Case presentation

1. Noon Conference
Calvin Knapp
3/23/2019

2. © 2016 Virginia Mason Medical Center 2
Outpatient Clinic Visit
Ms. M
• 73F with PMHx Stage III Rectal Cancer s/p resection and adjuvant
chemoradiation in 2010
• Presented to OSH in December 2018 with URI symptoms and
atypical chest pain, admitted with “SIRS” and possible pericarditis
• Subsequently underwent CT Scan demonstrating multiple
pulmonary nodules
• 2 x 1.2cm, RUL and LUL

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CT December 2018
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Differential Diagnosis
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right lung nodules and infiltrates
• Non-Maligant
• Infection
• Granulomatosis with polyangiitis
• Rheumatoid Arthritis
• Pulmonary AVM
• Pneumoconioses
• Malignant
• Pulmonary Adenocarcinoma
• Separate primary lesions
• Primary with contralateral metastases
• Lymphoma
• Pulmonary Metastases

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Next best step for this patient?
A. PET Scan
B. Endobronchial Biopsy (EBUS)
C. CT Guided Needle Biopsy
D.Watch and wait with follow up
imaging
E. Surgical Resection
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6. © 2016 Virginia Mason Medical Center
Follow up CT 01/2019
• RUL spiculated nodule, 2.3 x 1.7 x 1.6 cm
• LUL lobulated/spiculated 1.9x 1.6x 1.3 cm
• Additional stable 4mm, 2mm RUL nodule 6

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Multiple Pulmonary Nodule Algorithm
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As Compared to Solid Nodules
Solid <6mm Solid 6-8mm Solid >8mm Part- solid
Solitary No follow up
needed
Low risk:
CT 6-12 mo
High Risk:
CT at 6-12
mo, 18-24 mo
Low risk: Serial
CT at 3 mo, 12
mo, 24 mo
Med Risk: PET
High Risk:
Excise, +/- PET
<6mm: No follow up
6-8mm: CT at 3-6
mo, then qyear for 5
yrs
>8mm: PET
*Groundglass nodule
>6 mm: CT scan q2
years for 5 years
Multiple No follow up
needed
CT at 3-6 mo,
18-24 mo
CT at 3-6 mo,
18-24 mo
< 6mm: CT at 3-6 mo,
then no f/u
>6mm: varies
>8mm: resect
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If nodules are growing on follow up CT- biopsy vs. resect!

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Methods of Biopsy
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Nonsurgical Surgical
CT GuidedEndobronchial
Excisional
Biopsy

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Nonsurgical Methods of Biopsy
Endobronchial
• Transbronchial Biopsy
• 65-88% sensitive for large central
lesions, dropping to 34% for <2cm
peripheral lesions
• Radial endobronchial US Guided TBB
• 73-85% sensitive, declines with size
<20mm (71%), peripheral location
(56%)
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Nonsurgical Methods of Biopsy
CT Guided biopsy
• Transthoracic needle biopsy >90%
sensitive, >99% specific, lowering
with nodules <6mm
• Risk of PTX if needle must cross
fissure
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PET CT 02/2019
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Excisional Biopsy
• Appropriate if patient is appropriate
surgical candidate, >65% chance of
malignancy
• Cardiac workup
• PFT’s
• DLCO and FEV1 >60% - no issues
• FEV1 and DLCO 30-60% - increased
complication rate
• FEV1 or DLCO <30% - resection
contraindicated
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Types of Lung Resection
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Ms. M – Excisional Resection
on 3/11
Final Diagnosis
1. LEFT UPPER LOBE, SUBLOBULAR RESECTION:
Metastatic adenocarcinoma consistent with colonic origin.
A. Tumor size: 2 x 1.7 x 1.5 cm.
B. Distance to margin: 1 cm.
2. STATION 5:
One lymph node negative for malignancy (0/1).
3. 10L:
One lymph node negative for malignancy (0/1).
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Following surveillance CT’s and
surgical resection on the right, what is
the next recommended treatment
option?
A. Adjuvant Chemotherapy
B. Adjuvant Radiotherapy
C. Adjuvant Chemoradiotherapy
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Role of Adjuvant Therapies
Chemotherapy
• Formal recommendation of 6 months
of chemotherapy (i.e. FOLFOX)
• Despite studies being equivocal
Radiotherapy
• No formal recommendation
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Surgical Resection of Pulmonary
Metastases
Outcomes by tumor histology
• Colon – 35-70% 5 year survival (vs.
20% w/ chemo)
• Melanoma – 2-20% at 5 yr
• No data w/ checkpoint inhibtors
• Breast Cancer – 46% at 5 yr
• Sarcoma – 31-34% at 5 yr
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Summary
• Patients with multiple pulmonary nodules
<6mm do not need follow up, if larger will need
either imaging or biopsy
• Localized endobronchial and CT guided biopsy
are quite accurate but not always feasible
• Excision of pulmonary metastases 2/2 colon
cancer improves survival compared to
chemotherapy alone
• These patients should receive adjuvant
chemotherapy despite equivocal data
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MKSAP Question #5
A 72-year-old man is evaluated during a follow-up visit. He was
evaluated in the emergency department 2 weeks ago for the sudden
onset of chest pain. A CT scan was negative for pulmonary embolism
but demonstrated an 8-mm ground-glass nodule in the right upper
lobe. He has had no recurrence of chest pain. His history is
significant for hypertension treated with lisinopril.
Upon physical examination, vital signs are normal. The remainder of
the physical examination is normal. The patient undergoes follow-up
CT scans of his lung at 12 months and also at 2 years. The nodule is
unchanged.
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Which of the following is the most appropriate management of the lung nodule?
A Chest CT scans every 2 years for 5 years
B PET/CT scan
C Tissue sampling
D No further follow-up is needed

