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Matthew Eric Callister



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    ES 02 - Diagnostic and Interventional Radiology in Lung Cancer: Update 2017 (ID 511)

    • Event: WCLC 2017
    • Type: Educational Session
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      ES 02.02 - The Fleischner Guideline / Lung-RADs (ID 7588)

      11:00 - 12:30  |  Presenting Author(s): Matthew Eric Callister

      • Abstract
      • Presentation
      • Slides

      Abstract:
      The Fleischner Society guidelines (most recently revised in 2017) [1,2] are the most referenced guidelines for management of pulmonary nodules detected incidentally on CT images. In 2014, the American College of Radiology produced the Lung-RADS assessment categories specifically to guide management of nodules detected by Low Dose CT screening for lung cancer [3]. Nodule management guidelines have also been published by the American College of Chest Physicians (ACCP) in 2013 [4] and the British Thoracic Society (BTS) in 2015 [5]. Whilst the Fleisher guidelines and Lung-RADS predominantly offer specific recommendations for interpretation of CT images and guidance for surveillance imaging, the ACCP and BTS guidelines in addition offer more proscriptive recommendations for ongoing investigation or treatment of larger nodules with PET-CT, biopsy techniques, and surgical/non-surgical treatment. There is much common ground between the four proposals. Most of the high quality evidence for nodule management comes from screening studies that only included patients at high risk of lung cancer, and there is an acknowledged paucity of evidence for guiding nodule management in patients with a lower background risk of cancer. There is agreement about the need to minimise radiation dose for CT surveillance for nodules, and an acknowledgement of the low likelihood of malignancy in small nodules detected through any route. All guidelines recognise that sub-solid nodules require a different management algorithm which incorporates a less interventional approach (acknowledging the more indolent nature of the tumours that these may represent) but by implication the need for longer follow-up before nodules can be deemed benign or harmless. Differences between the recommendations are summarised in Table 1. The size below which nodules can be ignored differs slightly between the guidelines. Lung-RADS recommends no intervention for nodules <6mm (or <4mm for new nodules) on the assumption that the patient continues with annual LDCT screening. Determining a threshold for discharge of small nodules detected out a screening program is of potentially greater significance, as a patient with a small malignant nodule discharged in this context is likely to have a poor outcome if that nodule subsequently presents as a symptomatic lung cancer. The Fleischner Society guidelines select a threshold of 1% lung cancer risk (roughly equating to 6mm diameter) below which surveillance is not routinely recommended (although is an option if the patient is high risk). The BTS guidelines base their discharge threshold of 80mm­[3] (5mm) on data from the NELSON screening trial which demonstrated this to be the threshold below which the presence of a nodule did not appear to increase the likelihood of subsequently diagnosed lung cancer above that seen in screening participants with no nodules [6]. More recent data from NELSON has suggested a different size threshold for nodules newly appearing during the screening process. New incident nodules above 27mm[3] appeared to confer an increased risk of cancer [7], and this is reflected in the Lung-RADS category 3 which suggests a 6 month surveillance scan for new incident nodules ≥4mm. When an incidentally detected nodule can be shown to be new compared to recent CT imaging, a lower threshold for ongoing surveillance is probably merited, although not currently recommended in the three relevant guidelines. The use of composite risk-prediction scores in guiding nodule management differs between the various guidelines. The Fleischner guidelines highlight the various risk factors to be considered when deciding management but do not recommend use of a risk prediction score. The ACCP guidelines recommend either qualitative assessment of the probability of malignancy, or quantitative assessment using a validated model (referencing the Mayo model [8]). The BTS guideline recommend use of the Pancan lung cancer risk calculator [9] to decide which nodules should be evaluated with PET-CT on the basis of a validation study in a UK population [10]. Subsequent studies from Australia and Denmark have also demonstrated the utility of the Pancan model in screening studies. The guidelines also differ in the extent to which they promote use of semi-automated volumetry. No reference to volumetry is made in Lung-RADS assessment categories. Both the Fleischner and BTS guidelines acknowledge the better reproducibility of volumetry over diameter measurements and the superior sensitivity in detecting growth. Both however highlight the need to use identical software versions if comparing nodule volumes between scans due to clearly demonstrated variability between different software programs/versions. The Fleischner guidelines comment that robust validated volumetry is not currently widely used hence continuing to base recommendations predominantly on caliper long and short-axis diameter measurements, whereas the BTS guidelines have strongly recommended volumetry in an attempt to drive uptake of this technology. The definition of what constitutes nodule growth also differs between the guidelines. Lung-RADS and the Fleischner guidelines define growth as an increase is diameter of >1.5mm and ≥2mm respectively, reflecting possible inaccuracy in smaller increments in size according to caliper measurements. The threshold of 25% change in volume recommended in the BTS guideline is based on the nodule management stategy used in both NELSON and UKLS. By way of comparison, nodule growth from 7mm to 9mm represents a 113% increase in volume (from 180mm[3] to 381mm[3]). All four guidelines/assessment categories have been published within the last 5 years, and there have been few validation studies published to date. Lung-RADS was compared to the National Comprehensive Care Network guidelines for lung cancer screening and was shown to increase the positive predictive value without increasing false-negative results. Prospective comparisons between these guidelines/approaches are needed to guide future practice.

