cristian(ibarra(duprat int nodulo&pulmonar& · biopsia número hamartoma 5 granuloma 1...

NODULO&PULMONAR& Cristian(Ibarra(Duprat INT

Definiciones

  Nodulo Pulmonar Solitario(NPS)   Lesión dentro y rodeada por parenquima

pulmonar.   Menos de 3 cm   NO asociado a atelectasia, crecimiento del

hilio o derrame pleural

  Masa   Lesión Mayor de 3 cm

Definiciones NODULO?   Múltiples NODULOS   NODULOS NO completamente rodeados de pulmón

aireado   Nódulos Subcentimétricos: Nodulos ≤ 8 mm esféricos

o NO esféricos   Patrón de Opacificación:

  VIDRIO (NO SOLIDOS)   SOLIDOS   MIXTOS (VIDRIO y SOLIDO)

Causas de NPS

•  Neoplasicas –  Carcinoma(Broncogenico –  Tumor(Carcinoide –  Metastasis –  Sarcoma(Primario(

Pulmonar –  Plasmocitoma

•  Neoplasicas(benignas –  Hamartoma –  Condroma –  Lipoma –  Leiomyoma –  Hemangioma

  Vasculares   Infarto((organización)   Malformación(AV

  Enfermedad(del(Tejido(Conectivo   Nódulo(Reumatoideo   Granulomatosis(Wegener

Causas de NPS

  Inflamatorias   Granuloma

  TBC   Histoplasmosis   Coccidiomycosis   Cryptococcosis   Nocardiosis   Dirofilaria immitis

  Quiste Hidatidico   Mycetoma   Neumonía en Organización   Pseudotumor Inflamatorio   Neumonia Redonda

•  Otros –  Linfonodo(Intrapulmonar –  Amyloidosis –  Silicosis –  Neumonia(Lipoidea –  Cuerpo(extraño –  Hematopoiesis(Extramedular –  Atelectasis(redonda –  Impactación(Mucoide –  Opacidades(artificiales

•  Fluidos(en(la(cisura •  Opacidades(de(la(pared(torácica •  Artefacto

Etiologias MáS comunes de NPS

•  Malignas –  Cancer(Pulmonar(primario –  Carcinoide – Metastasis

•  Melanoma,(sarcoma,(colon,(mama,(riñon,(testicular •  Múltiples(nódulos

•  Benignas –  Granulomas(Infeccioso

•  Mycobacteria,(Histoplasmosis,(coccidiomycosis.( –  Hamartomas

Anatomía(Patológica(en(70(pacientes(con(Nódulos(pulmonares(sometidos(a(resección(durante(el(año(2010

Biopsia Número

Adenocarcinom(/(BAC 3((5.3%)

ADENOCARCINOMA 17((30.3%)

CARCINOMA(ESCAMOSO 3((5.3%)

CARCINOIDE 4((7.1%)

METASTASIS 29((51.8%)

TOTAL 56((100%)

Biopsia Número

HAMARTOMA 5

GRANULOMA 1

TUBERCULOMA 1

SILICOMA 2

Neumonía(en(Organización 1

Nódulo(Eosiniofílico 1

AMILOIDOMA 1

Fibrosis 1

Neumonía(descamativa 1

TOTAL 14

Evaluación NPS

  Edad   A mayor edad mayor probabilidad de

Malignidad   3% 35 – 39 años   15% 40 – 49 años   43% 50 – 59 años   50% ≥ 60 años

  Factores de Riesgo   Tabaquismo, Asbestosis, historia familiar   Historia de cáncer previo o concomitante

CASOS%CLINICO

  IM(73(AÑOS   Tabaquismo(suspendido(hace(10(años   TABACO(previo(25(paq/año   Cx(resección(Cáncer(Pulmonar(T1aN0M0(LII   TBC((f);(NAC((f);(EPD((f)

(Control(Tomografico(2009(Nódulo(Pulmonar(……..(

CASOS%CLINICOS

CASOS%CLINICOS% 1er TAC TORAX

CASOS%CLINICOS

ADENOCARCINOMA

Características Radiográficas

using the available information, including the patient’s clinical riskfactors and CT characteristics.

