0:00

On this lung cancer screening exam,

0:02

we have a 69-year-old man

0:06

and we're going to look through the lungs for evidence

0:08

of potential lung cancer as well

0:11

as any actual essential findings.

0:13

And as we quickly come to the left upper lobe apex,

0:15

we see a nodule in the left upper lobe.

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We magnify that up a little bit.

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It has a solid or denser component in the middle

0:24

and a thin rim of ground glass around it.

0:27

So this would be classified as a part solid nodule.

0:31

Uh, we can see on the soft tissue windows

0:33

that it doesn't have much dense soft tissue.

0:36

A solid, purely solid nodule of this size, uh,

0:39

would have a bigger visible footprint

0:42

on the soft tissue windows.

0:43

And this nodule measured approximately 11 millimeters

0:46

with a nine millimeter solid component.

0:49

And we're gonna try and take our calibers

0:51

and measure the solid component.

0:54

I think this can sometimes be very hard to determine

0:57

where the edge of the ground glass starts and stops

1:00

and the edge of the solid component starts and stops.

1:03

If you are managing a part solid nodule over time,

1:07

you wanna go back yourself

1:08

and make those measurements so that your measurement

1:10

of the solid component is in the same place over serial CT

1:13

exams and not take for granted

1:15

where the prior reader may have put the cursor.

1:18

It may have been their best estimation,

1:20

but it could be particularly challenging when you have

1:23

nodules where the ground glass,

1:24

the solid component look like they're blending together.

1:27

So you make your best estimate of where the density changes.

1:30

There are some software tools that will help you try

1:33

and measure nodule size and measure the solid

1:35

and part solid component,

1:36

but they too struggle when the density gradient

1:39

between the two areas is subtle as it is in this case.

1:43

First, we're gonna look throughout the remainder

1:45

of the chest for other pulmonary nodules,

1:48

lung parenchymal disease and incident findings.

1:53

As we come towards the lower lung in this patient,

1:55

they've got evidence of prior granulomas infection,

1:58

a nice solidly calcified, definitely benign nodule.

2:01

One of the benign patterns

2:03

of calcification we see solidly calcified nodules, nodules

2:07

with a central calcification

2:10

or rings of calcification like tree rings,

2:13

indicating an infection has maybe grown,

2:15

then become stagnant grown and become stagnant again.

2:18

Over time. Concentric rings representing growth

2:21

and healing of a granuloma from a fungal infection most

2:25

commonly, or sometimes tuberculosis.

2:27

And then we have the benign pattern of calcification,

2:29

which is called popcorn calcification,

2:32

which we can see in benign hematoma.

2:34

So we wanna apply those calcification criteria

2:37

to pulmonary nodules.

2:38

The four benign criteria, other pulmonary nodules

2:42

with calcification such as smudgy calcification,

2:44

that's amorphous stipple, little dotsa calcification

2:48

or excentric calcification are not considered definitely

2:52

benign calcification.

2:53

They can be seen both in benign and malignant lesions.

2:57

So it's important to make that distinction

2:59

When we come across calcified nodules

3:01

that we're applying those criteria correctly.

3:03

And not surprising, this patient has calcified right hilar

3:06

lymph nodes in the drainage pathway of

3:08

that right lower lobe nodule

3:10

and some calcified SubCal lymph nodes.

3:12

A pretty common pattern of healed tuberculosis

3:14

or healed fungal infection depending on what part

3:17

of the country that you live in.

3:19

So this patient subsequently underwent an image guided

3:22

biopsy of the nodule.

3:24

You can see on the thin section it's magnified up again,

3:27

a little bit more of the ground glass.

3:29

And then this more solid component in the middle.

3:31

They were able to do a CT guided percutaneous biopsy,

3:35

guide their needle straight to the nodule

3:37

and take a good needle sample.

3:39

And this turned out to be a well

3:41

differentiated adenocarcinoma.

3:43

This patient subsequently underwent a left upper lobe

3:46

thoracoscopic lobectomy

3:48

that took out the whole left upper lobe with the lingula.

3:51

And this patient has been disease free for 12 years now

3:54

with no evidence of recurrence.

3:57

It's important that while patients

3:59

who undergo lung cancer screening do

4:01

so based on eligibility criteria annually.

4:04

Once a patient becomes a lung cancer patient,

4:07

they move away from screening into what we call surveillance

4:10

that is covered by different guidelines such

4:13

as the National Comprehensive Cancer Networks guideline,

4:17

where surveillance cts are done on a periodic schedule based

4:21

on the invasiveness and extent of a patient's lung cancer.

4:25

And at some point, if patients are considered no active

4:28

disease, they move into an annual surveillance mode

4:31

that looks similar to screening,

4:33

but for billing purposes, it's considered a diagnostic exam.

4:37

We don't want older individuals

4:38

who exceed the Medicare upper age cap of 77 years

4:42

for screening to no longer be able

4:44

to get their surveillance exams

4:46

because they're incorrectly being coded

4:48

as lung cancer screening exams.

4:50

So treat lung cancer patients

4:52

as if they're in surveillance mode for life.