduced mortality. Biomarkers and microRNAs show promise as screening tools but require more research. Lung function tests and smoking cessation also remain important aspects of health surveillance for these workers. Overall, the benefits of screening must be weighed against the risks of repeated radiation exposure and invasive follow-up procedures.
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
This study evaluated the use of low-dose CT screening for lung cancer in 400 high-risk smokers in Toronto. It found that 16% had no nodules, 73% had small nodules that required annual follow up, and 27% had indeterminate nodules that needed further evaluation. Of those evaluated further, 9 biopsies confirmed lung cancer in 8 patients, all stage I and predominantly adenocarcinoma. The results show that low-dose CT can detect small, early-stage lung cancers in high-risk patients.
Il trattamento del carcinoma glottico in stadio iniziale nel paziente anzianoMerqurio
This study evaluated the impact of transoral laser surgery (TLS) for early-stage glottic cancer in 122 elderly patients aged 70-88 years old. TLS provided good oncological outcomes with a 10-year overall survival of 64.9%, tumor-specific survival of 84.8%, and laryngeal tumor-specific survival of 94.3%. TLS was found to be a feasible treatment for elderly patients that provided good disease-free survival, organ preservation, and quality of life. Patients had no intra- or post-operative complications and were able to resume normal activities quickly.
Screening in Asbestos-related diseases (lung cancer) at Helsinki Asbestos 2014Työterveyslaitos
This document discusses the history and evolution of guidelines for lung cancer screening. It outlines how early screening trials had limitations and found no clear mortality benefit from screening. Newer low-dose CT screening trials like NLST showed a 20% reduction in lung cancer mortality. Current USPSTF and ACS guidelines recommend annual low-dose CT screening for those aged 55-80 who have a 30 pack-year smoking history and quit within the last 15 years. Ongoing European trials are also investigating screening effectiveness. Guidelines are expected to continue evolving as more data becomes available on screening outcomes and technology improves.
This document discusses the benefits and drawbacks of using positron emission tomography (PET) scans to monitor patients who have achieved complete remission from Diffused Large B-cell Lymphoma (DLBCL) after primary treatment. While PET scans can detect relapses early and lead to better outcomes, they also expose patients to radiation and may not be necessary, as the majority of relapses are detected without scans. The document concludes that despite costs and radiation exposure, regular PET scans for two years are important to diagnose the 30% of relapses detected by scans alone and improve prognosis for these patients.
This document provides an overview of the management of non-small cell lung cancer (NSCLC). It discusses the anatomy of the lung and lymph node mapping. The clinical features, diagnostic workup including imaging and staging are covered. The various treatment approaches for early, locally advanced and metastatic NSCLC including surgery, radiation therapy, chemotherapy and targeted therapy are summarized. Techniques for radiation therapy planning and delivery such as 3D conformal radiation therapy, stereotactic body radiation therapy, proton beam therapy and brachytherapy are also outlined.
Resolving The Mystery of Puzzling Pulmonary NodulesKue Lee
This document provides an overview of the Lung Nodule Program at UCSF Fresno. It discusses:
1) The multidisciplinary team that oversees patient care through the lung nodule clinic, diagnostic services, and a tumor board.
2) Diagnostic services offered including various types of bronchoscopy, ultrasound-guided biopsy, and imaging.
3) Therapeutic interventions like stent placement, brachytherapy, and pleuroscopy.
4) The program has grown significantly over time and is the largest of its kind in the US, with a focus on research, training, and improving patient outcomes.
The document summarizes changes made in the WHO Classification of Tumours of the Central Nervous System fifth edition regarding brain tumor classification. Key changes include reclassifying some tumor types as distinct entities, incorporating molecular features into classifications, separating pediatric and adult tumor types, removing the term "anaplastic" in grading, and basing grading on both histological and molecular features. Molecular testing now plays an important role in diagnoses of several tumor types.
Protons Compared to Photons in Pediatric PatientsDanielle Buswell
Proton radiation therapy may reduce risks of late side effects compared to photon therapy for pediatric patients with medulloblastoma. Proton therapy decreases exit dose which can cause toxicities like heart problems, hearing loss, and neurocognitive deficits. Studies found proton therapy resulted in fewer neurocognitive deficits and lower risks of secondary cancers. While proton therapy may have better outcomes, its higher cost must be considered compared to photon therapy for each patient.
This document summarizes information about small cell lung cancer (SCLC), including its incidence, risk factors, staging, prognosis, diagnostic workup, and treatment approaches. Some key points:
- SCLC accounts for 15-20% of lung cancer cases and has a median age of diagnosis of 64. Most patients are smokers.
- Limited stage SCLC is confined to one lung and nearby lymph nodes, while extensive stage has spread further. Median survival is 25 months for limited vs 9 months for extensive disease.
- Workup includes imaging, biopsy, and brain MRI due to the risk of brain metastases. PET-CT helps determine extent of disease.
- Historically, surgery and chemotherapy alone did
This lecture proves an overview of assessing the thyrod nodule upon presentation. The use of imaging, including nuclear medicine, PET, CT/MR and Ultrasound is discussed.
There is more detail on ultrasound evaluation with particular emphasis on ACR TIRADS
This document provides information on the management of diffuse gliomas, including:
1. It defines diffuse gliomas and discusses their WHO classification, typically involving infiltration of normal brain tissue without clear borders.
2. Symptoms can include raised intracranial pressure, seizures, focal neurological deficits, and others depending on the tumor location.
3. Managing diffuse gliomas requires a multidisciplinary team including radiologists, neurosurgeons, oncologists and others.
4. Trial evidence is discussed regarding the use of radiotherapy and chemotherapy at different doses and timings for diffuse low-grade gliomas.
This document discusses the issue of lung cancer in Asia. It notes that lung cancer is primarily caused by smoking, and Asia accounts for over 60% of global lung cancer cases due to its high smoking rates, particularly in China, India, Indonesia, and South Korea. However, the document also discusses the rise of non-smoking related lung cancer in Asia due to factors like air pollution, second-hand smoke, and exposure to asbestos, industrial pollution, and cooking oil particles. Countries like China and Taiwan are seeing increasing rates of adenocarcinoma lung cancer in non-smokers due to air quality issues.
Articulo observacion importantes carotid body tumorMaynor Lopez
This study analyzed 49 carotid body tumor (CBT) resections in 39 patients over 25 years to assess outcomes. A neck mass was the most common presenting symptom. Complications occurred in 27% of cases, predominantly temporary nerve palsies which were more likely with larger tumors. Malignant disease was present in 15% of cases. During long-term follow up (average 11 years), 6 patients developed new paragangliomas, all with familial disease. Early resection of CBTs is recommended while still small to minimize risks, and lifelong follow up is essential in familial cases to screen for new tumors.
