Pretest Probability Of Malignancy Research Articles

Qualitative and Semiquantitative Parameters of 18F-FDG-PET/CT as Predictors of Malignancy in Patients with Solitary Pulmonary Nodule

This study aims to evaluate the reliability of qualitative and semiquantitative parameters of 18F-FDG PET-CT, and eventually a correlation between them, in predicting the risk of malignancy in patients with solitary pulmonary nodules (SPNs) before the diagnosis of lung cancer. A total of 146 patients were retrospectively studied according to their pre-test probability of malignancy (all patients were intermediate risk), based on radiological features and risk factors, and qualitative and semiquantitative parameters, such as SUVmax, SUVmean, TLG, and MTV, which were obtained from the FDG PET-CT scan of such patients before diagnosis. It has been observed that visual analysis correlates well with the risk of malignancy in patients with SPN; indeed, only 20% of SPNs in which FDG uptake was low or absent were found to be malignant at the cytopathological examination, while 45.45% of SPNs in which FDG uptake was moderate and 90.24% in which FDG uptake was intense were found to be malignant. The same trend was observed evaluating semiquantitative parameters, since increasing values of SUVmax, SUVmean, TLG, and MTV were observed in patients whose cytopathological examination of SPN showed the presence of lung cancer. In particular, in patients whose SPN was neoplastic, we observed a median (MAD) SUVmax of 7.89 (±2.24), median (MAD) SUVmean of 3.76 (±2.59), median (MAD) TLG of 16.36 (±15.87), and a median (MAD) MTV of 3.39 (±2.86). In contrast, in patients whose SPN was non-neoplastic, the SUVmax was 2.24 (±1.73), SUVmean 1.67 (±1.15), TLG 1.63 (±2.33), and MTV 1.20 (±1.20). Optimal cut-offs were drawn for semiquantitative parameters considered predictors of malignancy. Nodule size correlated significantly with FDG uptake intensity and with SUVmax. Finally, age and nodule size proved significant predictors of malignancy. In conclusion, considering the pre-test probability of malignancy, qualitative and semiquantitative parameters can be considered reliable tools in patients with SPN, since cut-offs for SUVmax, SUVmean, TLG, and MTV showed good sensitivity and specificity in predicting malignancy.

Differences in the management of thyroid nodules in children and adolescents as compared to adults.

To describe recent advances in the diagnosis and management of thyroid nodules in both children and adults, highlighting differences between the two groups. Thyroid nodules are less common in children than adults but the risk of malignancy is higher. Screening recommendations for patients with certain genetic syndromes or specific risk factors for thyroid nodules and cancer continue to evolve ultrasound is the most appropriate imaging modality for evaluating thyroid nodules in all patients, but radiographic risk stratification systems validated in adults have not been extensively studied in children. Criteria for proceeding to fine needle aspiration (FNA) biopsy differ some between children and adults, with nodule size being less of a consideration in young patients. Molecular testing continues to improve the diagnostic capabilities of FNA for all age groups, but options for pediatric thyroid nodules are currently limited. In children, only oncogene panels are validated and their exact utility, along with miRNA classifiers, is an evolving area of study. For adults, data support selection of a specific molecular test based on ultrasound characteristics and pretest probability of malignancy. Multiple series have shown that fusion mutations are more common in pediatric thyroid nodules, while point mutations are seen more often in adult thyroid nodules. Molecular data help guide management recommendations regarding the need for surgery when FNA is indeterminate, but clinical use is still being refined. Radiofrequency ablation is a nonoperative approach that has gained significant traction for the treatment of symptomatic benign nodules in adults, but data are currently extremely limited in children. There are difference in the diagnosis and treatment of thyroid nodules in adults and children, the nuances of which are important for clinical management.

Use of PET/CT to aid clinical decision-making in cases of solitary pulmonary nodule: a probabilistic approach.

ObjectiveTo determine the frequency with which 18F-FDG-PET/CT findings change the probability of malignancy classification of solitary pulmonary nodules.Materials and MethodsThis was a retrospective analysis of all 18F-FDG-PET/CT examinations performed for the investigation of a solitary pulmonary nodule between May 2016 and May 2017. We reviewed medical records and PET/CT images to collect the data necessary to calculate the pre-test probability of malignancy using the Swensen model and the Herder model. The probability of malignancy was classified as low if < 5%, intermediate if 5-65%, and high if > 65%. Cases classified as intermediate in the Swensen model were reclassified by the Herder model.ResultsWe reviewed the records for 33 patients, of whom 17 (51.5%) were male. The mean age was 68.63 ± 12.20 years. According to the Swensen model, the probability of malignancy was intermediate in 23 cases (69.7%). Among those, the application of the Herder model resulted in the probability of malignancy being reclassified as low in 6 (26.1%) and as high in 8 (34.8%).Conclusion18F-FDG-PET/CT was able to modify the probability of malignancy classification of a solitary pulmonary nodule in more than 50% of the cases evaluated.

