Mills-Peninsula Cancer Care Symposium - Clay H. Napper, M.D.

2. Low Dose CT
Lung Cancer
Screening
Update
2015
Clay H. Napper, M.D.

3. LET’S START OFF
WITH A TEST

4. We’re going to look at some
radiographs to see if we
can detect lung cancer.

6. ENEMY
• Easy
• Even without
the
annotations.

7. ???

8. THERE IS A 1.2 CM
LUNG CANCER IN
THE RIGHT LOWER
LOBE

9. O

10. It is
imperceptibl
e

11. Facts Regarding Chest
Radiographs
– Chest radiographs are limited in sensitivity
– Lesions are rarely seen if < 1 cm
– Lesions are reliably seen ONLY if > 2.5 cm
– Many lung cancers are not detected by CXR until
they are advanced stage, often with nodal
involvement and distant metastases.

12. Facts Regarding Chest
Radiographs
– Chest radiographs are limited in sensitivity
– Lesions are rarely seen if < 1 cm
– Lesions are reliably seen ONLY if > 2.5 cm
– Many lung cancers are not detected by CXR until
they are advanced stage, often with nodal
involvement and distant metastases.

13. Facts Regarding Chest
Radiographs
– Chest radiographs are limited in sensitivity
– Lesions are rarely seen if < 1 cm
– Lesions are reliably seen ONLY if > 2.5 cm
– Many lung cancers are not detected by CXR until
they are advanced stage, often with nodal
involvement and distant metastases.

14. Facts Regarding Chest
Radiographs
– Chest radiographs are limited in sensitivity
– Lesions are rarely seen if < 1 cm
– Lesions are reliably seen ONLY if > 2.5 cm
– Many lung cancers are not detected by CXR until
they are advanced stage, often with nodal
involvement and distant metastases.

15. Facts Regarding Chest
Radiographs
–Many lung cancers are not detected by
CXR until they are advanced stage,
often with nodal involvement and distant
metastases.

16. So if CXR can’t
reliably detect
small lung cancers
at an early,
treatable stage,…

17. So if CXR can’t
reliably detect
small lung cancer
at an early,
treatable stage,…
Shouldn’t we
come up with a
more reliable
screening tool?

18. Low
Dose
Computed
Tomography

19. Low
Dose
Computed
Tomography
LDCT

20. O
Remember
the 1.2 cm
RLL nodule?

21. Remember
the 1.2 cm
RLL nodule?
Imperceptible
on CXR…

22. O
Plain as day
by LDCT

23. What we know and what we
have known for a long time:

24. What we know and what we
have known for a long time.
1. Lung Cancer is not rare.

25. Projected New Lung Cancer
Diagnoses in the United States
for 2015
Lung Cancer Diagnoses: > 220,000
Men: > 115,000
Women: > 105,000
Lung Cancer Deaths: >155,000
Men: > 86,000
Women: >71,000

26. What we know and have known
for a long time.
2. Lung cancer is common. It is the
second most common cancer
diagnosis for women and men in
the United States.

27. What we know and have known
for a long time.
2. Lung cancer is common.
It is the second most common
cancer diagnosis for women and
men in the United States.

28. 2015 Estimated U.S. New Cancer Diagnoses
in Men and Women
Prostate 26% 29% Breast
Lung and Bronchus 14% 13% Lung and Bronchus
Colon and Rectum 8% 8% Colon and Rectum
Urinary Bladder 7% 7% Uterine Corpus
Melanoma 5% 6% Thyroid
NHL 5% 4% NHL
Kidney & Renal Pelvis 5% 4% Melanoma
Oral Cavity &Pharynx 4% 3% Pancreas
Leukemia 4% 3% Leukemia
Liver and Biliary 3% 3% Kidney & Renal Plvis
All other sites 23% 23% All other sites
MEN WOMEN

29. What we know and what we
have known for a long time:
• Lung cancer is the second most common
cancer in both women and men
3. LUNG CANCER IS DEADLY
• The leading cause of lung cancer in both
men and women is first hand smoke.

30. Projected Lung Cancer Deaths
in the United States for 2015
Lung Cancer Deaths: >157,000
Men: > 86,000
Women: >71,000

31. Projected Lung Cancer Deaths
in the United States for 2015
Lung cancer is currently the leading
cause of cancer deaths for both women
and men in the United States

32. 2015 Estimated U.S. Cancer Death in Men and Women
Lung & bronchus 28% 26% Lung & bronchus
Prostate 9% 15% Breast
Colon and Rectum 8% 9% Colon & rectum
Pancreas 7% 7% Pancreas
Leukemia 5% 5% Ovary
Liver and Biliary 5% 4% Leukemia
Esophagus 4% 4% NHL
NHL 4% 4% Uterine corpus
Urinary Bladder 4% 3% Liver and Biliary
Kidney 3% 2% Brain/CNS
All other sites 23% 23% All other sites
MEN WOMEN

33. What we know and have known
for a long time
1. Lung cancer is not uncommon
2. Lung cancer is common
3. Lung cancer is deadly
4. Smoking cigarettes causes
lung cancer.