1. Radiotherapy targeting only para-aortic nodes is insufficient for testicular seminoma patients with a history of pelvic or scrotal surgery, as the primary lymphatic drainage pattern may have been altered.
2. For these cases, the treatment plan should include ipsilateral iliac and inguinal nodes in classic dog-leg AP-PA fields.
3. Prophylactic irradiation of the contralateral iliac, inguinal, or scrotal region may also be indicated for prior maldescensus testis, inguinal or scrotal violation, or pT3/4 primary tumors.
This study examined predictors of contralateral breast cancer in unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (CPM). The study analyzed 542 patients who underwent CPM at one cancer center between 2000-2007. Univariate analysis found that younger age, Gail risk score >1.67%, ipsilateral invasive lobular histology, additional ipsilateral moderate-high risk pathology, and multicentric ipsilateral tumor predicted higher risk of contralateral breast cancer. However, multivariate analysis identified only younger age and ipsilateral invasive lobular histology as independent predictors of contralateral breast cancer. The study aimed to help identify which unilateral breast cancer patients might most benefit from CPM.
The document discusses methods for diagnosing and staging non-small cell lung cancer (NSCLC), including physical exams, imaging tests, biopsies and laboratory tests. It then describes the TNM staging system for NSCLC and outlines treatment options based on cancer stage, including surgery, radiation, chemotherapy and targeted therapy. Later sections provide details on studies evaluating the benefits of postoperative radiation therapy and chemoradiation for locally advanced NSCLC.
This document discusses advanced non-small cell lung cancer and targeted therapies. It provides an overview of lung cancer epidemiology and risk factors like smoking. It also reviews molecular targets in NSCLC like EGFR, KRAS, and EML4-ALK and associated targeted therapies. The document outlines NSCLC diagnosis, staging, and management approaches including surgery, chemotherapy, and newer targeted therapies based on molecular profiling.
Echoendoscopic Lymph Node Staging in Lung Cancer: An endoscopic alternativeKue Lee
Echoendoscopic lymph node staging in lung cancer provides an endoscopic alternative to surgical staging that is minimally invasive, accurate, and prevents unnecessary surgeries. Combined endobronchial ultrasound and endoscopic ultrasound (EBUS/EUS) procedures sample lymph nodes and detect metastasis with a sensitivity of 91% and specificity of 96%, outperforming surgical staging. EBUS/EUS is now considered the new gold standard for mediastinal staging as it is safer, less costly, and more comprehensive than surgical staging alone.
Diastolic heart failure occurs when a patient exhibits signs and symptoms of heart failure but has a normal left ventricular ejection fraction over 45%. It accounts for approximately 40-60% of heart failure cases. The main causes are hypertension and coronary artery disease. Diagnosis involves clinical signs and echocardiographic evidence of abnormal diastolic function with normal systolic function. Management focuses on controlling blood pressure, heart rate, and congestion with diuretics, along with revascularization for underlying coronary artery disease.
This document provides guidelines on myocardial revascularization from the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). It was developed with contributions from additional associations and experts in the field. The guidelines cover indications for and comparisons of revascularization strategies like percutaneous coronary intervention and coronary artery bypass grafting in various clinical settings such as stable coronary artery disease, acute coronary syndromes, and special patient groups.
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
This study evaluated the use of low-dose CT screening for lung cancer in 400 high-risk smokers in Toronto. It found that 16% had no nodules, 73% had small nodules that required annual follow up, and 27% had indeterminate nodules that needed further evaluation. Of those evaluated further, 9 biopsies confirmed lung cancer in 8 patients, all stage I and predominantly adenocarcinoma. The results show that low-dose CT can detect small, early-stage lung cancers in high-risk patients.
Il trattamento del carcinoma glottico in stadio iniziale nel paziente anzianoMerqurio
This study evaluated the impact of transoral laser surgery (TLS) for early-stage glottic cancer in 122 elderly patients aged 70-88 years old. TLS provided good oncological outcomes with a 10-year overall survival of 64.9%, tumor-specific survival of 84.8%, and laryngeal tumor-specific survival of 94.3%. TLS was found to be a feasible treatment for elderly patients that provided good disease-free survival, organ preservation, and quality of life. Patients had no intra- or post-operative complications and were able to resume normal activities quickly.
Screening in Asbestos-related diseases (lung cancer) at Helsinki Asbestos 2014Työterveyslaitos
This document discusses the history and evolution of guidelines for lung cancer screening. It outlines how early screening trials had limitations and found no clear mortality benefit from screening. Newer low-dose CT screening trials like NLST showed a 20% reduction in lung cancer mortality. Current USPSTF and ACS guidelines recommend annual low-dose CT screening for those aged 55-80 who have a 30 pack-year smoking history and quit within the last 15 years. Ongoing European trials are also investigating screening effectiveness. Guidelines are expected to continue evolving as more data becomes available on screening outcomes and technology improves.
This document discusses the benefits and drawbacks of using positron emission tomography (PET) scans to monitor patients who have achieved complete remission from Diffused Large B-cell Lymphoma (DLBCL) after primary treatment. While PET scans can detect relapses early and lead to better outcomes, they also expose patients to radiation and may not be necessary, as the majority of relapses are detected without scans. The document concludes that despite costs and radiation exposure, regular PET scans for two years are important to diagnose the 30% of relapses detected by scans alone and improve prognosis for these patients.
This document provides an overview of the management of non-small cell lung cancer (NSCLC). It discusses the anatomy of the lung and lymph node mapping. The clinical features, diagnostic workup including imaging and staging are covered. The various treatment approaches for early, locally advanced and metastatic NSCLC including surgery, radiation therapy, chemotherapy and targeted therapy are summarized. Techniques for radiation therapy planning and delivery such as 3D conformal radiation therapy, stereotactic body radiation therapy, proton beam therapy and brachytherapy are also outlined.
Resolving The Mystery of Puzzling Pulmonary NodulesKue Lee
This document provides an overview of the Lung Nodule Program at UCSF Fresno. It discusses:
1) The multidisciplinary team that oversees patient care through the lung nodule clinic, diagnostic services, and a tumor board.
2) Diagnostic services offered including various types of bronchoscopy, ultrasound-guided biopsy, and imaging.
3) Therapeutic interventions like stent placement, brachytherapy, and pleuroscopy.
4) The program has grown significantly over time and is the largest of its kind in the US, with a focus on research, training, and improving patient outcomes.
The document summarizes changes made in the WHO Classification of Tumours of the Central Nervous System fifth edition regarding brain tumor classification. Key changes include reclassifying some tumor types as distinct entities, incorporating molecular features into classifications, separating pediatric and adult tumor types, removing the term "anaplastic" in grading, and basing grading on both histological and molecular features. Molecular testing now plays an important role in diagnoses of several tumor types.