Clinical Risk Factors

The clinical assessment includes the patient’s history and phys-ical examination. Clinical risk factors associated with a higherprobability of malignancy are shown in Table 1 (1, 11, 13, 15).The physician should estimate the pretest probability of cancerby evaluating these risk factors and using clinical judgment.

Alternatively, models using logistic regression (16–18) can beused to estimate this probability. The logistic model of Swensenand coworkers (16) was developed using data from patients withnewly discovered solitary pulmonary nodules that were 4–30 mmin diameter and radiologically indeterminate. The model usesage, smoking history, history of cancer greater than or equal to 5years before the nodule was discovered, diameter, spiculation,and upper lobe location to estimate the probability of malig-nancy. No significant difference was found between results fromthe logistic model and the predictions of physicians (17). Free

Internet-based and mobile device applications are now avail-able that facilitate such calculations. A similar model was de-veloped and subsequently validated in a population witha higher prevalence of malignancy (18, 19).

CT Characteristics

The variables to assess with CT are the nodule’s size, bordercharacteristics, and density.

The probability of malignancy varies with size. For subcentim-eter pulmonary nodules, the overall prevalence of malignancy isrelatively low. In seven studies of nodules detected in lung cancerscreening trials, the prevalence of malignancy was 0–1% inpatients with nodules less than 5 mm in diameter, 6–28% for5- to 10-mm nodules, 33–64% for 11- to 20-mm nodules, and64–82% for nodules measuring greater than 20 mm (20).

Border characteristics can also be used to help estimate theprobability of malignancy. Nodules with irregular, lobulated, orspiculated borders are associatedwith a progressively higher prob-ability of malignancy than those with a smooth border. Similarly,nodules with a pure ground-glass or semisolid appearance havea higher probability of malignancy than pure solid lesions (20).

The density of nodules is also useful to discriminate betweenbenign and malignant nodules. Benign calcification patterns (dif-fuse, central, laminated, or popcorn patterns) and intranodularfat density (i.e., hamartoma) are associated with an extremelylow probability of malignancy, and nodules with these character-istics warrant careful (or even no) observation rather than addi-tional diagnostic testing (Figure 2) (21). Stippled and eccentriccalcification patterns do not exclude malignancy, and furtherwork-up is required.

Ground Glass Opacities (subsolid nodules)

Over the last 20 years, studies of screening-detected and inciden-tally detected peripheral adenocarcinomas have clarified associa-tions betweenCT characteristics, histopathology, growth rates, andclinical outcomes (22–25). In general, the prevalence of malig-nancy is especially high in nodules with pure ground-glass atten-uation (Figure 1A). Small, ground-glass lesions typically representadenocarcinoma in situ, previously referred to as bronchioloalveo-lar cell carcinoma (BAC), or its putative precursor lesion, atypicaladenomatous hyperplasia. These lesions tend to grow slowly andare associated with a very favorable prognosis, even when resec-tion is delayed by a period of observation (26, 27). Acceleratedgrowth or development of a solid component (Figure 1B) isstrongly associated with transition to invasive adenocarcinoma,so either of these findings should prompt surgical consultation.

Pre-test Probability and Post-test Probability

The pretest probability of cancer can be estimated from the clin-ical risk factors and theCT characteristics, as described previously.The posttest probability of cancer can be determined by combin-ing the pretest probability with test results, provided that the testcharacteristics (sensitivity and specificity) are known, by usingBayes’ theorem (see online supplement). However, even if onecan determine the posttest probability of cancer, one then has toask the following questions: Is this probability high enough towarrant surgery? Is it low enough to warrant careful observation?

CONCEPTUAL FRAMEWORK FOR DECISION MAKING

To answer these questions and evaluate management strategies,a conceptual framework is needed that facilitates comparison ofoptions. When selecting and interpreting tests for pulmonarynodule evaluation, it is important to consider not only the likelihood

Figure 1. (A) Ground-glassopacity. (B) Mixed ground-glass and solid nodule, alsocalled a semisolid nodule.(C) Solid lung nodule.