In Brief

In Brief

MA01.10 Performance of ACR Lung-RADS in the 1st Brazilian Lung Cancer Screening Trial (BRELT1)

In BRELT1 we found a significant number of low dose CT (LDCT) considered positive (nodules > 4mm). The aim of this study was to assess the effect of applying ACR Lung-RADS and Pre-Test Probability of Malignancy (PTPM) in suspicious nodules ≥ 8mm founded in a clinical CT lung screening program. Clinical LDCT (baseline and follow up) containing nodules ≥ 8mm were retroactively reclassified using the new ACR Lung-RADS™ structured reporting system and PTPM. The model used in this study to predict the probability of malignancy was designed by Swensen et al and included patient’s age, current or former smoker, diameter of the nodule, speculation and location. All LDCT had initially been interpreted by radiologists accredited in CT lung screening reporting following the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012), which considered as positive the same criteria from the National Lung Screening Trial. In BRELT1 were recruited 790 current or former smokers, with a heavy smoking history. A total of 552 nodules were found in 312 positive LDCT at baseline (39%). LDCT follow up was performed in 89.1% of this population. From them 74 patients presented solid or semi solid nodules ≥ 8mm in the highest diameter. According to ACR Lung-RADS™ 39 baseline LDCT were classified as 4A (52.7%), 6 as 4B (8.1%), 17 as 4X (22.9%) and 10 as 2 (13.5%). Follow-up LDCT showed reduction in the category in more than 80% of cases. Using the PTPM, 44 cases were considered at moderate risk (between 6 and 60%) and 30 cases of high risk for malignancy (over 60%). None was considered low risk (5% or less). Among 26 patients who underwent biopsy in BRELT1, we found 12 cases of lung cancer, of which 90% were stage IA or IB. The application of ACR Lung-RADS and PTPM associated with careful multidisciplinary assessment can help in the decision process. The follow-up of patients with positive nodules requires careful analysis of the main factors related to malignancy.

Design of a prospective, multicenter, global, cohort study of electromagnetic navigation bronchoscopy.

BackgroundElectromagnetic navigation bronchoscopy (ENB) procedures allow physicians to access peripheral lung lesions beyond the reach of conventional bronchoscopy. However, published research is primarily limited to small, single-center studies using previous-generation ENB software. The impact of user experience, patient factors, and lesion/procedural characteristics remains largely unexplored in a large, multicenter study.Methods/DesignNAVIGATE (Clinical Evaluation of superDimension™ Navigation System for Electromagnetic Navigation Bronchoscopy) is a prospective, multicenter, global, cohort study. The study aims to enroll up to 2,500 consecutive subjects presenting for evaluation of lung lesions utilizing the ENB procedure at up to 75 clinical sites in the United States, Europe, and Asia. Subjects will be assessed at baseline, at the time of procedure, and at 1, 12, and 24 months post-procedure. The pre-test probability of malignancy will be determined for peripheral lung nodules. Endpoints include procedure-related adverse events, including pneumothorax, bronchopulmonary hemorrhage, and respiratory failure, as well as quality of life, and subject satisfaction. Diagnostic yield and accuracy, repeat biopsy rate, tissue adequacy for genetic testing, and stage at diagnosis will be reported for biopsy procedures. Complementary technologies, such as fluoroscopy and endobronchial ultrasound, will be explored. Success rates of fiducial marker placement, dye marking, and lymph node biopsies will be captured when applicable. Subgroup analyses based on geography, demographics, investigator experience, and lesion and procedure characteristics are planned.DiscussionStudy enrollment began in April 2015. As of February 19, 2016, 500 subjects had been enrolled at 23 clinical sites with enrollment ongoing. NAVIGATE will be the largest prospective, multicenter clinical study on ENB procedures to date and will provide real-world experience data on the utility of the ENB procedure in a broad range of clinical scenarios.Trial registrationClinicalTrials.gov NCT02410837. Registered 31 March 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-016-0228-y) contains supplementary material, which is available to authorized users.