Protons Compared to Photons in Pediatric PatientsDanielle Buswell
Proton radiation therapy may reduce risks of late side effects compared to photon therapy for pediatric patients with medulloblastoma. Proton therapy decreases exit dose which can cause toxicities like heart problems, hearing loss, and neurocognitive deficits. Studies found proton therapy resulted in fewer neurocognitive deficits and lower risks of secondary cancers. While proton therapy may have better outcomes, its higher cost must be considered compared to photon therapy for each patient.
This document summarizes information about small cell lung cancer (SCLC), including its incidence, risk factors, staging, prognosis, diagnostic workup, and treatment approaches. Some key points:
- SCLC accounts for 15-20% of lung cancer cases and has a median age of diagnosis of 64. Most patients are smokers.
- Limited stage SCLC is confined to one lung and nearby lymph nodes, while extensive stage has spread further. Median survival is 25 months for limited vs 9 months for extensive disease.
- Workup includes imaging, biopsy, and brain MRI due to the risk of brain metastases. PET-CT helps determine extent of disease.
- Historically, surgery and chemotherapy alone did
This lecture proves an overview of assessing the thyrod nodule upon presentation. The use of imaging, including nuclear medicine, PET, CT/MR and Ultrasound is discussed.
There is more detail on ultrasound evaluation with particular emphasis on ACR TIRADS
This document provides information on the management of diffuse gliomas, including:
1. It defines diffuse gliomas and discusses their WHO classification, typically involving infiltration of normal brain tissue without clear borders.
2. Symptoms can include raised intracranial pressure, seizures, focal neurological deficits, and others depending on the tumor location.
3. Managing diffuse gliomas requires a multidisciplinary team including radiologists, neurosurgeons, oncologists and others.
4. Trial evidence is discussed regarding the use of radiotherapy and chemotherapy at different doses and timings for diffuse low-grade gliomas.
This document discusses the issue of lung cancer in Asia. It notes that lung cancer is primarily caused by smoking, and Asia accounts for over 60% of global lung cancer cases due to its high smoking rates, particularly in China, India, Indonesia, and South Korea. However, the document also discusses the rise of non-smoking related lung cancer in Asia due to factors like air pollution, second-hand smoke, and exposure to asbestos, industrial pollution, and cooking oil particles. Countries like China and Taiwan are seeing increasing rates of adenocarcinoma lung cancer in non-smokers due to air quality issues.
Articulo observacion importantes carotid body tumorMaynor Lopez
This study analyzed 49 carotid body tumor (CBT) resections in 39 patients over 25 years to assess outcomes. A neck mass was the most common presenting symptom. Complications occurred in 27% of cases, predominantly temporary nerve palsies which were more likely with larger tumors. Malignant disease was present in 15% of cases. During long-term follow up (average 11 years), 6 patients developed new paragangliomas, all with familial disease. Early resection of CBTs is recommended while still small to minimize risks, and lifelong follow up is essential in familial cases to screen for new tumors.
1. Radiotherapy targeting only para-aortic nodes is insufficient for testicular seminoma patients with a history of pelvic or scrotal surgery, as the primary lymphatic drainage pattern may have been altered.
2. For these cases, the treatment plan should include ipsilateral iliac and inguinal nodes in classic dog-leg AP-PA fields.
3. Prophylactic irradiation of the contralateral iliac, inguinal, or scrotal region may also be indicated for prior maldescensus testis, inguinal or scrotal violation, or pT3/4 primary tumors.
This study examined predictors of contralateral breast cancer in unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (CPM). The study analyzed 542 patients who underwent CPM at one cancer center between 2000-2007. Univariate analysis found that younger age, Gail risk score >1.67%, ipsilateral invasive lobular histology, additional ipsilateral moderate-high risk pathology, and multicentric ipsilateral tumor predicted higher risk of contralateral breast cancer. However, multivariate analysis identified only younger age and ipsilateral invasive lobular histology as independent predictors of contralateral breast cancer. The study aimed to help identify which unilateral breast cancer patients might most benefit from CPM.
The document discusses methods for diagnosing and staging non-small cell lung cancer (NSCLC), including physical exams, imaging tests, biopsies and laboratory tests. It then describes the TNM staging system for NSCLC and outlines treatment options based on cancer stage, including surgery, radiation, chemotherapy and targeted therapy. Later sections provide details on studies evaluating the benefits of postoperative radiation therapy and chemoradiation for locally advanced NSCLC.
This document discusses advanced non-small cell lung cancer and targeted therapies. It provides an overview of lung cancer epidemiology and risk factors like smoking. It also reviews molecular targets in NSCLC like EGFR, KRAS, and EML4-ALK and associated targeted therapies. The document outlines NSCLC diagnosis, staging, and management approaches including surgery, chemotherapy, and newer targeted therapies based on molecular profiling.
Echoendoscopic Lymph Node Staging in Lung Cancer: An endoscopic alternativeKue Lee
Echoendoscopic lymph node staging in lung cancer provides an endoscopic alternative to surgical staging that is minimally invasive, accurate, and prevents unnecessary surgeries. Combined endobronchial ultrasound and endoscopic ultrasound (EBUS/EUS) procedures sample lymph nodes and detect metastasis with a sensitivity of 91% and specificity of 96%, outperforming surgical staging. EBUS/EUS is now considered the new gold standard for mediastinal staging as it is safer, less costly, and more comprehensive than surgical staging alone.
Diastolic heart failure occurs when a patient exhibits signs and symptoms of heart failure but has a normal left ventricular ejection fraction over 45%. It accounts for approximately 40-60% of heart failure cases. The main causes are hypertension and coronary artery disease. Diagnosis involves clinical signs and echocardiographic evidence of abnormal diastolic function with normal systolic function. Management focuses on controlling blood pressure, heart rate, and congestion with diuretics, along with revascularization for underlying coronary artery disease.
This document provides guidelines on myocardial revascularization from the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). It was developed with contributions from additional associations and experts in the field. The guidelines cover indications for and comparisons of revascularization strategies like percutaneous coronary intervention and coronary artery bypass grafting in various clinical settings such as stable coronary artery disease, acute coronary syndromes, and special patient groups.
This document provides guidelines for the treatment of aspergillosis from the Infectious Diseases Society of America. It finds that voriconazole is recommended as primary treatment for most cases of invasive aspergillosis. Liposomal amphotericin B is considered an alternative. For salvage therapy, options include various antifungal drugs. The guidelines also make recommendations for antifungal prophylaxis and management of chronic and allergic forms of aspergillosis.
This document summarizes risk factors for venous thromboembolism (VTE) during pregnancy. It notes that pregnancy increases the risk of VTE 6-fold due to hypercoagulability. The leading causes of maternal death in the US are VTE. Additional risk factors discussed include inherited thrombophilia, prior VTE history, age over 35, obesity, cesarean delivery, and antiphospholipid antibody syndrome. Testing for thrombophilia is recommended for those with strong family history of VTE or a prior VTE associated with a transient risk factor. Recurrence risk of VTE is higher for pregnant women found to have an inherited thrombophilia.