34. What we know and have known
for a long time
1. Lung cancer is not uncommon
2. Lung cancer is common
3. Lung cancer is deadly
4. The number one cause of
lung cancer is first hand
smoke.

36. Smoking Cigarettes Kills

37. Tobacco and
Lung Cancer
Risk
– Lung Cancer is the leading cause of cancer death in
both men and women.
– 85% of lung cancer in the United states can
be directly related to smoking.
– There is a large population of smokers in the United
States.
– There are approximately 60 million current smokers
and 30 million former smokers in the United States

38. Tobacco and
Lung Cancer
Risk
– Lung Cancer is the leading cause of cancer death in
both men and women.
– 85% of lung cancer in the United states can be directly
related to smoking.
– There is a large population of smokers in the United
States.
– There are approximately 60 million current smokers
and 30 million former smokers in the United States

39. Tobacco and
Lung Cancer
Risk
There are approximately
60 million current smokers
and
30 million former smokers
in the United States

40. Smoking Cigarettes Kills

41. Smoking Cigarettes Kills

42. In the U.S,
approximately
443,000 Deaths
will be
attributed to
cigarette
smoking this
year
129,000 Lung Cancer
126,000 Ischemic Heart
Disease
93,000 COPD
35,300 Other Cancers
15,900 Stroke
44,000 Other Diagnoses

43. Those are the issues

44. What should we do?

45. What should we do?
Campaign against smoking by providing
information and tools to help our patients
quit smoking and encourage them to stay
quit.
Establish an effective screening tool to
detect lung cancer early, at a stage when
treatment can be successful.

46. What should we do?
Campaign against smoking by providing
information and tools to help our patients
quit smoking and encourage them to stay
quit.
Establish effective screening tools to
detect lung cancer early, at a stage when
treatment can be successful.

47. History of Lung Cancer
Screening

48. Lung Cancer Screening
In the 1970’s and 1980’s randomized and
nonrandomized trials and retrospective studies
were performed using CXRs to try to screen for
early, treatable lung cancer.
None of these trial showed a survival benefit for
screening CXRs. Lung cancer death rates for
patients screened with an annual PA chest
radiograph were essentially equal to the lung
cancer death rates for patients who received no
screening at all.

49. Lung Cancer Screening
In the 1970’s and 1980’s randomized and
nonrandomized trials and retrospective studies
were performed using CXRs to try to screen for
early, treatable lung cancer.
None of these trial showed a survival benefit for
screening CXRs. Lung cancer death rates for
patients screened with an annual PA chest
radiograph were essentially equal to the lung
cancer death rates for patients who received no
screening at all.

50. Lung Cancer Screening
In the 1970’s and 1980’s randomized and
nonrandomized trials and retrospective studies
were performed using CXRs to try to screen for
early, treatable lung cancer.
None of these trial showed a survival benefit for
screening CXRs. Lung cancer death rates for
patients screened with an annual PA chest
radiograph were essentially equal to the lung
cancer death rates for patients who received
no screening at all.

51. Lung Cancer Screening
In the 1980’s with the development of CT imaging,
it became apparent that some very small lung
nodules could be reliably detected, and there was
hope that CT screening for lung cancer might be
an effective tool some day.

52. Lung Cancer Screening
In the 1980’s with the development of CT imaging,
it became apparent that some very small lung
nodules could be reliably detected and that CT
screening for lung cancer might be an effective
tool some day.
But CT imaging was not yet widely available, and it
was neither time nor cost efficient.

53. Lung Cancer Screening
In the 1990’s, with the advent of more available
and faster CT scanners, some nonrandomized
trials and retrospective analyses showed that CT
could indeed detect early, treatable lung cancer.