      Fleischner [1,2] Lung-RADS [3] BTS [4] ACCP [5]
      Remit Incidentally detected nodules Screen-detected nodules Incidentally and screen-detected nodules Incidentally and screen-detected nodules
      Assessment of size Average of long & short axis diameter Average diameter Semi-automated volumetry As per Fleischner guidelines
      Threshold for discharge <6mm - optional follow-up below this size if high risk <6mm (revert to annual screen) <80mm[3] <5mm - optional follow-up below this size if high risk
      Selection of further investigation for larger nodules >8mm consider PET, PET-CT or biopsy ≥8mm PET-CT, biopsy or assess with Brock/Pancan score ≥8mm Brock/ Pancan score to guide PET-CT/other tests ≥8mm clinical judge-ment or validated model (e.g. Mayo)
      Assessment of growth Increase in size of ≥2mm Increase in size of >1.5mm Increase in volume of >25% Not specified
      Pure Ground Glass Nodules Surveillance only for 5 years duration Revert to annual screen (unless >20mm) Risk assess, but surveillance pref-erred (for 4 years) CT surveillance for 3 years
      Table 1: Summary of significant differences between nodule management strategies recommended by various guidelines/assessment categories Fleischner [1,2] Lung-RADS [3] BTS [4] ACCP [5] Remit Incidentally detected nodules Screen-detected nodules Incidentally and screen-detected nodules Incidentally and screen-detected nodules Assessment of size Average of long & short axis diameter Average diameter Semi-automated volumetry where possible As per Fleischner guidelines Threshold for discharge <6mm - optional follow-up below this size if high risk <6mm (revert to annual screen) <80mm3 <5mm - optional follow-up below this size if high risk Selection of further investigation for larger nodules >8mm - consider PET, PET-CT or biopsy ≥8mm - PET-CT, biopsy or assess with Brock/ Pancan score ≥8mm - Brock/ Pancan score to guide PET-CT/other tests ≥8mm - clinical judgement or validated model (e.g. Mayo) Assessment of growth Increase in size of ≥2mm Increase in size of >1.5mm Increase in volume of >25% Not specified Pure Ground Glass Nodules Surveillance only for 5 years duration Revert to annual screen (unless >20mm) Risk assess, but surveillance preferred (for 4 years) CT surveillance for 3 years References [1] MacMahon H, Naidich DP, Goo JM, et al. Guidelines for Management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology 2017;284:228-243 [2] Bankier AA, MacMahon H, Goo JM, et al. Recommendations for measuring pulmonary nodules at CT: a statement from the Fleischner Society. Radiology 2017, epub ahead of print. [3] American College of Radiology. Lung CT Screening Reporting and Data System (Lung-RADS). Available at : https://www.acr.org/Quality-Safety/Resources/LungRADS . Release date April 28, 2014, Accessed August 1, 2017. [4] Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e93s-e120S. [5] Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 2015;70:ii1-ii54 [6] Horeweg N, van Rosmalen J, Heuvelmans MA, et al. Lung cancer probability in patients with CT-detected pulmonary nodules: a pre-specified analysis of data from the NELSON trial of low-dose CT screening. Lancet Oncol. 2014;15:1332–41. [7] Walter JE, Heuvelmans MA, de Jong PA, et al. Occurrence and lung cancer probability of new solid nodules at incidence screening with low-dose CT: analysis of data from the randomised, controlled NELSON trial. Lancet Oncol. 2016;17:907-16. [8] Swensen SJ, Silverstein MD, Ilstrup DM, et al. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med 1997;157:849–55. [9] McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013;369:910–9. [10] Al-Ameri AMP, Malhotra P, Thygesen H, et al. Risk of malignancy in pulmonary nodules: a validation study of four prediction models. Lung Cancer 2015;89:27-30

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    WS 02 - IASLC Symposium on the Advances in Lung Cancer CT Screening (Ticketed Session SOLD OUT) (ID 631)

    • Event: WCLC 2017
    • Type: Symposium
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      WS 02.09 - Lung Cancer Guidelines (ID 10624)

      09:00 - 18:15  |  Presenting Author(s): Matthew Eric Callister

      • Abstract
      • Presentation

      Abstract not provided

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