This document analyzes and compares the album artwork of three female artists: Marina and the Diamonds, Lana Del Rey, and Ellie Goulding. For each artist, it discusses common elements in their album covers that help establish their image and musical genre. Some key points made are that Marina focuses on her face, eyes, and hair to portray an alternative pop style. Lana Del Rey consistently places herself in the center and emphasizes her hair and makeup over fashion to depict a glamorous indie pop image. Ellie Goulding's covers feature close-ups and lights in her hair to match her titles and represent her as a simpler indie pop artist.
Ryan Adams was born in 1974 in North Carolina and began playing guitar at age 14. He joined several local bands before dropping out of school to perform music full-time. Adams released his solo debut "Heartbreaker" in 2000 to critical acclaim but slow sales. His cover of "Wonderwall" increased his recognition, as did his songs being featured in television and film. Adams releases numerous albums each year on independent labels, changing his musical style frequently between alternative, country, and piano ballads.
This document summarizes common neonatal morbidities that can result from complications during pregnancy and delivery. It discusses how conditions like diabetes, hypertension, infection, and nutritional imbalances in the mother can negatively impact the health of the newborn. The summary provides management considerations for treating infants born with various medical issues and outlines how close collaboration between obstetric and neonatal clinicians is important for counseling families and ensuring the best outcomes for both mother and baby.
Lung cancer remains a leading cause of cancer death. While early detection improves survival rates, past screening studies using chest x-rays and sputum analysis failed to reduce mortality. New screening methods using low-dose CT scans have shown promise in detecting early-stage cancers. However, limitations include high false positive rates and the need for improved methods to assess growth of small nodules over time. Further research is still needed to determine if lung cancer screening using low-dose CT can reduce mortality and be cost-effective.
This study analyzed data from 2467 lung cancer cases diagnosed between 1996-2010 in southern Switzerland to assess the impact of immunohistochemical (IHC) studies on lung cancer subtypes. The four main histotypes were adenocarcinoma (AC), large cell carcinoma/non-small cell lung cancer (LCC/NSCLC), small cell carcinoma (SmCC), and squamous cell carcinoma (SqCC). Trend analysis showed a significant increase in AC incidence and decrease in LCC/NSCLC incidence beginning in 2003, coinciding with the introduction of IHC studies. Improved two-year survival was seen in SqCC while survival decreased in LCC/NSCLC. The results highlight that IHC studies impact
This document presents a lexicon developed by an ACR committee to standardize the terminology used in ultrasound reports for thyroid nodules. It defines six categories used to describe sonographic features of thyroid nodules: composition, echogenicity, shape, size/dimensions, margins, and flow/Doppler. The goal is to provide evidence-based recommendations for managing thyroid nodules based on standardized terminology that can improve diagnosis and risk stratification.
It Is Time to Reevaluate the Management of Patients With Brain MetastasesApple Samsung
This document discusses 5 common misconceptions that clinicians have regarding treatment of patients with brain metastases. It summarizes a presentation given by Dr. Tossif Ghodiwala aimed at reevaluating the management of these patients. The 5 misconceptions are: 1) all tumor histologies are the same, 2) number of lesions matters most rather than total tumor volume, 3) micrometastases are always present, 4) whole brain radiation is always harmful, and 5) most metastases cause obvious symptoms. For each misconception, the document provides the current evidence and perspective that these views are outdated and that a more personalized approach is needed.
This study evaluated the management of pulmonary nodules between 8-20mm by 18 community pulmonology practices across the US. The researchers reviewed records of 377 patients and found:
1) The prevalence of lung cancer was 25% (n=94). Nearly half of patients (46%) underwent surveillance alone while 33% had a biopsy and 20% had surgery.
2) Predicted probability of malignancy models had good accuracy but invasive procedures were still common in low risk nodules and surgery was performed in 35% of benign nodules.
3) Adherence to guidelines for pulmonary nodule management may be lacking, as invasive sampling and surgery of low risk nodules remained common despite available
1) PET evaluation of lung cancer shows promise as a noninvasive method to aid in the diagnosis of lung lesions, staging of non-small cell lung cancer, detecting distant metastases, and diagnosing recurrent disease.
2) Conventional imaging such as CT is used to evaluate characteristics of solitary pulmonary nodules such as shape, borders, densities, and patterns of calcification to determine if they are benign or malignant. However, more options are now available to clinicians.
3) Ground glass nodules are less dense than solid nodules and do not obscure lung parenchyma. They are more commonly malignant than solid nodules and include cell types such as bronchioalveolar carcinoma. PET has low
This document discusses advances in the treatment of inoperable lung cancer. It focuses on a study of 141 patients with stage I non-small cell lung cancer who were medically inoperable and treated with radiation alone. The study found a 2-year survival rate of 39% and cause-specific survival of 60% at 2 years and 32% at 5 years. Improved survival was associated with squamous cell cancer, incidental finding of cancer, younger age, less smoking, and better local tumor control from radiation. The document argues that more precise radiation techniques like stereotactic body radiosurgery could improve local control rates and survival outcomes for patients with inoperable lung cancer.
This document discusses the importance of CT lung cancer screening programs and provides guidance on developing a successful screening program. Key points include: CT screening significantly reduces lung cancer mortality compared to chest x-rays based on results from the National Lung Screening Trial; nurse navigators play a central role in implementing screening programs and guiding patients; multidisciplinary conferences help manage abnormal screening results; and guidelines for starting a screening program include assembling a team, determining costs and guidelines, collecting data, and marketing to providers and patients.
- Ms. M presented with multiple pulmonary nodules found on CT scan during workup for atypical chest pain
- Differential diagnosis included infection, granulomatosis, rheumatoid arthritis, malignancy
- Follow up imaging showed growth of some nodules, recommending biopsy vs resection
- She underwent left upper lobe resection, pathology found metastatic adenocarcinoma from previous colon cancer
- Given her history, the recommended next step is 6 months of adjuvant chemotherapy despite equivocal data on its benefits
This study examined 52 cases of lung cancer that presented atypically on initial chest x-rays. In 30 cases (57.69%), the chest x-ray showed an abnormality but lung cancer was not suspected. Pneumonia was the most common misdiagnosis. Further investigation with CT, bronchoscopy or thoracoscopy revealed the diagnoses were actually lung cancer. The study concludes that further investigation is warranted for continuing or changing respiratory symptoms even if the initial chest x-ray is not suggestive of lung cancer.
This study analyzed histopathological features of 94 early lung adenocarcinoma samples using image analysis. Samples were classified as adenocarcinoma in situ, microinvasive adenocarcinoma, or lepidic predominant adenocarcinoma. Several parameters were measured from images of gland structures and nuclei, including generalized line reference number density of cancer cells, adhesion rate of nuclei, nucleolus occurrence rate, maximum distance between glands, and nuclear morphology parameters. Statistical analysis found several parameters had significant differences among the three pathological types, while others did not. These parameters may help with quantitative analysis and differential diagnosis of early lung adenocarcinoma types.