54. Lung Cancer Screening
In the 1990’s some nonrandomized trials and
retrospective analyses showed that CT could
indeed detect early, treatable lung cancer.
However, there had been no large, randomized
clinical trials to absolutely prove the survival
benefits of lung cancer screening with CT

55. Lung Cancer Screening
• Then, in the early 2000’s, several large
trials were crafted to prove the efficacy of
CT for lung cancer screening.
I-ELCAP Early Lung Cancer Action Program
MPHS was a participant
NLST National Lung Screening Trial

56. Lung Cancer Screening
• Then, in the early 2000’s, several large
trials were crafted to prove the efficacy of
CT for lung cancer screening.
I-ELCAP Early Lung Cancer Action Program
MPHS was a participant
NLST National Lung Screening Trial

57. Lung Cancer Screening
• Then, in the early 2000’s, several large
trials were crafted to prove the efficacy of
CT for lung cancer screening.
I-ELCAP Early Lung Cancer Action Program
MPHS was a participant
NLST National Lung Screening Trial

58. I-ELCAP
• Non-randomized trial involving 31,000
patient screened with LDCT that showed
significant 10 year survival benefit due to
detection of small lung cancers at an early
stage.
• Criticized for being non-randomized

59. I-ELCAP
• Non-randomized trial involving 31,000
patient screened with LDCT that showed a
significant 10 year survival benefit due to
detection of small lung cancers at an early
stage.
• Criticized for being non-randomized

60. NLST
Randomized trial beginning in 2002 studying
53,454 subjects, randomized to be screened
with either annual LDCT or annual CXR for
3 years.
The patients were then followed clinically for
an additional 3.5 years.
The goal was to prove a survival benefit of
screening with LDCT

61. NLST
Randomized trial beginning in 2002 studying
53,454 subjects, randomized to be screened
with either annual LDCT or annual CXR for
3 years.
The patients were then followed clinically for
an additional 3.5 years.
The goal was to prove a survival benefit of
screening with LDCT

62. NLST
Randomized trial beginning in 2002 studying
53,454 subjects, randomized to be screened
with either annual LDCT or annual CXR for
3 years.
The patients were then followed clinically for
an additional 3.5 years.
The goal was to prove a survival benefit of
screening with LDCT

63. NLST
In November of 2010, the NLST closed
early because the study had reached its
endpoint.
There was evidence of a 20% lung cancer
mortality reduction using LDCT vs CXR.
There was also evidence of a 6.7 % all
cause mortality reduction.

64. NLST
In November of 2010, the NSLT was closed
early because the study had reached its
endpoint.
There was evidence of a 20% lung cancer
mortality reduction using LDCT vs. CXR
There was evidence of a 6.7 % all cause
mortality reduction (including additional findings such as
coronary artery disease, thyroid cancer, renal cancers).

65. NLST
It was shown that screening for lung cancer
with LDCT could prevent one lung cancer
death for every 320 patients screened.

66. NSLT
It was shown that screening for lung cancer
with LDCT could prevent one lung cancer
death for every 320 patients screened.
In comparison, it takes 1339 individuals
screened with mammography to prevent one
breast cancer death.
For flexible colonoscopy it takes 817
screened patients to prevent one colorectal
cancer death.

67. NSLT
It was shown that screening for lung cancer
with LDCT could prevent one lung cancer
death for every 320 patients screened.
In comparison, it takes 1339 individuals
screened with mammography to prevent one
breast cancer death.
It takes 817 patients screened with flexible
colonoscopy to prevent one colorectal
cancer death.

68. NLST
The original results showing the survival
benefit of LDCT screening for lung cancer
were published in the NEJM in August 2011
In November 2011, an article outlining the
cost effectiveness of LDCT was published in
the NEJM siting a cost of $81,000 per QALY
gained.

69. NLST
The original results showing the survival
benefit of LDCT screening for lung cancer
were published in the NEJM in August 2011
In November 2011, an article outlining the
cost effectiveness of LDCT was published in
the NEJM, siting a cost of $81,000 per
QALY gained. (similar to or less than many other currently used
screening tools)

70. NLST
In November 2011, an article outlining the
cost effectiveness of LDCT was published in
the NEJM siting a cost of $81,000 per QALY
gained.
In the second article, it stated that the final
costs of a LDCT lung cancer screening
program could be significantly decreased
with only modest changes to the
assumptions made in the original study .

71. USPSTF
December 2013 U.S. Preventative Services
Task Force issued a recommendation of
screening for lung cancer with LDCT with
criteria only slightly modified from NLST:
55-80 years of age
30-pack-year (or greater) smoking history
Current smoker or quit smoking within the
past 15 years.
Asymptomatic (no signs/sxs of lung cancer)

72. USPSTF
December 2013 U.S. Preventative Services Task Force
issued a recommendation of screening for lung cancer
with LDCT with criteria only slightly modified from NSLT:
Adults 55-80 years of age
30-pack-year (or greater) smoking history
Current smoker or quit smoking within the
past 15 years.
Asymptomatic (no signs/sxs of lung cancer)

