0:01

We added some new additions in 2022

0:03

with atypical pulmonary cysts and cavitary nodules.

0:07

An area for which there's not a lot of evidence.

0:09

You will talk about this in the mastery course under the

0:12

section on cystic lesions.

0:14

And then we added some clarifications, nodules

0:17

that touch the pleural surface airway nodules,

0:20

nodule growth, introduce this new concept

0:23

of step management, reinforced what to do with findings

0:27

that could be infectious or inflammatory,

0:30

and talk about the S modifier for incidental findings.

0:34

So lung rads, uh,

0:35

will always be on the ACRs lung cancer screening resource

0:38

webpage as uh, downloadable.

0:41

I have a link to it on our PAX Workstation dashboard so

0:44

that it's easily accessible to all

0:46

of us when we're interpreting uh, lung cancer screening cts.

0:49

I was the inaugural chair of the Lung RADS committee

0:52

and continue to serve on that group.

0:54

But there are so many categories

0:56

and details that I always refer back to this,

0:58

particularly when I'm getting into the higher categories

1:01

of abnormal screens.

1:03

And we'll go into these in more detail

1:04

as we talk about these.

1:06

Uh, looking at cases later.

1:08

And we have positive screens, long RADS three, four a,

1:11

four B, and four x, which range from probably benign

1:15

to suspicious, very suspicious.

1:19

Um, that would have a more intense followup recommendation.

1:22

And you'll see in each category we have solid

1:25

part solid nod solid.

1:26

And now we have added cystic lesions.

1:30

Jux pleural nodules are a good one to talk about.

1:32

Um, it it's fairly brief

1:34

and that any nodule that is along any pleural surface

1:38

that meets the criteria for an intra pulmonary lymph node

1:42

and is under 10 millimeters can be called a negative screen.

1:46

Category two, whether they're along the mediastinal pleura,

1:49

the costal pleura or the diaphragmatic pleura.

1:51

And previously the pleural nodule criteria applied only

1:55

to peri fial nodules.

1:57

And there is now evidence from two studies looking at costal

2:01

and diaphragmatic pleural nodules

2:02

that we can treat them the same.

2:04

Typical inter pulmonary lymph nodes are bi convex,

2:08

triangular, angular and shape.

2:10

They abut pleural surfaces are smooth

2:13

and are under a centimeter

2:15

and these can now comfortably be called lung rats,

2:17

two negative screens no matter which pleural

2:19

surface they touch.

2:21

Whereas nodules that have acute angles

2:24

with the pleural surface are lobulated with acute angles

2:27

or ill-defined part solid

2:29

and like this nodule, all

2:32

of these will be considered abnormal screens

2:34

and do not meet the criteria for jux pleural nodules.

2:38

By having these criteria for jux pleural nodules,

2:41

we reduce the percentage of positive screens

2:43

by downgrading long RADS three cases to lung RADS two.

2:47

The cystic or cavitary nodule update is an important one.

2:51

There is much less evidence behind this.

2:53

So I would say there's more informed knowledge of practice

2:57

that is in this part of the

2:58

Guideline of recommendations in lung RADS compared

3:01

to the other nodule types

3:02

and we hope this will drive the collection

3:04

of more information in the future.

3:07

Endo bronchial nodules, um, some additional information

3:10

and clarification and now putting them

3:12

in the lung rads table.

3:13

They occur in about half a percent

3:15

of individuals undergoing lung cancer screening most resolve

3:19

on followup imaging and are simply benign secretions,

3:23

but sometimes they're not.

3:24

So we've included criteria on what to do with them

3:27

as they get larger, particularly when they get into the

3:30

segmental airways and are fixed

3:32

or larger airways

3:33

where these become higher level positive screens

3:36

for follow-up and management usually involving a

3:39

bronchoscopy at the largest airway sizes.

3:43

We've added some clarification for how to treat findings

3:46

that are infectious or inflammatory when interpreting lung

3:48

cancer screening cts.

3:50

These findings of infection are things you see day

3:53

to day when interpreting chest cts.