Kshivets O. Lung Cancer: Optimal Treatment StrategiesOleg Kshivets
This document describes a study examining optimal treatment strategies for non-small cell lung cancer (NSCLC) patients. The study reviewed data from 535 NSCLC patients who underwent complete surgical resection between 1985-2008. Patients received one of three treatments: surgery alone (316 patients), surgery plus postoperative radiotherapy (102 patients), or surgery plus adjuvant chemoimmunoradiotherapy (117 patients). The study found that adjuvant chemoimmunoradiotherapy resulted in significantly higher 5-year survival rates compared to radiotherapy or surgery alone, especially for patients with lymph node involvement. Overall 5-year survival for the entire group was 63.6%, demonstrating the benefit of aggressive surgical resection and adjuvant therapies.
The document provides an overview of chest imaging techniques used to diagnose and monitor lung diseases. It discusses how chest x-rays are commonly used first but CT is more accurate. CT is also important for screening programs to detect early-stage lung cancers. Radiologists interpret imaging tests and work with other specialists to determine diagnoses and treatments. Chest imaging has little risk but can find diseases before symptoms appear or track response to therapies.
This document reviews rare types of breast cancer. It summarizes information on 16 epithelial subtypes classified by the World Health Organization, including histopathology descriptions and clinical parameters. While rare cancers cannot be studied through large randomized trials, this review aims to provide clinicians an understanding to help determine optimal treatment approaches. It discusses cancers such as tubular carcinoma and mucinous carcinoma, which typically have a good prognosis and are often estrogen receptor positive with low lymph node involvement.
White Paper- A non-invasive blood test for diagnosing lung cancerDusty Majumdar, PhD
Lung cancer is the leading cause of cancer death worldwide. While low-dose CT screening can reduce lung cancer mortality, it has low specificity resulting in many false positives and unnecessary invasive follow-ups that increase costs. A blood-based biomarker test could potentially improve the specificity of CT screening by reducing false positives. Exact Sciences and MD Anderson are collaborating to develop a multi-marker blood test to complement CT screening for lung cancer, with the goal of a test that matches or exceeds CT's performance to make screening more effective and cost-efficient.
Objective: Lung cancer is the leading cause of cancer death in North America. Low-dose computed tomography screening can reduce lung cancer–specific mortality by 20%.
8 th edition TNM classification and significance of depth of invasionishita1994
Diagnosis of oral cancer is completed for:
Initial diagnosis
Staging
Treatment planning
A complete history, and clinical examination is first completed, then a wedge of tissue is cut from the suspicious lesion for tissue diagnosis. In this procedure, the surgeon cuts all, or a piece of the tissue, to have it examined under a microscope by a pathologist.
CT scans still play a critical role in managing COVID-19. Patients with a severe coronavirus infection show different features on their computed tomography
This document discusses thyroid cancer guidelines from ESMO. It covers:
1) Incidence and epidemiology of the main types of thyroid cancer, including higher rates in women and certain races.
2) Diagnosis using ultrasound and fine needle aspiration biopsy to evaluate nodules, with molecular testing also showing promise.
3) Treatment for differentiated thyroid cancer typically involving total thyroidectomy followed by staging and risk assessment to guide further treatment and follow-up.
Circulating Tumor Cells and Cell-Free Nucleic Acids as Predictor Factors for ...daranisaha
Pancreatic cancer remains as one of the most aggressive and deadliest of cancers largely due to formidable challenges in diagnosis and therapy. Consensus standard treatment for patients with nonmetastatic Pancreatic Cancer (PC) incorporates possible neoadjuvant chemotherapy with timely surgical resection and adjuvant chemotherapy. However, despite all the sophistication of modern radiological and endoscopic techniques, the decision regarding operability is often only made intra-operatively, therefore subjecting a patient to unnecessary surgical intervention, and postponing the possibility of starting early chemotherapy.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise stimulates the production of endorphins in the brain which elevate mood and reduce stress levels.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This presentation was provided by Rebecca Benner, Ph.D., of the American Society of Anesthesiologists, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
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THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...indexPub
The recent surge in pro-Palestine student activism has prompted significant responses from universities, ranging from negotiations and divestment commitments to increased transparency about investments in companies supporting the war on Gaza. This activism has led to the cessation of student encampments but also highlighted the substantial sacrifices made by students, including academic disruptions and personal risks. The primary drivers of these protests are poor university administration, lack of transparency, and inadequate communication between officials and students. This study examines the profound emotional, psychological, and professional impacts on students engaged in pro-Palestine protests, focusing on Generation Z's (Gen-Z) activism dynamics. This paper explores the significant sacrifices made by these students and even the professors supporting the pro-Palestine movement, with a focus on recent global movements. Through an in-depth analysis of printed and electronic media, the study examines the impacts of these sacrifices on the academic and personal lives of those involved. The paper highlights examples from various universities, demonstrating student activism's long-term and short-term effects, including disciplinary actions, social backlash, and career implications. The researchers also explore the broader implications of student sacrifices. The findings reveal that these sacrifices are driven by a profound commitment to justice and human rights, and are influenced by the increasing availability of information, peer interactions, and personal convictions. The study also discusses the broader implications of this activism, comparing it to historical precedents and assessing its potential to influence policy and public opinion. The emotional and psychological toll on student activists is significant, but their sense of purpose and community support mitigates some of these challenges. However, the researchers call for acknowledging the broader Impact of these sacrifices on the future global movement of FreePalestine.
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This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
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Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
A Free 200-Page eBook ~ Brain and Mind Exercise.pptxOH TEIK BIN
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This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
2. tion, with a view to achieving the highest nodule that would qualify for this proto- CT. If the nodule did not exhibit un-
possible cure rate while gaining further col (2). equivocally benign characteristics (be-
insight into the behavior and character- The rationale for recommending serial nign pattern of calcification, smooth
istics of small malignant lesions. There- follow-up studies for all indeterminate margins, and size less than 20 mm), it
fore, patients whose nodules are detected small nodules is that some of them will was followed up with thin-section CT at
Radiology
incidentally during the course of CT per- turn out to be cancers and that early in- 3 months and subsequently at 6, 12, and
formed for other reasons should not nec- tervention will provide an opportunity 24 months in the absence of change.