73. USPSTF
December 2013 U.S. Preventative Services Task Force
issued a recommendation of screening for lung cancer
with LDCT with criteria only slightly modified from NSLT:
Adults 55-80 years of age
30-pack-year (or greater) smoking history
Current smoker or quit smoking within the
past 15 years.
Asymptomatic (no signs/sxs of lung cancer)

74. USPSTF
December 2013 U.S. Preventative Services Task Force
issued a recommendation of screening for lung cancer
with LDCT with criteria only slightly modified from NSLT:
Adults 55-80 years of age
30-pack-year (or greater) smoking history
Current smoker or quit smoking within
the past 15 years.
Asymptomatic (no signs/sxs of lung cancer)

75. USPSTF
December 2013 U.S. Preventative Services Task Force
issued a recommendation of screening for lung cancer
with LDCT with criteria only slightly modified from NSLT:
Adults 55-80 years of age
30-pack-year (or greater) smoking history
Current smoker or quit smoking within the
past 15 years.
Asymptomatic (no signs/sxs of lung cancer)

76. USPSTF
The recommendation was issued with a
Grade B favorable rating:

77. USPSTF
The recommendation was issued with a
Grade B favorable rating:
“There is either a high certainty that the net
benefit of screening is positive
Or
There is a moderate certainty that the net
benefit of screening is substantial.”

78. USPSTF
The recommendation was issued with a
Grade B favorable rating.
Under the Affordable Care Act (ACA)
private insurers must provide coverage for
LDCT lung screening to qualified patients,
and the screening must be provided
without a co-payment

79. USPSTF did not make a
statement regarding CMS

80. CMS
• In March 2015 (15 months later), Centers
for Medicare and Medicaid Services
approved similar coverage (with slight
modifications) for qualifying Medicare and
Medicaid patients.

81. CMS
• In March 2015 (15 months later), Centers
for Medicare and Medicaid Services
approved similar coverage (with slight
modifications) for qualifying Medicare and
Medicaid patients.
• According to some, the most important
news in Radiology this year.

82. Let’s Review

83. LDCT – Who do we screen?

84. LDCT – Who do we screen?
• First, we try to adhere to USPSTF
guidelines:

85. LDCT – Who do we screen?
• First, we try to adhere to USPSTF
guidelines:
• Adults age 55-80

86. LDCT – Who do we screen?
• First, we try to adhere to USPSTF
guidelines:
• Adults age 55-80
• 30-pack-year (or greater) smoking history

87. LDCT – Who do we screen?
• First, we try to adhere to USPSTF
guidelines:
• Adults age 55-80
• 30-pack-year (or greater) smoking history
• Current smoker or having quit smoking
within the last 15 years.

88. LDCT – Who do we screen?
• First, we try to adhere to USPSTF
guidelines:
• Adults age 55-80
• 30-pack-year (or greater) smoking history
• Current smoker or having quit smoking
within the last 15 years.
• Asymptomatic – meaning without signs or
symptoms suggestive of lung cancer

89. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

90. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

91. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

92. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

93. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

94. LDCT – Who do we screen?
We also make allowances for patients nearly
meeting criteria who also possess another
known risk factor as laid out in the NCCN
guidelines, including:
• Personal history of cancer
• Family history of lung cancer
• History of asbestos exposure
• History of radon exposure
• Dx of COPD or Pulmonary Fibrosis

95. LDCT – Who do we screen?
Age 55-80
30-pack-year (or greater) smoking history
Current smoker or quit smoking within the last 15 years.
Without current signs or symptoms suggestive of lung cancer
Of the 60 million current smokers and
30 million former smokers in the U.S.,
somewhere between 7 million and 10
million individuals qualify for screening
with LDCT

96. LDCT – How is the study
performed?
• Simple for the patient
• No oral or intravenous contrast.
• Time in the Radiology Department is
usually less than an hour spent mostly
checking in, changing into a gown and
being escorted to and positioned on the
CT scanner.
• Actual scan time is 3-7 seconds, an easy
breath hold for almost all patients.

97. LDCT – How is the study
performed?
• Simple for the patient
• No oral or intravenous contrast.
• Time in the Radiology Department is
usually less than an hour spent mostly
checking in, changing into a gown and
being escorted to and positioned on the
CT scanner.
• Actual scan time is 3-7 seconds, an easy
breath hold for almost all patients.

98. LDCT – How is the study
performed?
• Simple for the patient
• No oral or intravenous contrast.
• Time in the Radiology Department is
usually less than an hour spent mostly
checking in, changing into a gown and
being escorted to and positioned on the
CT scanner.
• Actual scan time is 3-7 seconds, an easy
breath hold for almost all patients.