3:55

Ordinarily for patients who do have infection

3:58

but they confound our ability to give a screening result

4:01

because they cover up parts of the lung,

4:03

whether it's segmental or lower consolidation.

4:06

A nodule like this with surrounding ground glass,

4:09

perhaps an atypical form of infection

4:11

or somebody with multiple new nodules, ary nodules

4:15

or peri bronchial nodules perhaps aspiration.

4:18

These things all make it difficult

4:20

to clear a part of the lungs.

4:22

So we recommend calling infection things

4:25

that you think are infection.

4:26

Lung ran zero and doing a followup CT in one to three months

4:29

to be able to reassess that portion of the lung parenchyma.

4:33

The concept of step management I think is very important

4:37

and it really matches the follow-up that we're doing

4:40

for positive screens to the risk of cancer.

4:43

In the original versions of Lung rads,

4:45

if you had a lung RADS three or four A

4:48

and underwent a six month

4:50

or three month interim ct, if that CT was negative

4:54

with no growth, the recommendation was

4:56

to continue screening in a year and that didn't feel right

5:00

because the higher risk four a lesions were waiting 12

5:03

months as were the lower risk three lesions going

5:06

for 12 month follow up.

5:08

So our new schema is that if you have a long RADS three

5:12

or four A and you get an interim six

5:14

or three months CT, that instead of going all the way down

5:18

to long RADS two for everybody continuing annual screening,

5:21

you just step down one category at a time.

5:25

So in long RADS version 1.1, if you had a lung RADS three,

5:29

you would get a followup CT in six months

5:32

and then you would continue your screening calendar.

5:35

Now you're going to go to negative screen category two,

5:39

which means you go out to 12 months from

5:41

that stable interim exam.

5:44

A lung RADS four a CT

5:46

would normally get a three month interim ct.

5:49

And then after that return

5:51

to their annual screening calendar,

5:52

which was quite a ways out.

5:54

Now they go from long rats, four A

5:57

To long rats, three if it's stable,

5:59

and then if that's stable again to category two.

6:01

So we step people down by category

6:05

as they've had positive screens so

6:07

that we get closer management of the higher risk lesions

6:09

and the lower risk lesions go further out in time.

6:13

Similarly, we can use step management for four B

6:16

and four X lesions that have had their workup

6:19

and thought to be benign.

6:21

For example, they might have had a specific benign diagnosis

6:25

or a presumed benign diagnosis based on lack of tissue,

6:29

evidence of tumor or a negative PET scan.

6:32

And we don't want to step them all the way down from four B

6:36

to negative screen.

6:38

That would be taking some

6:39

of the highest risk lesions in WA waiting 12 months.

6:42

So once patients fall into this four B

6:45

or four X category where the lesion is thought to be benign

6:48

by workup, usually done by a pulmonary medicine physician,

6:51

then they step down to four A

6:54

and then they step down to three

6:56

before they go down to category two.

6:58

So we continue to watch them closely

7:00

and then extend that follow-up

7:02

until they get back into the annual

7:03

screening at 12 month mark.

7:06

Not wanting to miss a false negative cancer

7:09

after its initial workup.

7:11

There's lots of information available

7:13

to you on the 2022 Lung-RADS update.

7:17

The summary of changes for Lung-RADS version 2022 compared

7:21

to the earlier versions is available on the Lung-RADS

7:24

webpage at the A CR.

7:25

There are two publications in print.

7:28

Uh, one from the Lung-RADS committee itself

7:30

that was published in JACR recently

7:33

and one also published in Radiographics that go through

7:37

and explain the updates.

7:39

I think the one that's in JACR has a lot of detail

7:41

behind the thinking of the long rans committee

7:44

and why it decided to make the updates

7:46

where the evidence is strong

7:48

and where the evidence is combined with a lot

7:50

of expert wisdom as in the case of cystic nodules.

7:54

The modules in this course we will discuss,

7:56

include nodule types, look at them in a case-based format,

8:00

from solid parts, solid nonsolid, cystic to airway nodules,

8:04

as well as some of the important essential

8:06

findings in more detail.

8:08

Thanks so much for learning more about lung rats together

8:11

and an overview and what will be coming next

8:13

as we do our case-based review format.