essarily be treated in the same way as for cure. The “downside” of this policy Only one cancer was less than 5 mm in
subjects in a screening program. Nonethe- includes potential morbidity and mor- diameter at the time of detection in the
less, although CT screening has not as yet tality from surgery for benign nodules baseline (10-mm-collimation) study. The
been proved to help reduce mortality from and other false-positive findings, poor results of the repeat screening were re-
lung cancer, these programs provide an utilization of limited resources, in- ported in 2001. Seven new cancers were
important source of information for deter- creased health care costs, unnecessary detected at the repeat screening; three of
mining the optimal management of “inci- patient anxiety, loss of credibility for these were 5 mm in size (defined as the
dental” nodules detected in other situa- radiologists who may seem to recom- average of the length and width in that
tions. mend excessive numbers of CT scans study); all the other proved cancers were
Our intent in this position statement is with little benefit, and increased radia- larger (8).
to provide practical guidelines for the tion burden for the affected popula- Swensen et al (7) reported the results of
management of small pulmonary nod- tion. The radiation issue is particularly the Mayo Clinic Lung Cancer Screening
ules that are detected during the course important in younger patients and Trial after completion of three annual
of CT examinations performed for pur- must be taken into account in deter- low-dose CT examinations in 1520 smok-
poses other than lung cancer screening. mining appropriate follow-up strategies ers. The subjects were aged 50 years or
We recognize that this issue is complex (10 –13). older and had a smoking history of 20
and difficult to reduce to a simple algo- There remains a growing need to reex- pack-years or more. Two years after base-
rithm. We also realize that the definition amine the radiologic approach to small line screening, 2832 noncalcified pulmo-
of a pulmonary nodule is itself elusive, nodules, particularly when CT is per-
nary nodules had been identified in 1049
and that not all focal opacities qualify as formed for indications other than screen-
(69%) participants. Thirty-six lung can-
nodules. Yet, we believe that there is a ing. Several fundamental issues need to
cers were diagnosed with the aid of CT
practical need in the medical community be considered before an imaging strategy
(2.6% of participants, 1.4% of nodules):
for guidance in this area. is recommended. Since the decision to
26 at baseline (prevalence) and 10 at sub-
perform follow-up studies relies on size,
sequent annual (incidence) CT examina-
lesion characteristics (eg, morphology),
BACKGROUND tions. Thirty-two (80%) of these cancers
and growth rates (typically described as
were larger than 8 mm, and only one was
doubling time), an understanding of
smaller than 5 mm at the time of detec-
Available data indicate that fewer than these features and their relationship to
tion. Two cancers were detected by using
1% of very small ( 5-mm) nodules in malignancy should dictate further evalu-
sputum cytology, and there were two in-
patients without a history of cancer will ation. In addition, the patient’s risk pro-
terval cancers.
demonstrate malignant behavior (ie, de- file, including age and smoking history,
tectable growth or metastases over a pe- needs to be integrated into the diagnostic Benjamin et al (14) reported the results
riod of 2 or more years) (5,7,9). Nonethe- algorithm. of a retrospective review of 334 non-
less, multiple follow-up examinations screening cases in which a lung nodule or
over a 2-year period are commonly per- nodules were detected that were less than
Nodules Detected on CT Scans 10 mm in their long axis and for which
formed when such nodules are detected
incidentally. Guidelines for the manage- During the past 5 years, new informa- follow-up CT was recommended. These
ment of the solitary pulmonary nodule tion regarding the morphology, biologic nodules were identified from 3446 con-
were published in 2003 by the American characteristics, and growth rates of small secutive chest CT studies performed at
College of Chest Physicians (2) and in a lung cancers has become available from their institution. Among patients with a
review in by Ost and colleagues in the CT lung cancer screening programs nodule, 87 patients had “definitive” fol-
New England Journal of Medicine (1). How- throughout the world. Selected studies low-up results (2 years without change or
ever, neither of these articles specifically are summarized below as representative biopsy). Nodules in 10 (11%) of these
addressed the issue of the very small nod- of the present state of knowledge in this patients were malignant. Nine of these
ule that is detected as an incidental find- area. cases were metastases from known pri-
ing on a CT scan. Ost and colleagues con- Henschke et al (9) published the initial mary tumors, and one turned out to be a
cluded by recommending CT follow-up results from the Early Lung Cancer Ac- metastasis from an occult primary tumor.
at 3, 6, 12, 18, and 24 months for all tion Project CT screening project in 1999. This high incidence of metastases is a
“low-probability” indeterminate nodules They enrolled 1000 asymptomatic smok- reflection of the patient population that
(ie, nodules with a low likelihood of be- ers or ex-smokers with at least 10 pack- was used for this study, in that 56% of
ing cancer), regardless of size (1). The years of cigarette smoking who were aged the included patients had a known pri-
American College of Chest Physicians 60 years or older. Screening CT studies mary tumor. The authors of that article
recommendation for management of in- were performed with 10-mm collima- suggested that the malignancy rate in
determinate solitary nodules was similar, tion. The investigators found noncalci- small nodules in patients without a
with the proposal for 3-, 6-, 12-, and 24- fied nodules in 23% of subjects and ma- known neoplasm may be as low as 1%
month CT follow-up intervals, also with- lignant nodules in 2.7%. All detected and that follow-up may not be necessary
out any specified lower size limit for a nodules were subjected to thin-section in such cases.
396 Radiology November 2005 MacMahon et al
3. Nodule Size pers, or software that performs auto- diameter of 20.3 mm in 12 months,
mated volumetric measurement of the whereas a similar nodule with a doubling
On the basis of analysis of information
nodule (15). The minified display used time of 240 days would reach a diameter
from the ongoing Mayo Clinic CT
for hard copy makes accurate measure- of only 7.1 mm in the same period.
Screening Trial, Midthun et al (4) re-
ment of subcentimeter nodules virtually
ported that fewer than 1% of very small
Radiology
impossible. Even with a state-of-the-art
( 5-mm) nodules in patients without a Relative Risk
soft-copy display and electronic calipers,
history of cancer were malignant. They
substantial inter- and intrareader varia- Sone et al (22) reported the results of a
indicated a likelihood of malignancy of
tions in two-dimensional measurements CT screening program carried out in Ja-
0.2% for nodules smaller than 3 mm,
have been documented (16). Revel and pan in 1996 –1998 that enrolled 5483
0.9% for those 4 –7 mm, 18% for those colleagues (16) determined that two-di- subjects. They found an equal prevalence
8 –20 mm, and 50% for those larger than mensional measurements obtained with (0.5%) of lung cancer in smokers and
20 mm. electronic calipers were unreliable as a nonsmokers, although the death rate
Henschke and colleagues (5) recently basis for distinguishing benign from ma- from lung cancer in smokers in Japan is
addressed the issue of optimal follow-up lignant solid nodules in the 5–15-mm approximately four times higher than
intervals for nodules smaller than 5 mm size range. Limited studies (15,17) that that in nonsmokers (23). This discrep-
in diameter. They performed a retrospec- have been performed with automated ancy may be explained by an overdiag-
tive review of a total of 2897 baseline three-dimensional analysis suggest that nosis bias, as many of these slow-growing
screening studies performed between such systems can be considerably more cancers in nonsmokers might never have
1993 and 2002 in order to identify those accurate and consistent than unaided been detected or become symptomatic if
subjects with noncalcified nodules that, radiologists in determining interval the subjects had not been screened. It is
at initial detection, were (a) smaller than changes in small nodules. However, Kos- unclear how many of the nonsmokers in
5 mm in diameter and (b) 5–9 mm in tis and colleagues (18) have shown that this study may have been affected by sec-
diameter. In accordance with the screen- even sophisticated automated volume- ond-hand smoke and whether this phe-
ing program guidelines, indeterminate measurement methods are susceptible to nomenon, or underreporting of smoking
nodules were rescanned at 3-, 6-, and 12- errors due to motion artifacts or segmen- by screening subjects, might account for
month intervals, while some in the tation problems, particularly in the case the relatively high lung cancer mortality
5–9-mm range that had particularly sus- of very small nodules. in nonsmokers in Japan compared with
picious morphology were recommended that in the United States (24).