99. LDCT – How is the study
performed?
• Simple for the patient
• No oral or intravenous contrast.
• Time in the Radiology Department is
usually less than an hour spent mostly
checking in, changing into a gown and
being escorted to and positioned on the
CT scanner.
• Actual scan time is 3-7 seconds, an easy
breath hold for almost all patients.

100. LDCT – How is the study
performed?
The actual scan time is 3-7 seconds
(an easy breath hold for almost all patients)

101. LDCT – How is the study
performed?
• The examination is performed with a low
dose protocol using the lowest radiation
dose possible to obtain a diagnostic scan.
• Radiation dose from a Low Dose CT falls
in the range of 0.61 – 1.5 mSv

102. LDCT – How is the study
performed?
• Radiation dose from a LDCT falls in the
range of 0.61 – 1.5 mSv

103. LDCT – How is the study
performed?
• Radiation dose from a LDCT falls in the
range of 0.61 – 1.5 mSv
What does that mean?

104. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
– For reference, the background average
annual radiation dose in the U.S. is
approximately 3.1 mSv
– Background radiation dose is affected by
terrestrial and celestial sources of background
radiation

105. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
– For reference, the background average
annual radiation dose in the U.S. is
approximately 3.1 mSv
– Background radiation dose is affected by
terrestrial and celestial sources of background
radiation

106. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
• The atmosphere offers some protection
from celestial radiation; so living at lower
altitude has an intrinsically protective
effect and reduces our dose of
background radiation.

107. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
• Living at lower altitude results in a lower
annual background radiation dose.

108. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
• The difference in annual background
radiation dose between living in San
Francisco (at sea level) and living in
Denver (mile high) is approximately
1.5 mSv

109. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
• The difference in annual background
radiation dose between living in San
Francisco (at sea level) and living in
Denver (mile high) is approximately
1.5 mSv

110. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?

111. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
•The dose is very low.

112. Radiation dose from the LDCT falls in
the range of 0.61 – 1.5 mSv
• What does that mean?
•The dose is very low.
•The dose is less than
background differences between
living in Denver and living in San
Francisco.

113. LDCT – How is the study
interpreted and reported?
• We use LungRADS structured reporting
and guidelines for recommendations
regarding followup and treatment.

114. LDCT – How is the study
interpreted and reported?
• We use LungRADS structured reporting
and guidelines for recommendations
regarding followup and treatment.

115. LungRADS
• LungRADS was devised along a
framework similar to BIRADS, the Breast
Imaging reporting system that has been in
use for over 20 years.

116. LungRADS
• To determine the significance of detected
lung nodules and to determine the
appropriate surveillance or action needed,
LungRADS attends to :
• (1) nodule size
• (2) nodule consistency
• (3) nodule stability

117. LungRADS
• To determine the significance of detected
lung nodules and to determine the
appropriate surveillance or action needed,
LungRADS attends to :
• (1) nodule size
• (2) nodule consistency
• (3) nodule stability

118. LungRADS
• To determine the significance of detected
lung nodules and to determine the
appropriate surveillance or action needed,
LungRADS attends to :
• (1) nodule size
• (2) nodule consistency
• (3) nodule stability

119. LungRADS
• To determine the significance of detected
lung nodules and to determine the
appropriate surveillance or action needed,
LungRADS attends to :
• (1) nodule size
• (2) nodule consistency
• (3) nodule stability

120. LungRADS
• (1) nodule size
– Larger nodules are more concerning than
smaller nodules
• Smaller nodules are more likely to be
postinflammatory or benign

121. LungRADS
• (2) nodule consistency

122. LungRADS
• (2) nodule consistency
– Solid
– Part solid
– Non-solid (ground glass)
• The more solid a nodule or the larger the solid
component of a nodule, the more worrisome the
finding

123. LungRADS
• (3) nodule stability
– Stability is a marker of benignity
• Growing or changing nodules or nodules that have
newly developed since previous imaging are more
concerning

124. LungRADS
• (3) nodule
stability
20132015

125. LungRADS
• (3) nodule
stability
20132015
Adenocarcinoma
in situ

126. LungRADS
• (3) nodule
stability
20132015
Adenocarcinoma
in situ
Minimally invasive
adenocarcinoma

127. LungRADS
• LungRADS categorizes the findings of a
LDCT lung screening examination with a
numeric value (0 to 4, increasing in level of
concern) with a corresponding established
recommendation for followup imaging or
other action.