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Answer
#5
Educational Objective: Evaluate a subsolid solitary pulmonary nodule.
Key Point: Subsolid lung nodules 6-8 mm in size should be initially followed up at 6-12 months and then
every 2 years for 5 years because of the slow rate of growth if such masses are malignant.
The most appropriate management of the pulmonary nodule is to perform follow-up chest CT scanning
at 6-12 months and then every 2 years for 5 years, as recommended by the Fleischner Society
Guidelines. Nodules are classified as solid or subsolid. Subsolid nodules are either pure ground-
glass nodules (no solid component) or part-solid nodules (both ground-glass and solid
components). A ground-glass nodule is defined as a focal area of increased attenuation in the lung
through which normal parenchymal structures can still be seen. The classification of nodules helps in
the assessment of malignant potential (for example, adenocarcinoma is more likely to present as a
subsolid and part-solid nodule) and guides appropriate follow-up. This patient has a solitary pure
ground-glass subsolid nodule that is larger than 6 mm. Earlier guidelines recommended initial
follow-up at 3 months, but this was changed to 6-12 months because earlier follow-up is
unlikely to affect the outcome of these characteristically indolent lesions. The average doubling
time of subsolid, cancerous nodules typically is 3-5 years. Therefore, longer initial and total follow-up
intervals are recommended for subsolid nodules than for solid nodules.
Evaluation with a PET/CT scan would be recommended for a solid nodule that is greater than 8 mm in
size. This test most commonly uses fluorodeoxyglucose (FDG) as a metabolic marker to identify rapidly
dividing cells such as tumor cells and, to a lesser degree, any inflammatory lesion. A nodule that
demonstrates no FDG uptake is unlikely to be malignant. PET/CT imaging can also be used for staging a
cancer by determining the presence or absence of metastatic disease.
Tissue sampling would not be appropriate at this stage because the vast majority of these lesions are
not malignant.
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MKSAP Question #35
A 72-year-old woman is evaluated during a routine visit. She has a 30-pack-
year smoking history and quit 5 years ago. She has a history of mild COPD
and breast cancer diagnosed 15 years ago, currently in remission. A chest
radiograph from 5 years ago showed no signs of disease recurrence.
Medications are albuterol and tiotropium inhalers.
On physical examination, vital signs are normal. Lung examination reveals
prolonged expiration and diminished breath sounds throughout. The breast
examination is unremarkable.
A screening low-dose chest CT scan shows a peripheral 9-mm solid
pulmonary nodule in the left upper lobe and emphysema but no mediastinal
or hilar lymphadenopathy and no pleural effusion. A PET/CT scan using
fluorodeoxyglucose (FDG) is performed and the nodule is intensely
hypermetabolic. There is no evidence of distant uptake.
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Which of the following is the most appropriate management strategy?
A Bronchoscopy with biopsy
B Serial chest CT scans
C Surgical wedge resection
D Transthoracic needle aspiration

23. © 2016 Virginia Mason Medical Center
Answer
#35
Educational Objective: Evaluate a solitary pulmonary nodule in a patient at high risk for
malignancy.
Key Point: Patients with a solid indeterminate lung nodule larger than 8 mm and high probability of
malignancy should be staged using a PET/CT scan followed by definitive management.
Definitive treatment is recommended for this patient and, therefore, a surgical wedge resection is
appropriate. She has several risk factors for malignancy, including age, size of the nodule,
upper-lobe location of the nodule, smoking history, and history of malignancy. In addition, the
PET/CT scan showed fludeoxyglucose avidity, confirming the high probability of malignancy but without
evidence of distant metastasis. As with subcentimeter nodules, the availability of previous imaging of
the chest to assess the stability or growth of these lesions is helpful. An enlarging or new pulmonary
nodule warrants more aggressive evaluation with tissue diagnosis or excision depending on the nodule's
pretest probability of malignancy. The first step when evaluating a solid pulmonary nodule that is larger
than 8 mm is to estimate the probability of malignancy. This can be done either clinically or using
quantitative models and should place the patient in one of three categories: low probability (less than
5%), intermediate probability (5% to 65%), or high probability (greater than 65%). This is most useful
when nodules are 8-30 mm. If the lesion is larger than 30 mm, the likelihood of malignancy is so high
that it typically is resected; in contrast, when the lesion is smaller than 8 mm, the likelihood of
malignancy is low and the patient should undergo routine radiological surveillance with serial CT scans.
Biopsy of the nodule or a transthoracic approach is preferred when the probability of
malignancy is intermediate (5% to 65%) and would not be appropriate for this patient with
a hypermetabolic nodule on PET/CT scan suggesting a high probability of malignancy.
Furthermore, the sampling procedure is chosen according to size and location of the nodule, availability,
and local expertise. Typically, peripheral nodules are sampled using CT-guided transthoracic needle
aspiration, and more central lesions are sampled using bronchoscopic techniques. This lesion is
described as peripheral.
Radiologic surveillance with serial CT scans is preferred if the probability of malignancy is low (less than
5%).
This patient's lung nodule is highly suspicious for malignancy on CT/PET scan so sampling with CT-
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