for biopsy. On the basis of the results of The relative risk for developing lung
these follow-up studies and biopsies, the Growth Rate
carcinoma in male smokers was about 10
authors determined that when the largest Hasegawa et al (19) reported an analy- times that in nonsmokers in the eight
noncalcified nodule was smaller than 5 sis of the growth rates of small lung can- prospective studies reviewed for the 1982
mm in diameter (378 patients), a fol- cers detected during a 3-year mass screen- report of the Surgeon General on “The
low-up study in 12 months would have ing program. They classified nodules as Health Consequences of Smoking” (25).
resulted in no case of delayed diagnosis, ground-glass opacity, as ground-glass For heavy smokers, the risk was 15–35
compared with more aggressive short- opacity with a solid component, or as times greater (25,26). Despite initial evi-
term follow-up. However, when the larg- solid. Mean volume doubling times were dence suggesting an increased risk of
est nodule was 5–9 mm in diameter, ap- 813 days, 457 days, and 149 days, respec- lung cancer in women compared with
proximately 6% of cases (all of which tively, for these three types, all of which that in men with an equal smoking his-
were malignant) showed interval nodule were significantly different. In addition, tory, this has not been confirmed in
growth detectable on 4 – 8-month fol- the mean volume doubling time for can- more recent studies (27–30).
low-up scans. Therefore, they recom- cerous nodules in nonsmokers was signif- A history of lung cancer in first-degree
mended that patients with nodules no icantly longer than that for cancerous relatives is also a notable risk factor, and
larger than 5 mm in diameter on a base- nodules in smokers. The mean volume strong evidence for a specific lung cancer
line screening CT scan should be referred doubling time was also significantly susceptibility gene has been discovered
for repeat annual screening in 12 months longer for nodules not visible on chest recently (31,32). Other established risk
time, with no interval scans. This recom- radiographs (presumably a function of factors include exposure to asbestos, ura-
mendation differs only slightly from the their smaller average size and/or their nium, and radon (33–35). However, cig-
current protocol for the ongoing Na- lesser average opacity). These data further arette smoke remains the overwhelm-
tional Lung Screening Trial, in which pa- support the use of extended follow-up ingly dominant culprit.
tients with nodules smaller than 4 mm in intervals for small nonsolid or partly Several large screening programs are
diameter are recommended to return for solid nodules, even in high-risk patients. continuing, and we will learn more from
screening after 12 months, without inter- Authors of a number of other series these studies in the next several years.
val scans or other work-up. Note that (20,21) have confirmed similar findings Although the available data are still in-
these recommendations refer to high-risk and have estimated the median tumor complete, certain tentative conclusions
subjects who have enrolled in a screening doubling times, assuming a constant can be drawn at the present:
program. growth rate to be in the 160 –180-day 1. Approximately half of all smokers
A further practical issue arises in the range. Authors of all of these reports, over 50 years of age have at least one lung
follow-up to detect interval growth of however, recognize wide variations, and nodule at the time of an initial screening
very small nodules. Comparison of cur- in one study 22% of tumors had a vol- examination. In addition, approximately
rent and previous scans can be performed ume doubling time of 465 days or more 10% of screening subjects develop a new
by using hard copy with manual mea- (21). Note that a 5-mm nodule with a nodule during a 1-year period (36).
surement, soft copy with electronic cali- doubling time of 60 days will reach a 2. The probability that a given nodule
Volume 237 Number 2 Fleischner Society Statement on CT of Small Pulmonary Nodules 397
4. is malignant increases according to its
size (4,5). Even in smokers, the percent- Recommendations for Follow-up and Management of Nodules Smaller than
8 mm Detected Incidentally at Nonscreening CT
age of all nodules smaller than 4 mm that
will eventually turn into lethal cancers is Nodule Size
very low ( 1%), whereas for those in the (mm)* Low-Risk Patient† High-Risk Patient‡
Radiology
8-mm range the percentage is approxi- 4 No follow-up needed §
Follow-up CT at 12 mo; if
mately 10%–20% (4,7,8,37). unchanged, no further follow-up
3. Cigarette smokers are at greater risk 4–6 Follow-up CT at 12 mo; if Initial follow-up CT at 6–12 mo then
for lethal cancers, and malignant nodules unchanged, no further follow-up at 18–24 mo if no change
6–8 Initial follow-up CT at 6–12 mo then Initial follow-up CT at 3–6 mo then
in smokers grow faster, on average, than at 18–24 mo if no change at 9–12 and 24 mo if no change
do those in nonsmokers (19,25,26). Also, 8 Follow-up CT at around 3, 9, and 24 Same as for low-risk patient
the cancer risk for smokers increases in mo, dynamic contrast-enhanced
proportion to the degree and duration of CT, PET, and/or biopsy
exposure to cigarette smoke (38). Note.—Newly detected indeterminate nodule in persons 35 years of age or older.
4. Certain features of nodules correlate * Average of length and width.
† Minimal or absent history of smoking and of other known risk factors.
with likelihood of malignancy, cell type, ‡ History of smoking or of other known risk factors.
and growth rate. For instance, small §
The risk of malignancy in this category ( 1%) is substantially less than that in a baseline CT scan
purely ground-glass opacity (nonsolid) of an asymptomatic smoker.
nodules that have malignant histopatho- Nonsolid (ground-glass) or partly solid nodules may require longer follow-up to exclude
logic features tend to grow very slowly, indolent adenocarcinoma.
with a mean volume doubling time on
the order of 2 years (19). Solid cancers, on
the other hand, tend to grow more rap-
idly, with a mean volume doubling time be subjected to a minimum of four or five this regard. Rather, we have elected to
on the order of 6 months. The growth follow-up CT examinations before being focus on the issue of follow-up imaging
rate of partly solid nodules tends to fall designated benign and the patient being of smaller nodules. Specifically, for what
between these extremes, and this partic- reassured (1,2). As summarized above, kinds of lesions is it appropriate to fol-
ular morphologic pattern is highly pre- data from ongoing CT screening pro- low, and if followed, at what intervals?
