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Thorax cardio chest imaging in up to 50 year old non symptomatic smoker g ferrettit
1. Chest imaging in up to 50-yo
non symptomatic smokers
G Ferretti
CHU Grenoble
FRANCE
2. — CT
acquisitions in people > 50 yo
— Lung cancer screening studies
— Early detection of pulmonary fibrosis
— Screening for asbestosis
have increased our need to better understand
the morphology of the lung in aging population
and particularly in those who have smoking
habits
Dalal PU Eur Radiol 2006
Hansell DM Radiology 2010
3.
4. Aging +/- cigarette smoking
—
Abnormalities without
clinical consequences
◦ “Wrinkles” within the lung
—
Abnormalities with potentially
severe evolution
◦
◦
◦
◦
◦
◦
Lung nodules
Emphysema
Respiratory broncholitis
NSIP/UIP pattern
Chronic bronchitis
Air trapping
6. 55 yo patient
GGO Opacity in the posterior
lung
ILD ?
Re scan the patient in prone
position
7. Increase pulmonary density in a 67yo patient
suspected of PE due to incomplete inspiration and
contrast injection
Confusing pattern for ILD
8. Fibrosis adjacent to spinal
osteophytes
Localized GGO or reticular pattern
near dorsal Osteophytes (right side >>> left side
No evolution in time
Not related to asbestose exposure
Not indicative of early UIP
Otake S. AJR 2002;179:893–896.
9. Aging pattern of the lung (1)
—
Bronchial dilatation (Richards DW Bull NYAM 1956)
—
Enlargement of alveolar spaces : senile
emphysema? (Janssens JP ERJ 1999)
12. Localized fibrosis of lung parenchyma
• Sub pleural reticulation in 60% of asymptomatic
subjects > 75 yo vs 0% < 55 yo
• Interlobular septal enlargement more frequent in
older persons
Copley SJ Radiology 2009
13. Aging lung (2)
— Pulmonary
cysts with thin walls in 25% of
subjects > 75yo but absent in < 55yo
◦ These cysts are related to aging but not to
tobacco
◦ Their volume is limited
Copley SJ Radiology 2009
16. Emphysema
— the
link between smoking and emphysema
is well demonstrated
◦ Interstitial abnormalities used to be called
“dirty lung” on CXR
◦ Respiratory bronchiolitis / RB ILD has been
described more recently
– Centrilobular GGO micronodules
– Upper lung
17. Bronchiolite respiratoire
Pathologie tabagique : EXCES DE MACROPHAGES
Bronchiolite respiratoire
– inflammation chronique bronchiolaire,
macrophages tatoué
Bronchiolite respiratoire avec infiltration
pulmonaire diffuse (RB-ILD)
– Extension dans l ’espace des anomalies TDM.
Pneumopathie interstitielle desquamative (DIP))
18. 5
years
la2er
*Remy-‐Jardin
et
al,
Radiology
1993,
186:
107-‐115
**Remy-‐Jardin
et
al,
Radiology
1993,
186:
643-‐651
***
Remy-‐Jardin
et
al
Radiology,
2002,
222:
261-‐70
20. Tobacco and ILD
— Do
smokers develop limited and
progressive pulmonary fibrosis ?
◦ Remain controversial
◦ Experts supports that smoking is a direct
cause for developing UIP/NSIP
Cordier
JF
et
Co8n
V
ERJ
2013
21. 2007
2012
l
2007, 58 yo man chronic cough
l
What do you see?
l
2012 , heterogeneous
distribution of ILD
l Reticulation
l Honey combing
l Bronchectasis
l Sub pleural distribution
UIP pattern
l
Raghu
G
AJRCCM
2011
21
│
22. The lung of smokers in screening program for
lung cancer
692 heavy smokers from the Multicentric Italian Lung Detection (MILD)
Four CT patterns were considered:
• usual interstitial pneumonia(UIP)
• other chronic interstitial pneumonia (OCIP)
• respiratory bronchiolitis (RB)
• indeterminate
the evolution of ILD after 3 yrs was assessed
UIP pattern in
0.3%
OCIP pattern
3.8% progression three (25%) of 12
RB pattern in
15.7%
indeterminate pattern in 3%
Sverzella+
N
ERJ
2011
23. — Age, male
sex and current smoking status
were factors associated with the presence
of OCIP and UIP pattern
— Thin-section
CT features of ILD, probably
representing smoking-related ILD, are not
uncommonin a lung cancer screening
population and should not be overlooked.
Sverzella+
N
ERJ
2011
24. The lung of smokers in screening program
for lung cancer
• 884 smokers from the NLST
– ILD at base line
– ILD were classified into
• nonfibrotic (ground-glass opacity, consolidation, mosaic attenuation),
• fibrotic (GGO with reticular pattern, reticular pattern, honeycombing).