128. reported?BASIC CHART
showing
LungRADS
categories and
corresponding
recommendations

129. Complete Chart including nodule size, consistency and stability

130. LungRADS Categories

131. LungRADS
• CATEGORY 0: “INCOMPLETE”

132. LungRADS
• CATEGORY 0: “INCOMPLETE”
– Images degraded by motion
– The region of interest is not entirely included

133. LungRADS
• CATEGORY 0: “INCOMPLETE”
– Images degraded by motion
– The region of interest is not entirely included
PATIENT NEEDS TO BE RECALLED FOR
COMPLETION OF IMAGING

134. LungRADS
• CATEGORY 1: “NEGATIVE”

135. LungRADS
• CATEGORY 1: “NEGATIVE”
– EITHER NO LUNG NODULES OR ONLY
DEFINITELY BENIGN NODULES
(granulomas, hamartomas, etc.)

136. LungRADS
• CATEGORY 1: “NEGATIVE”
– EITHER NO LUNG NODULES OR ONLY
DEFINITELY BENIGN NODULES
(granulomas, hamartomas, etc.)
FOLLOWUP LDCT IN ONE YEAR

137. LungRADS
• CATEGORY 2: “BENIGN”

138. LungRADS
• CATEGORY 2: “BENIGN”
– VERY SMALL NODULES (<6mm) OR
NODULES THAT ARE KNOWN TO BE
STABLE OR DECREASING IN SIZE

139. LungRADS
• CATEGORY 2: “BENIGN”
– SMALL LUNG NODULES AND NODULES
WITH PROVEN STABILITY
FOLLOWUP LDCT IN ONE YEAR

140. LungRADS
• CATEGORY 3: “PROBABLY BENIGN”

141. LungRADS
• CATEGORY 3: “PROBABLY BENIGN”
– SLIGHTLY LARGER BUT STILL SMALL
NODULES WITHOUT PROVEN STABILITY

142. LungRADS
• CATEGORY 3: “PROBABLY BENIGN”
– SLIGHTLY LARGER BUT STILL SMALL
NODULES WITHOUT PROVEN STABILITY
SHORTER TERM FOLLOWUP LDCT IN
6 MONTHS
To establish stability or regression and exclude lesion growth

143. LungRADS
• CATEGORY 4: “SUSPICIOUS”

144. LungRADS
• CATEGORY 4: “SUSPICIOUS”
– LARGER NODULES OR SUSPICIOUS
APPEARING NODULES WITHOUT PROVEN
STABILITY

145. LungRADS
• CATEGORY 4: “SUSPICIOUS”
– LARGER NODULES OR SUSPICIOUS
APPEARING NODULES WITHOUT PROVEN
STABILITY
3-MONTH CT FOLLOWUP, ADDITIONAL
CHARACTERIZATION WITH PET-CT OR
TISSUE SAMPLING
(BRONCHOSCOPY, PERCUTANEOUS NEEDLE BIOPSY,
EXCISIONAL BIOPSY, VATS, MEDIASTINOSCOPY)

146. LungRADS
• CATEGORY 4: “SUSPICIOUS”
The vast majority of these findings are
followed with imaging alone.

147. LungRADS
• CATEGORY 4: “SUSPICIOUS”
The vast majority of these findings are
followed with imaging alone.
Only about 1% of initial CT lung screens result
in a need for tissue sampling.

148. What Constitutes a NEGATIVE
Screen?

149. What Constitutes a NEGATIVE
Screen?
• Any LDCT for which annual LDCT
followup is recommended

150. What Constitutes a NEGATIVE
Screen?
• Any LDCT for which annual LDCT
followup is recommended
• LungRADS categories 1 and 2
• “Negative” or “Benign”

151. What Constitutes a NEGATIVE
Screen?
• Any LDCT for which annual LDCT
followup is recommended
• LungRADS categories 1 and 2
• “Negative” or “Benign”
• >90% of all initial screens

152. What Constitutes a Positive Screen?

153. What Constitutes a Positive Screen?
• Any LDCT finding for which follow up other
than annual screening is recommended.

154. What Constitutes a Positive Screen?
–LungRADS 3 “Probably Benign”
• (6 mos f/u LDCT)
• ~5% of initial screens
–LungRADS 4 “Suspicious”
• (3 mos f/u, PET-CT, and/or tissue
sampling)
• ~4% total, most being followed with
LDCT in 3 mos or with CT or PET-CT

155. What Constitutes a Positive Screen?
–LungRADS 3 “Probably Benign”
• (6 mos f/u LDCT)
• ~5%
–LungRADS 4 “Suspicious”
• (3 mos f/u CT, PET-CT, and/or tissue
sampling)
• ~4% of initial screens, most being followed
with imaging

156. What Constitutes a Positive Screen?
–LungRADS 4 “Suspicious”
• (3 mos f/u, PET-CT, and/or tissue
sampling)
• ~4% total, most being followed with
LDCT in 3 mos or with CT or PET-CT
• Only approximately 1% of initial
screenings result in a recommendation
for tissue sampling. The rest are further
evaluated with imaging alone.

