0:00

While the primary focus

0:02

of looking at the lungs on lung cancer screening CT exams is

0:05

to identify early evidence of lung cancer.

0:08

There are many abnormalities that can be seen in the lungs

0:12

that are associated with cigarette smoking, as well

0:14

as the usual findings

0:15

that we can see on any chest CT that we're interpreting.

0:20

Patients undergoing lung cancer screening cts are often at

0:23

increased risk for both interstitial

0:25

and obstructive lung disease.

0:27

Sometimes these diseases are already known

0:29

and recognized clinically and sometimes they're not.

0:33

In COPD, we have emphysema small a, a wall thickening as

0:37

commonly seen in patients with chronic bronchitis

0:39

or chronic asthma, mucus plugging and bronchiectasis.

0:44

And in interstitial lung disease,

0:45

the most common findings related

0:47

to cigarette smoking are respiratory bronchiolitis

0:49

and langer hand cell histiocytosis.

0:52

But we're also now picking up early interstitial lung

0:55

disease or interstitial lung abnormalities on

0:57

screening cts as well.

1:00

If we look to the American College

1:01

of Radiology's Lung Cancer Screening Registry for

1:04

how frequently we see these findings

1:06

and the first 1.7 million screens in the lung cancer

1:10

screening registry, 2.2%

1:12

of patients had interstitial lung disease other than

1:15

pulmonary fibrosis, things like respiratory bronchitis

1:18

or laying or hand cell histiocytosis,

1:21

and half a percent of patients had frank pulmonary fibrosis.

1:24

So that's nearly 3%

1:26

of patients having interstitial lung disease.

1:29

Emphysema that is moderate

1:31

or severe occurred in 1% of all the screening cts

1:35

and represented 6% of all the abnormalities.

1:38

I put a caveat on the way emphysema is reported into the

1:41

lung cancer screening registry.

1:43

Many people expect

1:45

to see emphysema on lung cancer screening cts due

1:48

to the Association of Heavy Smoking history with

1:53

emphysema, as well as with lung cancer,

1:56

which is the primary reason we're doing the

1:58

screening CT exam.

1:59

So the majority of people don't report emphysema

2:02

as an S modifier finding as they consider expected.

2:06

We strongly encourage people to report emphysema as moderate

2:10

or severe using the S modifier,

2:13

but for mild emphysema, it's perfectly fine

2:15

to mention in the report.

2:17

I will say that increasingly early evidence of various forms

2:21

of small airway disease

2:22

and emphysema, as well as even small areas

2:25

of mucus plugging are being recognized to be associated

2:28

with increased morbidity and mortality.

2:31

So as I'm thinking about this more looking into the future,

2:35

it's not just important enough

2:37

to mention those findings in the body of the report.

2:40

It's gonna become increasingly important to recognize

2:43

and report early evidence of obstructive disease, emphysema,

2:47

mucus plugging, and so on in the impression as well,

2:50

particularly the first time it's detected.

2:53

If we look to the ACRs, a quick guide

2:56

for incidental findings, we have a section for lung and

2:58

Pleural abnormalities.

3:00

Much of this language here is intended

3:02

to help primary care physicians

3:04

or nurse coordinators of nurse navigators

3:06

and lung cancer screening programs understand how

3:10

to translate what we say as radiologists into actionable

3:13

or not actionable next steps for a patient

3:16

or to answer patient's questions

3:18

as they get their reports electronically.

3:20

Very commonly now through the patient portals, a little bit

3:24

of mild subsegmental, aacts

3:26

or scar, not really an actual finding, emphysema

3:30

and bronchial wall thickening wall expected should still be

3:34

considered for evaluation by the PCP to maximize

3:38

any treatments for COPD that the patient may be appropriate

3:41

for and to consider pulmonary function tests

3:43

and potentially a pulmonary medicine consultation.

3:47

Advances in treatment are really accelerating in the space

3:50

of obstructive lung disease.