S72 Clinical Prediction Models For Malignancy In Solitary Pulmonary Nodules - A Validation Study In A Uk Population

Background Management of solitary pulmonary nodules (SPNs) depends critically on the pre-test probability of malignancy. Several quantitative prediction models have been developed using clinical and radiological criteria. Three models include CT criteria (Mayo, Veterans Association, Brock University) with a fourth model (Herder) incorporating FDG avidity on CT-PET scan in addition. These models have not been validated in a UK population, and the current study aimed to compare their performance in a population of patients recruited from a UK teaching hospital. Methods Patients with SPNs (4–30 mm) were retrospectively identified from the lung cancer MDT and a nodule follow-up clinic (n = 246). All patients had a final diagnosis confirmed by histology or radiological stability on a 2-year follow up. For each patient, the probability of the pulmonary nodule being malignant was calculated using the four models described. The models were used both in a restricted cohort of patients based on their respective exclusion criteria, and in the total cohort of patients. The accuracy of each model was assessed by calculating the area under the receiver operating characteristic (ROC) curve. Results The median age of the patient population was 69 years (range 32–94) and 50% were male. The prevalence of malignancy was 40.6% (33.3% primary lung cancer, 7.3% metastatic disease). Figure 1 shows the distribution of the probabilities of malignancy according to the four different models. The areas under the ROC curves for the cohorts restricted by respective exclusion criteria were (AUC, 95% CI): Mayo 0.892 (0.847–0.937); VA 0.736 (0.672–0.801); Brock 0.901 (0.855–0.947) and Herder 0.924 (0.875–0.974). For the total cohort, the AUC values were Mayo 0.873, VA 0.736, Brock 0.867 and Herder 0.916. There was no statistical difference between the Mayo and Brock models, but both were significantly better than VA (AUC difference of 0.14 and 0.13 respectively, p ≤ 0.0001 for both). The Herder model performed significantly better than both Mayo and Brock models (AUC difference of 0.10 and 0.14 respectively, p ≤ 0.01). Conclusion Both the Mayo and the Brock models perform well in a UK population, but accuracy is improved by incorporating CT-PET findings using the Herder prediction model.

Quel bilan effectuer pour un nodule pulmonaire ?

With the increasing use of computed tomography, pulmonary nodules are very frequently detected. Solid pulmonary nodules must be distinguished from subsolid nodules, as their management will differ. Several guidelines present algorithms for both types of nodules to help physicians to identify pulmonary nodules of malignant cause and to limit iatrogenic consequences of the diagnostic strategy.In solid pulmonary nodules, a pre-test probability of malignancy is defined, using clinical criteria (mainly age, smoking, prior history of cancer) and the characteristics of the nodules at thoracic CT-scan (mainly size, doubling time, calcifications, margins). According to the estimated risk of cancer and to the size of the nodule, follow-up or medical or surgical biopsy of the nodule will be proposed. Follow-up will consist of repeated low-dose non contrast-enhanced thin-section thoracic CT-scans.Subsolid nodules are malignant in about 75 % of cases. They consist of adenocarcinomas in situ, mini-invasive adenocarcinomas or predominantly lepidic adenocarcinomas, which are often diagnosed in younger patients and non-smokers, and which usually, have a slower growth rate. According to the size, if the nodule persists at a thoracic CT-scan performed at 3 months, either follow-up or biopsy can be proposed. In case of follow-up, it should be maintained at least 3 or 5 years, or even longer, according to guidelines.

Multimodality systematic approach to mediastinal lymph node staging in non-small cell lung cancer.

Establishing an accurate diagnosis and stage for non-small cell lung cancer has important implications for treatment and prognosis. Ideally, the process should be performed in a way that maximizes the information from each procedure while minimizing the risk to the patient. The concepts of decision analysis and Bayes' theorem form a basis to develop the strategy. In this framework, the pre-test probability of malignancy is estimated in the lung nodule or mass, the regional lymph nodes and in distant sites. Invasive diagnostic tests are performed in sites with a pre-test probability greater than the testing threshold, beginning with those sites that would yield the highest stage, if positive. Modalities are chosen that are able to biopsy the suspicious sites and present the least amount of risk to the patient. Following each test, the post-test probability of malignancy is calculated to determine if it crosses the testing or test-treatment thresholds. The process continues with further tests until a diagnosis and stage are established.