157. Practice Parameters for the
performance and interpretation of
LDCT for Lung Cancer Screening
Established by ACR and STR
Designated Lung Screening Center under CT
accreditation program for equipment, imaging
protocols, and interpreting radiologists.
LungRADS structured reporting and management
tool
Participate in a Lung Cancer Screening Registry
Follow patient selection guidelines

158. Practice Parameters were established
by agreement between many interested
organizations

159. Practice Parameters for the
performance and interpretation of
LDCT for Lung Cancer Screening
Screening should be performed at a designated
Lung Screening Center under a CT accreditation
program that specifies CT equipment, imaging
protocols, and experience and skills of the
interpreting radiologists.
LungRADS structured reporting and management
tool should be employed
Participate in a Lung Cancer Screening Registry
Follow patient selection guidelines

160. Practice Parameters for the
performance and interpretation of
LDCT for Lung Cancer Screening
Screening should be performed at a designated
Lung Screening Center under a CT accreditation
program for equipment, imaging protocols, and
interpreting radiologists.
LungRADS structured reporting and management
tool should be employed for reporting and decision
making.
Participate in a Lung Cancer Screening Registry
Patient selection guidelines should be followed

161. Practice Parameters for the
performance and interpretation of
LDCT for Lung Cancer Screening
Screening should be performed at a designated
Lung Screening Center under a CT accreditation
program for equipment, imaging protocols, and
interpreting radiologists.
LungRADS structured reporting and management
tool
The screening center should participate in a Lung
Cancer Screening Registry
Patient Selection guidelines should be followed

162. Practice Parameters for the
performance and interpretation of
LDCT for Lung Cancer Screening
Screening should be performed at a designated
Lung Screening Center under a CT accreditation
program for equipment, imaging protocols, and
interpreting radiologists.
LungRADS structured reporting and management
tool
The screening center should participate in a Lung
Cancer Screening Registry
Patient selection guidelines should be followed

163. LDCT: Referring Provider
What are the roles of the referring provider?

164. LDCT: Referring Provider
• Complete an order for LDCT
• Affirm the patient’s eligibility (usually a
checkbox form)
• Provide shared decision making with the
patient prior to the first screening LDCT

165. LDCT: Referring Provider
• Complete an order for LDCT
• Affirm the patient’s eligibility (usually a
checkbox form)
• Provide shared decision making with the
patient prior to the first screening LDCT

166. LDCT: Referring Provider
• Complete an order for LDCT
• Affirm the patient’s eligibility (usually a
checkbox form)
• Provide shared decision making with the
patient prior to the first screening LDCT

167. LDCT: Shared Decision Making
• What is shared decision making?

168. LDCT: Shared Decision Making
• Information sharing between the patient
and physician regarding the potential
benefits and harms of undergoing LDCT.
Benefits:
• Detecting early lung cancer in it’s treatable
stages.
• Detecting other unknown treatable findings
• Encouragement of smoking cessation

169. LDCT: Shared Decision Making
• Information sharing between the patient
and physician regarding the potential
benefits and harms of undergoing LDCT.
Benefits:
• Detecting early lung cancer in it’s treatable
stages.
• Detecting other treatable findings
• Encouragement of smoking cessation

170. LDCT: Shared Decision Making
• Information sharing between the patient
and physician regarding the potential
benefits and harms of undergoing LDCT.
Benefits:
• Detecting early lung cancer in it’s treatable
stages.
• Detecting other treatable findings
• Encouragement of smoking cessation

171. LDCT: Shared Decision Making
• Information sharing between the patient
and physician regarding the potential
benefits and harms of undergoing LDCT.
Benefits:
• Detecting early lung cancer in it’s treatable
stages.
• Detecting other treatable findings
• Encouragement of smoking cessation

172. LDCT: Shared Decision Making
Potential Harms:
•Radiation exposure (as little as possible --
similar to the difference between living in SF
versus Denver for a year
•False positive results – findings that require
additional follow up, imaging, or tissue
sampling that do not eventually prove to be
lung cancer.

173. LDCT: Shared Decision Making
Potential Harms:
•Radiation exposure (as little as possible --
similar to the difference between living in SF
versus Denver for a year
•False positive results – findings that require
additional follow up, imaging, or tissue
sampling that do not eventually prove to be
lung cancer.

174. LDCT: Shared Decision Making
Potential Harms:
•Overdiagnosis – the phenomenon of
detecting a lung cancer that is so indolent
that it would not go on to result in lung
cancer death if it remained undetected and
untreated.