364 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 185 2012






CT Characteristics


















CT Characteristics













Características Radiográficas •  Tamaño(y(probabilidad(de(Malignidad

–  <(3(mm:(0.2% –  4f7(mm:(0.9% –  8f20(mm:(18% –  >(20(mm:(50%

•  Bordes(y(probabilidad(de(Malignidad –  Lisos:(20% –  Lobulados:(60% –  Espiculados:(90% –  Corona(radiada:(95%

LISO LOBULADO

ESPICULADO IRREGULAR


Bordes'Ondulados'


Lobulados'


Bordes'Espiculados'


Corona'Radiada'

Características Radiográficas •  Calcificación

–  Sugerente(de(benignidad •  Difusa,(homogenea •  Central •  Laminada((concentrica) •  Popcorn

–  No((sugerente(de(benignidad •  Reticular •  Punteado •  Amorfo •  Exentrico

•  Atenuación –  No(útil(in(general –  Grasa(sugiere(Hamartoma


Patrones'de'Calcifica8on'benigna'


Calcificación'No'Necesariamente'Benigna'

CASOS%CLINICOS%

EC(62(años   Tabaco:(5(cig/día(por(20(años   TBC((f);(NAC((f);(EPD((f)   VEF1(78%   Hcto(34%   PCR(40(mg/L   Derivado(desde(consultorio(por(Nodulo(pulmonar(que(se(observaen(control(radiológico(por(cuadro(de(�Resfrio(refuerte�.

CASOS%CLINICOS

Granuloma=Calcificado


CT=relative=attenuation=coefficients=(Hounsfield=units,=HU)

Fat f50(to(f100

Water 0

Cyst 0(to(20

Fresh(blood(clot 40(to(60

Noncalcified(nodule 40(to(160

Calcified(nodule( >200

Bone 1000

Air f1000


Hamartoma'con'Grasa'


Hamartoma'con'Grasa'y'Calcificación'

CASOS%CLINICOS%

GL(68(años Antecedente(de(Cáncer(Renal(operado(hace(8(años TABACO(Activo(=(Más(30(paq/año TBC((f);(NAC((f);(EPD((f) VEF1(80% Hcto(37% Derivado(desde(Urología(por(Nódulo(Pulmonar(en(control(TAC(de(Abdomen

CASOS%CLINICOS

Hamartoma


  Morfología   Nódulos de bordes lisos, adheridos o

próximos a la pleura o adheridos a Cisuras, localizados juxtavascularmente, y <10 mm probablemente son benignos   Linfonodos Intrapulmonares   Cicatrices Nodulares   Granulomas   Placas pleurales Nodulares

Características Radiográficas •  Morfología

–  (Nodulos(Cavitados •  Pared(Fina(<=1=mm:(usualmente(benigno •  Grosor(Pared((1K4=mm:(Frecuentemente(benigno •  Grosor(Pared(>=5=mm:(usualmente(maligno

–  Nodulos(rodeados(por(un(halo •  Aspergilosis(Angioinvasora(o(zygomicosis •  Linfoma •  Carcinoma(Bronquioalveolar( •  Coccidiomicosis •  Infeccion(bacteriana

Carcinoma escamoso


  Quistes paredes delgadas   Coccidiomicosis   Neumocistis Jiroveci   Metastasis de Cancer de Vejiga, menos

comunmente Sarcoma o Cáncer Tiroideo   Laceración pulmonar Traumatica

  Nodulos rodeados por pequeñas lesiones satélites son usualmente benignas.


•  Crecimiento –  Revisar(Rx(o(TAC(previos –  Lesiones(Malignas(tienden(a(tener(tiempos(de(doblaje((entre(20(y(400(dias.

–  Lesiones(Benignas(generalmente(tienen(tiempos(de(doblaje(<(20(dias(a(>(400(días

–  Doblaje(de(Volumen(=(30%(incremento(en(el(diametro –  Una(guía(general(es(que(2(años(de(estabilidad,(fuertemente,(sugiere(benignidad •  NO(aplicable(para(Opacidades(en(Vidrio(Deslustrado •  NO(aplicable(para(Carcinoide

CASOS%CLINICOS%

HRU(75(años Trabaja(en(pinturas(y(barnices TABACO(1(cig/día(por(7(años DM(tipo(2((+)(–(HTA((+)( TVP(hace(6(años.(Disnea(de(Esfuerzo.(Disminucion(apetito TBC((f);(NAC((f);(EPD((f) VEF1(96%(