– the rate of progression of ILAs on 2-year follow-up
• Résults
– prevalence of equivocal ILD: 11.5%
– prevalence of ILD: 9.7%
• Fibrotic 2.1%
• Non fibrotic
• Mixed
Progression 37%, improved 0%
5.9%
improved 49%
1.7%
• The percentage of current smokers (P = .001) and mean number of
cigarette pack-years (P = .001) were significantly higher in those with
ILA than those without.
Jin
GY
Radiology
2013
25. Air trapping
Need expiratory acquisitions
seen in patients with normal PFT
— present in healthy asymptomatic nonsmoking
individuals (Verschakelen JA Eur Radiol 1998)
— more frequent in cigarette smokers (Mastora I Radiology
2001)
—
found in approximately 50% of asymptomatic
subjects. The frequency of air trapping increased
with age, and its severity increased with age and
smoking (Lee KW Radiology 2000)
26. Asymptoma+c
smokers
INSPIRATION
EXPIRATION
•
82
asymptoma-c
persons
•
Air
trapping
present
in
50%
•
increased
Frequency
with
age
•
increased
Frequency
in
smokers
(>10PA)
Lee
et
al
Radiology
2000,
214:
831-‐36
27.
28. Tobacco and lung cancer
— Lung
cancer is the leading cause of
cancer-related deaths worldwide.
— 85% of lung cancer patients are smokers
— Most patients are diagnosed with
advanced-stage tumors, precluding
curative-intent treatment.
30. NLST showed a 20%
decrease in lungcancer-specific
mortality
The National Lung Screening Trial Research Team.
Reduced Lung-Cancer Mortality with Low-Dose
Computed Tomographic Screening. N Eng J Med 2011;
365(5): 395–409.
31. Guideline Recommendations
—
US Preventive Service Task Force
Humphrey MM Ann Intern Med 2013
—
The IASLC
Heidi R J Thorac Oncol. 2013
—
The National Cancer Center Network
Wood DE J Natl Compr Canc Netw 2012
—
—
—
The American Society of Clinical Oncology,
The American Association of Chest Physician
The American Association for Thoracic Surgery,
Mirkin JN JAMA 2012
—
French groups IFCT, SIT, GOLF
S Couraud Ann Oncol 2013
Recommended individual screening for lung cancer
32. Eligibility
- aged between 55 and 74 years;
- at least 30 pack-year tobacco exposure;
- active smoker or quit during the last 15 years;
- no serious progressive disease (history of cancer other than nonmelanoma skin cancer or carcinoma in situ over the past 5 years1;
severe co-morbidity, including respiratory insufficiency
contraindicating invasive chest examination; prior hemoptysis;
unexplained weight loss over 10% over
the past 12 months);
- no pulmonary infection over the 12 past weeks;
- accepts repeated scans or additional investigations in
the case of abnormal findings;
- accepts considering help to quit smoking (active
smokers).
34. 3 types of nodules
Etiology
VDT
Prognostic
Action
• Solid
• Part-solid
• Nonsolid
78.9%
1.1% cancer
4.3%
6.6% cancer
15.8%
1.9% cancer
McWilliams A NEJM 2013
35. NLST
NELSON
1
2
NLST
(Baseline + rounds 1-2)
NELSON
(Baseline + round 1)
75 126
14 846
2
3
N
screening
CT
1
3
N
posi-ve
N
Cancers
%
de
cancer/scr
18 146
24.1%
324
2.2%
Stade
I
649
649
3.6%
3.6%
0.86%
61.6%
126
126
38.9%
38.9%
0.85%
69.8%
FP: 96.6%
FP: 61.1%
36.
37. Follow up of Pulmonary nodules
(Fleischner, Radiology 2005)
Guidelines adapted to solid nodules only
Specific guidelines for nGGO 2013
38. Positif test Nelson study
Negatif
CT at 3-4 months
GROWCAT C if
VDT < 400 days
Positif
39. V = 4.19 x R3
V x 2 when R x 1.26
Reich JM Eur J Radiol 2011 ;80
1039mm3 at baseline to1539 mm3 at
3 months. T1N0M0 adenocarcinoma
A Marchiano Radiology 2009; 251
43. Conclusion
— HRCT
can demonstrate very early disease,
sometimes in people without symptoms or
PFT abnormalities.
— The
lung of asymptomatic smokers > 50yo
may be affected by
◦ Non significant abnormalities mainly related to
aging
◦ Significant diseases that should be followed
— Smoking
the lungs
may have a premature aging effect on
Nyunoya T Am J Respir Crit Care Med 2009