175. LDCT: Shared Decision Making
Several excellent tools provide guidance
regarding shared decision making and
provide patients with useful information
regarding potential benefits and harms of
lung cancer screening with LDCT

176. LDCT: Shared Decision Making
Should I Screen?
http://www.shouldiscreen.com/
Web based decision making aid with a risk
calculator that patients can use to determine their
risk of developing lung cancer based on factor
including age, smoking history, personal cancer
history, family lung cancer history, history of COPD
or pulmonary fibrosis

177. LDCT: Shared Decision Making
Should I Screen?
http://www.shouldiscreen.com/
Web based decision making aid that describes
lung cancer, lung cancer screening, the dangers of
smoking and provides a risk calculator that
patients can use to determine their risk of
developing lung cancer based on their age and
personal risk factor profile.

178. Should I Screen?

179. NCCN Lung Cancer
Screening Booklet

180. LDCT: Shared Decision Making
http://www.nccn.org/patients/guidelines/lung_s
creening/
Web based booklet provided by the National
Comprehensive Cancer Network that can be
navigated online or printed.
Provides patients with educational materials to help
inform them of the potential benefits and harms of
lung cancer screening with LDCT

181. LDCT: Shared Decision Making
http://www.nccn.org/patients/guidelines/lung_s
creening/
Web based booklet provided by the National
Comprehensive Cancer Network that can be
navigated online or printed.
Provides patients with educational materials to help
inform them of the potential benefits and harms of
lung cancer screening with LDCT

182. NCCN

183. What’s do we do next?
• Talk to your patients about smoking
cessation and help them decide if LDCT
screening for lung cancer is right for them
• Refer appropriate patients for LDCT at a
reputable, accredited screening facility.
• Stay informed.

184. What’s do we do next?
• Talk to your patients about smoking
cessation and help them decide if LDCT
screening for lung cancer is right for them
• Refer appropriate patients for LDCT at a
reputable, accredited screening facility.
• Stay informed.

185. What’s do we do next?
• Talk to your patients about smoking
cessation and help them decide if LDCT
screening for lung cancer is right for them
• Refer appropriate patients for LDCT at a
reputable, accredited screening facility.
• Stay informed.

186. What’s do we do next?
• Talk to your patients about smoking
cessation and help them decide if LDCT
screening for lung cancer is right for them
• Refer appropriate patients for LDCT at a
reputable, accredited screening facility.
• Stay informed. The landscape is changing
daily, and there new information and new
ideas are emerging all the time.

187. Low Dose CT
Lung Cancer
Screening
Update
2015
Clay H. Napper, M.D.

188. Thank
you for
your
attention

191. Stay Informed - Changing
Landscape
• Journal of the National Cancer Institute
– October 19, 2015 (hot off the press)
“CT lung cancer screening may benefit
even those with fewer than 30 pack-
years of smoking history.” After reviewing the
“records of more than 30,000 smokers and former smokers who participated in
the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) and
had smoking histories ranging from 20 to 29 pack-years,” researchers found that
“their risk of developing cancer was very similar to that of patients eligible for
screening in the National Lung Screening Trial (NLST), which focused on
individuals with smoking histories of 30 pack-years or more.”

192. Radiographic Differential Diagnosis
• Post-inflammatory granuloma (80%)
• Benign neoplasm (e.g. hamartoma)
• Pulmonary AVM
• Solitary lung metastasis
• Primary lung cancer
• Other miscellaneous nodules (nodular sarcoid,
rheumatoid nodule, pulmonary-renal syndrome granuloma,
bronchogenic cyst, hematoma, abscess, others…)

193. • Solitary pulmonary nodule
• Rates of Growth
– Volume doubling time for most bronchial /lung
carcinomas is 1-18 months.
– A 26% increase in diameter is equivalent to a
doubling in volume
• 5 mm --> 6.3 mm --> 7.7 mm
• 10 mm --> 12.6 mm --> 15
• For small lesions, growth may not be perceptible until the
tumor has doubled or even quadrupled in volume

194. • Solitary pulmonary nodule
• Rates of Growth
– Volume doubling time for most bronchial/lung carcinomas is 1-18
months.
– Volume doubling is equivalent to only a 26% increase
in diameter
For small lesions, growth may not be perceptible until
the tumor has doubled or even quadrupled in volume
• 5 mm --> 6.3 mm --> 7.7 mm
• 10 mm --> 12.6 mm --> 15

195. Applications
• Solitary pulmonary nodule: Percutaneous BX
• Risks of Percutaneous Biopsy
– Pneumothorax 20-25%
– Chest tube required 5-10%
– Hemoptysis 5%
– Malignant seeding 0.01%
– Air embolism 0.1%
– Death 0.2%