3:53

If fibrotic interstitial lung diseases identified such

3:56

as IPF pulmonary fibrosis,

3:59

a pulmonary medicine consultation is strongly recommended

4:02

as antifibrotic therapies are now becoming the standard

4:05

of care and we recognize the increased association

4:08

of fibrotic lung disease with unrecognized

4:10

and undiagnosed connective tissue disease more

4:13

and more when we see bronchiectasis, ground glass opacity,

4:17

cystic lung disease and diffuse nodule disease.

4:20

Yes, the pulmonary medicine physician can certainly do an

4:22

assessment for signs and symptoms of the disease

4:25

and undergo a referral for pulmonary medicine consultation

4:29

and pulmonary function testing evaluation.

4:32

We don't see a lot

4:33

of unexpected plural findings on lung cancer screening

4:37

disease such as a fusion thickening or mass.

4:39

We usually recommend significant findings in these areas

4:42

to the PCP or consider pulmonary function testing

4:45

with pulmonary medicine consultation,

4:47

particularly when there are pulmonary symptoms,

4:50

and we apply the same criteria we would when

4:52

interpreting NHS ct.

4:55

I think it's important to understand

4:57

that we know a lot more about COPD than we ever used to,

5:01

but we still know so very little

5:03

and have a lot more to learn.

5:05

COPD is characterized by persistent airflow limitation

5:09

that's usually progressive

5:10

and associated with an enhanced chronic inflammatory

5:13

response in the airways and the lung to noxious particles

5:16

or gas symptoms include shortness of breath, cough,

5:20

wheezing, decreased activity, and weight loss.

5:24

The severity of COPD is rated on what's known

5:29

as the gold scale for the global initiative

5:32

for chronic obstructive lung disease.

5:35

Risk factors for COPD include smoking,

5:38

and that's one of the most common risk factors for COPD,

5:41

but at least one in six individuals

5:43

who do not smoke have COPD.

5:47

This is usually related

5:48

to environmental exposures like chemicals, dust fumes,

5:52

outdoor air pollution.

5:53

Cooking in poorly ventilated kitchens is a manifestation

5:57

of indoor air pollution and in some cases secondhand smoke.

6:01

It can also be seen in genetic conditions such

6:03

as alpha one antitrypsin deficiency.

6:06

The gold score, as I mentioned, is used

6:08

to classify the severity of COPD.

6:11

So if you see the gold score in a reason for exam,

6:14

a patient's having shortness of breath with a gold score

6:16

of 1, 2, 3, 4, you can understand its significance.

6:20

Gold 1, 2, 3, and four described as mild, moderate, severe,

6:24

and very severe obstructive pulmonary disease based on the

6:27

FEV 1% predicted with relatively preserved fev one

6:31

of an 80%

6:33

or greater being considered mild by the gold score,

6:36

and a less than 30% predicted FEV

6:39

one considered very severe.

6:42

COPD is underdiagnosed in the US and around the world.

6:47

Just in this three year timeframe from 2007 to 2010, eight

6:51

and a half million adults were diagnosed with COPD,

6:54

but more than 18 million had evidence

6:57

of impaired lung function on pulmonary function testing.

7:00

So we know that we are under diagnosing COPD

7:04

and that has long-term implications for patient morbidity,

7:08

lung function, and mortality.

7:11

So one thing we can do

7:12

with our lung cancer screening cts is report early evidence.

7:16

The prevalence of COPD ranges across the United States

7:20

and is more common in areas with higher tobacco use.

7:23

So it's expected that the states

7:25

that have higher tobacco use,

7:27

higher cigarette smoking have higher rates of COPD.

7:30

In general, COPD is extremely costly based on all

7:35

the treatments in the outpatient space, ER visits,

7:38

home health office-based care

7:40

and inpatient admissions, as well as prescription drugs

7:43

that are increasingly being developed

7:45

and changed to treat COPD.