dictive of adenocarcinoma (39 – 41). grams with multidetector CT with 5-mm Therefore, we propose a set of guidelines,
5. Increasing patient age generally cor- collimation indicate that approximately summarized in the Table, for the man-
relates with increasing likelihood of ma- half of all smokers over 50 years of age agement of small pulmonary nodules de-
lignancy. Lung cancer is uncommon in have at least one lung nodule on the ini- tected on CT scans.
patients younger than 40 years and is rare tial scan (36). In addition, approximately Note that the recommendations
in those younger than 35 years (42). At 10% of screening subjects develop a new shown in the Table apply only to adult
the other end of the age scale, although nodule over a 1-year period, and about patients with nodules that are “inciden-
the likelihood of cancer increases, surgi- 12% can be expected to have one or more tal” in the sense that they are unrelated
cal intervention carries greater risks. Also, additional nodules that were missed on to known underlying disease. The follow-
the likelihood of a small nodule evolving the original scan (36). Assuming similar ing examples describe patients to whom
into a cancer that will cause premature demographics, approximately 20% of pa- the above guidelines would not apply.
death becomes a lesser concern as comor- tients who have a nodule detected on CT Patients known to have or suspected of
bidity increases in a person and predicted scans can be expected to have at least one having malignant disease.—Patients with a
survival decreases with advancing years. new nodule detected during the cur- cancer that may be a cause of lung me-
rently recommended 2-year minimum tastases should be cared for according to
follow-up period, which will in turn the relevant protocol or specific clinical
Management Approach
mandate another series of follow-up CT situation. Pertinent factors will include
A number of investigators have already studies with similar opportunities for the site, cell type, and stage of the pri-
raised serious concerns about current new nodules to be detected during the mary tumor and whether early detection
management strategies for the indeter- additional follow-up period. Therefore, of lung metastases will affect care. In this
minate small nodule, particularly after strict application of the existing recom- setting, frequent follow-up CT may be
encountering an overwhelming number mendations would result in multiple fol- indicated.
of such abnormalities on CT scans low-up studies over 2 or more years for a Young patients.—Primary lung cancer is
(7,14,36). In the study by Henschke et al large proportion of all patients who un- rare in persons under 35 years of age
(5) described earlier, the authors found dergo thoracic CT. ( 1% of all cases), and the risks from
no cancers in patients in whom the larg- In the case of nodules larger than 8 radiation exposure are greater than in the
est noncalcified nodule was less than 5 mm, additional options such as contrast older population. Therefore, unless there
mm in diameter on the initial scan (zero material– enhanced CT, positron emis- is a known primary cancer, multiple fol-
of 378 patients). Thus there was no ad- sion tomography (PET), percutaneous low-up CT studies for small incidentally
vantage in performing short-interval fol- needle biopsy, and thoracoscopic resec- detected nodules should be avoided in
low-up for nodules smaller than 5 mm in tion can be considered (43– 46). Because young patients. In such cases, a single
their study, even in high-risk patients. these approaches depend greatly on low-dose follow-up CT scan in 6 –12
Therefore, we recommend altering the available expertise and equipment and months should be considered.
existing recommendations, which indi- have limited applicability to nodules in Patients with unexplained fever.—In cer-
cate that every indeterminate nodule, re- the subcentimeter range, we have chosen tain clinical settings, such as a patient
gardless of size and morphology, should not to offer detailed recommendations in presenting with neutropenic fever, the
398 Radiology November 2005 MacMahon et al
5. presence of a nodule may indicate active conclusive evidence, as yet, that serial CT malignancy and should be managed ac-
infection, and short-term imaging fol- studies with early intervention for de- cordingly (39). Depending on the cir-
low-up or intervention may be appropri- tected cancers can reduce disease-specific cumstances, follow-up imaging studies or
ate. mortality, even in high-risk patients (7). intervention may be appropriate. Con-
Previous CT scans, chest radiographs, Therefore, we do not recommend fol- servative management is generally ap-
and other pertinent imaging studies low-up CT for every small indeterminate
Radiology
propriate for nodules in very elderly pa-
should be obtained for comparison nodule. tients or in those with major comorbid
whenever possible, as they may serve to Management decisions should not be disease. Interval growth of any nodule
demonstrate either stability or interval based on nodule size alone. While any suggests an active process, and further
growth of the nodule in question. calcification in a small nodule favors a evaluation or intervention should be
A low-dose, thin-section, unenhanced benign cause, central, laminar, or dense considered in such cases.
technique should be used, with limited diffuse patterns of calcification are reli- It is impossible to ignore medicolegal
longitudinal coverage, when follow-up of able evidence of benignancy (49). Fat considerations when discussing manage-
a lung nodule is the only indication for content suggests a hamartoma or occa- ment of pulmonary nodules. The current
the CT examination. sionally a lipoid granuloma or lipoma practice in the United States of recom-
(50). Solid versus nonsolid appearance, mending follow-up studies for all inde-
spiculation, or other characteristics influ- terminate opacities is partly related to
DISCUSSION ence the likelihood of malignancy and perceived liability if a cancer should de-
probable growth rate in any given case velop (59). When the medical commu-
Not every focal opacity qualifies as a nod- (19,39,49,51,52). Longer follow-up in- nity has preached the importance of
ule. Unfortunately, the familiar lung tervals are appropriate for nonsolid early detection of cancer for so long, it
nodule has eluded all efforts at precise (ground-glass opacity) and very small may prove difficult to convince physi-
definition. A committee of the Fleischner opacities (19,40). For instance, even if cians and the public that follow-up CT of
Society on CT nomenclature described malignant, a nonsolid nodule that is every nodule in every patient is unneces-
the pathologic definition of a nodule as a smaller than 6 mm will probably not sary. Nonetheless, it is our hope that the
“small, approximately spherical, circum- grow perceptibly in much less than 12 guidelines presented here will support a
scribed focus of abnormal tissue” and the months (19,40). Also, as discussed earlier, practical and medically appropriate ap-
radiologic definition as a “round opacity, it has been established that accurate mea- proach to the management of inciden-
at least moderately well marginated and surement of growth in subcentimeter tally detected small pulmonary nodules.
no greater than 3 cm in maximum diam- nodules is problematic (16). The recommendations presented here
eter” (47). Therefore, a linear or essen- Other features such as clustering of are based on our current understanding
tially two-dimensional opacity that does multiple nodules in a single location in of pulmonary nodules, and we expect
not have an approximately spherical the lung tend to favor an infectious pro- that they will continue to evolve as more
component is not a nodule. In general, cess, although a dominant nodule with information becomes available.
purely linear or sheetlike lung opacities adjacent small satellite nodules can be
are unlikely to represent neoplasms and seen in primary lung cancer (53,54). For a
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