0:00

Now the A CR Lung Cancer Screening Committee had a working

0:04

group that took all of the white papers that have come out

0:08

of the A CR for incidental findings

0:10

and pulled together those that you might see in a chest ct.

0:13

So lower neck, chest, and upper abdominal findings.

0:17

And so you'll see on this a CR lung cancer screening,

0:21

CT incidental finding quick reference guide,

0:23

those findings are all pulled into one space.

0:26

This was pulled together for two reasons.

0:29

One, we had primary care physicians

0:32

and organizations like folks at the American Academy

0:34

of Family Physicians say,

0:36

I understand radiology can do low dose chest CT

0:40

for lung cancer screening

0:41

and do it with low radiation exposure.

0:43

One of our biggest concerns is all the incidental findings

0:46

that you radiologists detect

0:48

and we need help understanding what needs

0:51

to be managed and what doesn't.

0:53

And the other input to this where nurse navigators

0:55

and coordinators and lung cancer screening programs

0:58

who are getting these reports back

1:00

and not knowing what to do with findings

1:02

or getting questions from patients.

1:04

Remember these are patients who are generally

1:06

otherwise healthy from a thoracic

1:08

and cardiovascular standpoint.

1:10

So you'll see that we have findings by each

1:12

of the body parts, adrenal, kidney, liver, pancreas, so some

1:15

of the upper abdominal findings

1:17

and musculoskeletal findings like bone mineral density

1:20

that could be reported on each CT

1:23

by simply putting a a cursor

1:24

or region of interest on your L one vertebral body if you

1:27

have it, if not T 12, to measure density as a measure

1:30

of osteopenia or osteoporosis,

1:33

which is an important population health type of measurement.

1:37

This is the front and backside

1:39

of the CT incidental findings.

1:40

Quick reference guide and you'll see not only the abdominal

1:44

musculoskeletal systems, you'll see cardiovascular, breast,

1:48

esophagus, lung, pleura, mediastinum and thyroid findings.

1:52

Now wherever you see, okay, it's intended to indicate

1:55

to the primary care physician or nurse navigator

1:58

and coordinator that there's no action needed.

2:01

But where you see something in bold, those are the type

2:04

of findings where a management recommendation is made.

2:06

So for example, if you look under lung atelectasis,

2:10

that's mild or subsegmental, okay?

2:13

No action is needed if you have emphysema

2:16

and wall thickening,

2:17

while it might be an expected finding in somebody who's

2:20

smoked, you should consider PCP evaluation

2:23

and may benefit from a pulmonary consult.

2:26

For fibrotic ILD, we come down a little bit more firmer

2:30

fibrotic ILD is progressive, so pulmonary fibrosis

2:34

and it's can be treated with antifibrotics.

2:37

So referral to pulmonary medicine is critically important if

2:40

a patient is not known to have fibrotic ILD

2:42

before screening and so on.

2:44

So this is intended to be a quick guide again focused on

2:47

primary care providers or nurse navigators,

2:50

but it can also be useful for the to the radiologist

2:52

and pulling it all together in one place to be able

2:55

to make a good recommendation

2:56

to your primary care physicians, uh,

2:58

when they get the results back for their screening tests

3:01

so they know what to do

3:02

and you've been the one that's helped them do that.

3:05

I'll just talk about a couple findings

3:07

and one that I think is particularly important is coronary

3:09

artery calcification as a marker of atherosclerosis.

3:13

We know it correlates with the extent

3:15

of atherosclerotic plaque

3:16

and can be used to predict coronary heart disease risk.

3:19

It's a common finding on chest cts.

3:21

In general, over half of patients with no history

3:24

of coronary disease may have coronary art.

3:26

Total calcification. It's seen in about 40%

3:29

of people over the age of 40

3:31

and about 25% of people undergoing a CT exam

3:34

for pulmonary embolism.

3:35

So these are not screening cts

3:37

and yet we're seeing it in high numbers

3:40

whenever we see coronary arterial calcification.

3:42

It's important that we include it in our reports

3:46

in our structured field of our reports

3:48

for lung cancer screening.

3:50

In fact, for all chest cts we have a standard section

3:53

for cardiovascular findings

3:55

and one specifically for coronary artery calcification

3:58

where we pick whether it's non mild, moderate or severe.

4:02

And that's in all

4:03

of our chest CT reports including screening.

4:06

There are software tools

4:07

that will now help you actually do a true tson coronary

4:10

artery calcium score on any chest ct

4:13

and we're starting to see slow implementation

4:15

of those in practice if you have heavier,

4:18

severe calcification in the moderate

4:20

or severe range, that's

4:22

where cardiovascular risk assessment is really important

4:25

as well as the referring physician PCP evaluating clinically

4:29

for signs and symptoms of cardiovascular disease.