CASOS%CLINICOS

CASOS%CLINICOS%

CASOS%CLINICOS

TUBERCULOSIS

PET- NPS •  PET(es(más(preciso(que(el(CT(en(distinguir(entre(

lesiones(benignas(y(malignas

•  Sensibilidad(90%,(Especificidad(80% •  MENOS=SENSIBLE=EN=NODULOS=<=8=–=10=mm

•  Falsos=positivos:(Infecciosos((Micosis(endémicas(o(infecciones(por(micobacterias,(Sarcoidosis,(Nòdulos(reumatoideos(y(otras(lesiones(granulomatosas

•  Falsos=negativos:(Adenocarcinoma(in(situ,(Tumor(Carcinoide,(y(algunos(Adenocarcinomas(bien(diferenciados((Mucinoso)

•  SUVmax=>=2.5=sugiere=Cáncer=o=inflamación=activa

BIOPSIA=GUIADA=POR=CT:

  Sensibilidad(90%.

  La(Sensibilidad(varía(ampliamente((65(–(94%)

  Riesgo(de(Neumotórax(varía:(15(–(43%((Mediana(27%).(El(Riesgo(de(requerir(tubo(de(Drenaje(es(de(4(–(18%

Factores(de(riesgo(para(Neumotórax:   Lesiones(pequeñas   Localización(profunda   Enfisema

  Sitio(de(punción(lateral   Cercanía(con(las(cisuras   Ángulo(de(entrada(en(la(pleura(bajo.

Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132:94S–107S.

ESTIMAR(LA(PROBABILIDAD(DE(CANCER

  Swensen(SJ,(Silverstein(MD,(Edell(ES,(Trastek(VF,(Aughenbaugh(GL,(Ilstrup(DM,(Schleck(CD.(Solitary(pulmonary(nodules:(clinical(prediction(model(versus(physicians.(Mayo=Clin=Proc=1999;74:319–329.

  Gould(MK,(Ananth(L,(Barnett(PG.(A(clinical(model(to(estimate(the(pretest(probability(of(lung(cancer(in(patients(with(solitary(pulmonary(nodules.(Chest=2007;131:383–388.

  Schultz(EM,(Sanders(GD,(Trotter(PR,(Patz(EF(Jr,(Silvestri(GA,(Owens(DK,(Gould(MK.(Validation(of(two(models(to(estimate(the(probability(of(malignancy(in(patients(with(solitary(pulmonary(nodules.(Thorax=2008;63:335–341.

WinerAMuram.'Radiology'2006;'239:34'

Manejo 1

•  Nodulo que está claramente creciendo debe ser biopsiado o resecado.

•  Si está estable por más de 2 años debe ser considerado benigno a menos que tenga morfología de vidrio esmerilado.

•  Nodulo con baja probabilidad de cáncer pueden ser seguidos con TAC seriados.

•  Nodulos < 1 cm y probabilidad intermediaria de cáncer pueden ser seguidos con TAC seriados.

Manejo 2

•  Nodulos(>(1(cm(o(probabilidad(intermedia(de(cáncer(puede(ser(evaluado(con(PET(or(biopsiado –  PET(negativo:(CT(tórax(seriado –  PET(positivo:(Resección(or(biopsia,(si(no(es(candidato(a(cirugia.

•  Nodulo(con(alta(probabilidad(de(cáncer(debe(ser(resecado.

•  CT(Tórax(seriado –  Fleischner(Society(guidelines –  NO(aplicable(a(posibles(cánceres(extratorácicos

•  Screening(con(TAC(Tórax(ha(demostrado(un(significativo(número(de(nuevos(nódulos,(la(mayoría(son(benignos.(

Fleischner'Society'Guidelines'

ACCP'Guidelines:'<'8'mm'Nodule'

ACCP'Guidelines:'8A30'mm'Nodule'

Original(Ar*cle((Reduced(Lung1Cancer(Mortality(with(Low1Dose(Computed(

Tomographic(Screening(

N'Engl'J'Med'Volume'365(5):395A409'

August'4,'2011'