Indeterminate Lung Nodules in Cancer Patients: Pretest Probability of Malignancy and the Role of 18F-FDG PET/CT

The purpose of this study was to determine likelihood of malignancy for indeterminate lung nodules identified on CT comparing two standardized models with (18)F-FDG PET/CT. Fifty-nine cancer patients with indeterminate lung nodules (solid tumors; diameter, ≥5 mm) on CT had FDG PET/CT for lesion characterization. Mayo Clinic and Veterans Affairs Cooperative Study models of likelihood of malignancy were applied to solitary pulmonary nodules. High probability of malignancy was assigned a priori for multiple nodules. Low (<5%), intermediate (5-60%), and high (>60%) pretest malignancy probabilities were analyzed separately. Patients were reclassified with PET/CT. Histopathology or 2-year imaging follow-up established diagnosis. Outcome-based reclassification differences were defined as net reclassification improvement. A null hypothesis of asymptotic test was applied. Thirty-one patients had histology-proven malignancy. PET/CT was true-positive in 24 and true-negative in 25 cases. Negative predictive value was 78% and positive predictive value was 89%. On the basis of the Mayo Clinic model (n=31), 18 patients had low, 12 had intermediate, and one had high pretest likelihood; on the basis of the Veterans Affairs model (n=26), 5 patients had low, 20 had intermediate, and one had high pretest likelihood. Because of multiple lung nodules, 28 patients were classified as having high malignancy risk. PET/CT showed 32 negative and 27 positive scans. Net reclassification improvements respectively were 0.95 and 1.6 for Mayo Clinic and Veterans Affairs models (both p<0.0001). Fourteen of 31 (45.2%) and 12 of 26 (46.2%) patients with low and intermediate pretest likelihood, respectively, had positive findings on PET/CT for the Mayo Clinic and Veterans Affairs models, respectively. Of 15 patients with high pretest likelihood and negative findings on PET/CT, 13 (86.7%) did not have lung malignancy. PET/CT improves stratification of cancer patients with indeterminate pulmonary nodules. A substantial number of patients considered at low and intermediate pretest likelihood of malignancy with histology-proven lung malignancy showed abnormal PET/CT findings.

The Importance of Recognizing Hibernomas as Possibly Not So Rare Pitfalls in FDG PET—A Histologically Verified Case and Literature Review

We present a glucose avid hibernoma hampering the re-staging of advanced breast cancer with FDG PET and summarize the results of the available literature. FDG PET, CT, MRI, ultrasound and histology were performed according to standardized protocols in our case. The literature search was performed on PubMed.gov. The literature search revealed 29 relevant publications starting with 2002. The high metabolic activity of hibernomas is a precarious pitfall in the staging of patients with a high pretest probability of malignancy and an increasing number of published cases indicate a possibly underestimated problem necessitating histological work-up in most cases. In our experience and in accordance with the literature unusually high uptake of a lesion and fat equivalent density in the CT should raise the suspicion for a hibernoma. The differential diagnosis between hibernomas and liposarcoma is often impossible without biopsy and histological work-up to prevent unnecessary treatment.

Endobronchial and Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Must for Thoracic Surgeons

A thoracic surgeon facile in endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can accurately sample mediastinal lymph nodes (MLNs) for histologic assessment of mediastinal adenopathy and for thoracic malignancy staging. Although mediastinoscopy is the gold standard for histologic MLN assessment, EBUS-FNA and EUS-FNA have emerged as useful, less-invasive sampling techniques that offer access to a wider range of MLN stations than mediastinoscopy and can be used to biopsy suspicious lesions within (ie, peribronchial masses) and outside the mediastinum (ie, left adrenal gland masses, liver lesions, and enlarged celiac lymph nodes). The negative predictive value of EBUS-TBNA and EUS-FNA in patients with malignancy is somewhat lower than the negative predictive value of mediastinoscopy. Therefore, we recommend that nonmalignant EBUS or EUS cytologic findings should be confirmed with a surgical MLN biopsy (ie, mediastinoscopy or thoracoscopy) if the pretest probability of malignancy is high.