4:33

There is a society of cardiac

4:35

cts TR 2016 guideline which recommends reporting coronary

4:40

arterial calcification on all patients cts irrespective

4:43

of the scan indication

4:45

or their patient risk status for cardiovascular disease.

4:48

And I was, uh, grateful

4:49

to be a participant in the production of that work.

4:52

So if you see coronary arter calcification reported

4:55

non mild, moderate severe is a grading system which

4:58

correlates well with the tson scoring system as shown

5:02

by a nice study by Carolyn Chiles et al

5:04

who looked at the NLST data.

5:07

This is the translation of the visual score

5:10

to the TSON score.

5:11

The traditional way of doing a dedicated coronary calcium

5:15

calculation exam.

5:17

The non mild moderate severe visual score correlates very

5:21

well with the tson score categories

5:24

and these categories of the different amounts

5:26

of increasing calcium correlate with a patient's risk

5:30

of subsequent downstream cardiovascular events from very low

5:34

risk to high risk.

5:36

So a patient with no coronary calcium has a risk event rate

5:39

of two per thousand annually, whereas a patient

5:42

with moderate coronary calcium

5:44

has a greater than two per hundred chance

5:47

of having a cardiovascular event annually.

5:50

Patients with severe coronary calcification,

5:52

whether visually or by calcium score over 400 have a

5:56

between two and five chance per hundred

5:59

or a 15% chance

6:00

of having obstructive coronary disease at the time the exam

6:04

was read and consideration should be given to stress echo

6:07

or stress nuclear exam.

6:09

In this case, when we see severe coronary trial

6:12

calcification, the patient hasn't seen a cardiologist.

6:15

This is something that our primary care physicians

6:18

would usually refer for.

6:20

And here's an example using the tson scoring system,

6:24

or you can use the visual non mild, moderate severe system.

6:27

So here's the traditional uh, calculation

6:30

of coronary calcium, which can actually be done on non

6:34

coronary calcium cts.

6:35

You can do this on a lung cancer screening CT if you want

6:38

to, and there are software tools that you can use to apply

6:41

to all chest cts to do this to calculate a true AON score.

6:46

More practices are currently using the non mild moderate

6:48

severe categorization.

6:50

In this case it would be severe multi-vessel

6:53

coronary trail calcification.

6:56

Another cardiovascular, uh, finding that's important

6:59

to report is dilatation or aneurysms of the aorta.

7:03

They tend to be silent compared

7:05

to abdominal aortic aneurysms and less well understood

7:09

and less frequently detected

7:10

before patients come in with signs

7:13

of thoracic aortic aneurysm.

7:15

Acute rupture, an aneurysm is defined as 150%

7:20

of normal diameter.

7:21

So in the aorta we consider five centimeters an aneurysm in

7:25

the ascending and four centimeters in the descending aorta.

7:29

Below that, between normal

7:31

and that size we consider dilated.

7:33

So we'll also often report them as fusiform dilatation

7:36

of the ascent aorta when it hits 40 millimeters or larger.

7:42

The freemium heart study that used ECGG non-contrast a T

7:46

and several thousand individuals has reported

7:48

what the norms are with a standard deviation around it

7:52

for men and women.

7:54

But it's important that we do things like adjust

7:56

for patient size.

7:58

Unfortunately, there are no good nomograms for us to use

8:01

as radiologists in practice to say a 38 millimeter aorta

8:05

and a tiny person is probably abnormal,

8:07

whereas a 42 millimeter aorta in the A setting is probably

8:10

normal in a larger individual, we don't have that degree

8:13

of information available

8:15

to us at the time of interpretation.

8:17

Whenever the thoracic aorta,

8:19

especially the ascending is greater than five

8:21

and a half centimeters, it should be a referral

8:23

to cardiac surgery because of the high risk of rupture

8:27

and even smaller at five centimeters if patients have

8:30

underlying diseases like Marfans

8:31

or Alos Danlos

8:33

where surgical replacement is often done earlier,

8:36

if you're particularly interested in the thoracic aorta,

8:39

there is an updated American College of cardiology,

8:42

a HA guideline for the diagnosis

8:44

and management of aortic disease.

8:47

It has, uh, had a widespread adoption uptake since its

8:51

publication and it looks at this issue of aortic

8:54

Size and the relative risk

8:56

of having an aortic dissection, for example.

8:59

So once you hit four centimeters

9:01

or greater in the ascent aorta, your risk of rupture starts

9:05

to go up or aortic dissection

9:06

and your risk gets particularly high if your

9:08

as centimeter is four

9:09

and a half centimeters, which is why we use this 40

9:13

millimeter ascending aortic diameter as important to report.

9:17

So that's a look at some important incidental findings on

9:21

lung cancer screening, the philosophy

9:23

behind why it's important

9:25

and some of the specific findings

9:27

that we can make a difference for our patients.