0:00

Let's look at a case with a solid pulmonary nodule

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and what's happened to that nodule over time.

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So here's an individual who's come

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for their baseline lung cancer screening CT exam.

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We can see that there's some mild upper lobe predominant

0:14

central lobular emphysema, these low density holes

0:18

with no discrete walls.

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And as we come down the lung it starts

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to peter out a little bit

0:23

because this is usually an upper lobe predominant problem.

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And we found our first nodule here, we have a solid nodule.

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It is in the right upper lobe

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and you'll notice it's tethering the plural surface like

0:36

it's pulling on it.

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It's deforming the shape of the fissure.

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It's got mild speculations around the edge of it

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as we look at its shape areas

0:44

of loation lobular contour and speculation.

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And it's gonna be important for us to understand

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how this has changed over time.

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So whenever we have a lung cancer screening ct, uh,

0:56

we always wanna look at prior chest cts.

0:58

We might even look at prior abdomen cts or neck cts

1:01

or spine cts, anything that might include the part

1:04

of the lung that's helpful to us.

1:06

I also use our electronic health record to identify cts

1:09

that might have been done in other healthcare facilities

1:11

and try and get those old exams so I can compare

1:14

to new nodules that I found on our current exams.

1:19

So we're gonna look at a prior comparison this patient had

1:22

back in 2012 and we got this outside exam

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and there is a small nodule here, same location,

1:31

it's more ground glass and density.

1:33

It's only about four millimeters

1:34

and that tethering of the pleural surface

1:36

of the fissure hasn't really happened yet,

1:38

just maybe a little bit.

1:40

But here we see a ground glass four millimeter nodule

1:43

compared to what we have now,

1:45

which is a seven millimeter speculated nodule.

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So we've got growth of a nodule

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and we've got change in consistency of the nodule.

1:52

So because of that change that we're going to recommend

1:57

with this lung RADS three case, we're gonna recommend uh,

2:01

follow-up CT in six months.

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Now individual discussions with patients might change

2:06

that recommendation if they're considered to be high risk

2:08

for lung cancer using a patient risk calculator

2:11

and discussion with pulmonary uh medicine, they may choose

2:14

to be more aggressive depending on the individual patient,

2:18

but in general this would be a long RADS three with

2:21

that seven millimeter nodule

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and we would recommend that they get an interval ct.

2:26

And then let's look at what's happened

2:28

to this patient over time.

2:31

So we started with this nodule back in 2012,

2:33

but we compared to our current exam

2:35

and we're seeing it growing

2:37

and then we have examinations

2:38

that follow from September 21 hasn't changed.

2:42

We follow it the next year, September 22 has not changed

2:46

and then we follow it into September 20 threes annual

2:50

screening exam and now it's growing.

2:53

So we can see it here.

2:55

It has a larger surface of contact with that major

2:58

Fisure. The overall

2:59

solid component has now increased

3:01

to 10 millimeters at this time.

3:04

The patient underwent a PET ct so we could look to see

3:08

what the activity is of the lesion,

3:10

but knowing that it's grown, we would expect it

3:12

to be pet positive.

3:14

So as we look at the pet CT

3:16

and look for the nodule, we go to the area of the nodule

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and we just have some mild activity.

3:23

It was not an intense uptake.

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Sometimes if you have cysts around a nodule

3:28

or emphysema around a nodule,

3:30

it can decrease the overall density.

3:31

But it had some mild uptake here because it had grown.

3:36

Now it's a long where it's four, be it 10 millimeters

3:38

and they're undergoing a diagnostic assessment here

3:40

with a PET ct.

3:42

Uh, the next question would be, should this patient

3:45

to proceed to tissue sampling

3:46

or do they want to do more watchful waiting?

3:49

In this case, they decided with the growth

3:51

and the lack of significant uptake on the PET CT

3:54

that they would use a watchful waiting approach.

3:57

And so this patient was going to their next CT

4:00

to happen in about six months to see if it's changed.

4:03

You notice this patient also has a pleural effusion,

4:06

is another incidental finding, um, on the exam,

4:09

and has some new errors of atelectasis in the right lung

4:12

that are contiguous with that nodule.

4:14

And that could be making the nodule look larger than it

4:17

really is because it's contiguous

4:19

with this band of atelectasis.

4:20

So we look forward to bringing this patient back in three

4:23

months for a long reds four A if we're gonna downgrade this

4:26

by one category and make sure that it hasn't grown,

4:29

and if it has grown, to treat the patient

4:32

accordingly for a higher risk lesion now

4:35

that it's grown once, it has an increased

4:37

likelihood of growing again.

4:39

And the whole purpose

4:40

of lung cancer screening is early detection

4:42

and we wanna find it

4:43

before there's evidence of tumor,

4:45

metastasis and advanced stage.

4:47

So bring this patient back

4:49

and check for stability would be the next steps.