TEP-TDM pour l’exploration du nodule pulmonaire solitaire : acquis et perspectives

Positron emission tomography (PET) with 18F-FDG has become an important tool for the characterization of solitary pulmonary nodules (SPN). The results of the main meta-analyses show that the sensitivity and specificity of 18F-FDG PET for determining malignancy of SPN are close to 95% and 80% respectively. The limits of the technology are now well known. False negative results are mainly due to certain histological types with low metabolic activity (such as bronchiolo-alveolar carcinoma and typical carcinoid), or small size (nodules less than 8 mm). False positives are mainly represented by granulomatous and infectious processes. A gain in accuracy occurred with the advent of hybrid PET/CT machines that combine the functional data from 18FDG-PET and the morphological data of computed tomography. Improved imaging protocols (eg. injection of iodinated contrast media) could further enhance the performance of PET-CT. Further improvements will rely on respiratory synchronization protocols and on the advent of new PET tracers. 18F-FDG PET-CT should be performed for any nodule over 8 mm in size when the pre-test probability of malignancy is not deemed negligible.

A Study to Validate the Pretest Probability of Malignancy in Solitary Pulmonary Nodule

Background: Solitary pulmonary nodules (SPN) are encountered incidentally in 0.2% of patients who undergo chest X-ray or chest CT. Although SPN has malignant potential, it cannot be treated surgically by biopsy in all patients. The first stage is to determine if patients with SPN require periodic observation and biopsy or resection. An important early step in the management of patients with SPN is to estimate the clinical pretest probability of a malignancy. In every patient with SPN, it is recommended that clinicians estimate the pretest probability of a malignancy either qualitatively using clinical judgment or quantitatively using a validated model. This study examined whether Bayesian analysis or multiple logistic regression analysis is more predictive of the probability of a malignancy in SPN. Methods: From January 2005 to December 2008, this study enrolled 63 participants with SPN at the Kangnam Sacred Hospital. The accuracy of Bayesian analysis and Bayesian analysis with a FDG-PET scan, and Multiple logistic regression analysis was compared retrospectively. The accurate probability of a malignancy in a patient was compared by taking the chest CT and pathology of SPN patients with ＜30 mm at CXR incidentally. Results: From those participated in study, 27 people (42.9%) were classified as having a malignancy, and 36 people were benign. The result of the malignant estimation by Bayesian analysis was 0.779 (95% confidence interval [CI], 0.657 to 0.874). Using Multiple logistic regression analysis, the result was 0.684 (95% CI, 0.555 to 0.796). This suggests that Bayesian analysis provides a more accurate examination than multiple logistic regression analysis. Conclusion: Bayesian analysis is better than multiple logistic regression analysis in predicting the probability of a malignancy in solitary pulmonary nodules but the difference was not statistically significant.

The evaluation and management of the solitary pulmonary nodule

Solitary pulmonary nodules (SPNs) are increasingly detected with the widespread use of chest computed tomography (CT) scans. The primary goal of the evaluation of these nodules is to determine whether...

Impact of Endoscopic Ultrasound (EUS) on Management of Patients with Large Gastric Folds and Endoscopic Biopsies Negative for Malignancy (LGF-NB)

Background: The management of patients with large gastric folds is a challenge in clinical practice. Moreover, it is known that endoscopic biopsies negative for malignancy do not exclude this possibility. Aim: 1) To evaluate the clinical impact of EUS in the diagnosis of malignancy in patients with LGF-NB and 2) To assess the EUS predictive features of malignancy. Patients and methods: We included all patients with LGF-NB referred for EUS evaluation between March 97 and December 02. EUS was performed with a radial echoendoscope (Olympus GF UM20). 12 variables were registered from endoscopic and EUS findings. We used pathology of resected specimens or clinical follow-up (range 12-68 months) as gold standard. Likelihood ratios (LR) and a logitic regression model were used to assess the clinical impact and independent EUS predictive factors for malignancy respectively. Results: we included 64 patients (35M/29F; mean age 58+17). Definitive diagnosis disclosed benignity in 42 patients (66%) and malignancy in 22 (34%). The Table below shows the performance characteristics for EUS compared with upper endoscopy for diagnosis of malignancy. The pre-test probability of malignancy in our series (34%) increased up to 91% when EUS suggested malignancy (positive LR=19) whereas decreased to 2,6% when EUS precluded this diagnosis (negative LR=0.053). Predictive factors in the univariate analysis were: thickened wall, involvement of deep layers, impaired distensibility, and the presence of ascites or lymph nodes. The only independent predictive factor of malignancy in the multivariate analysis was the presence of lymph nodes. Conclusions: 1) EUS is a very accurate technique with a high clinical impact for diagnosis of malignancy in patients with LGF-NB 2) The only independent predictive factor for malignancy is the presence of lymph nodes.