Cumula8ve'Numbers'of'Lung'Cancers'and'of'Deaths'from'Lung'Cancer'

Protocolo&de&pesquisa&precoz&de&cáncer&pulmonar&%   Criterios=de=inclusión:   1.(Edad(≥(de(55(años(que(fuman(≥(15(paquetes(año(o(que(dejaron(de(fumar(esa(cantidad(hace(<(15(años

  2.(Edad(≥(40(años,(fumadores(habituales(con(antecedentes(familiares(de(cáncer(pulmonar

Berg(C,.(Reduced(LungfCancer(mortality(with(low(dose(computed(tomographic(Screening.(NLSTRT.(N(Engl(J(Med(2011;(365:395f409(

Clasificación=de=los=nódulos=en=TAC=de=tórax 1.=Benignos:=

•  1A.(Con(calcificación(central,(en(toda(la(periferia(o(uniforme.(

•  1B.(Con(grasa(

•  1C.(Nódulo(sólido(sin(cambios(en(tamaño(por(2(años

•  1D.(Diámetro((en(cualquier(medición)(<(4(mm(

2.=Indeterminados:

•  2A.(Diámetro(entre(4(y(10(mm

•  2B.(Nódulo(que(crece(sin(alcanzar(los(7(mm

3.=Sospechosos:

•  3A.(Diámetro(>10(mm

•  3B.(Nódulo(que(crece(alcanzando((7(mm

•  3C.(Diámetro(entre(4(y(10(mm(con(bordes(espiculados (

Nódulo'pulmonar'

Nódulo'benigno'

Calcificaciones'con'patrón'de'benignidad'

Densidad'grasa'

Ausencia'de'crecimiento'en'2'años'

Nódulo'maligno'

Nódulo''sólido'>'2'cm'

Nódulo'sólido'contorno'espiculado'

Nódulo'sólido'con'broncograma'aéreo'

Nódulo'no'sólido'persistente'>'1'cm'

Nódulo'mixto''persistente'

Calcificaciones'punteadas'o'excéntrica'

Nódulo'indeterminado'

Nódulo'sólido'<'2'cm':'

''Asin'espiculaciones'

'''Asin'broncograma'

'''Asin'calcificaciones''''''''malignas''

''A'sin'calcificaciones''''''benignas'o'grasa''

Nódulo'no'solido''persistente'<'1'cm'

resecar Controlar,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,abandonar

Dr. Juan Carlos Diaz Hospital Clínico Universidad de Chile Clínica Alemana de Santiago

NODULO(PULMONAR

Radiología(previa( (Rx(o(TAC(Tórax)

EVALUAR(RIESGO(DE(CANCER(PULMONAR

BAJO INTERMEDIO ALTO

EDAD((años) <(45( 45f60 >60 Ant(Cáncer NO SI Uso(TABACO NUNCA <(1(Paq/día ≥(1(paq/día Cese(habito ≥(7(años <(7(años NUNCA EPOC NO SI SI Expo(Asbesto NO SI TAMAÑO <(8 8f20 >(20 Bordes Lisos Lobulados Espiculados

Antecedentes=de=RIESGO=DE=CANCER=PULMONAR: f(HISTORIA(DE(TABAQUISMO(ACTUAL(O(PREVIO f(CONTACTO(CON(ASBESTO f(HISTORIA(PERSONAL(DE(CANCER f(HISTORIA(FAMILIAR(DE(CANCER(PULMONAR f(ANTECEDENTES(DE(EPOC(O(FIBROSIS(PULMONAR f(TABAQUISMO(PASIVO

TAC=TORAX=dosis=plena

ALGORITMO(NODULOS(SOLIDOS

NODULO=SOLIDO =≤=4=mm

NODULO=BENIGNO

NO=REQUIERE=CONTROL

NO=REQUIERE=CONTROL=

CONTROL ANUAL=POR=2=AÑOS TAC=BAJA=DOSIS

BAJO=RIESGO

RIESGO=INTERMEDIO

ALTO=RIESGO

NODULO=SOLIDO =5=–=10=mm

TAC(TORAX(BAJA(DOSIS (3(–(6(meses

Paciente(factores(de(riesgo((+) Tamaño(nódulo Contorno(espiculado Presencia(de(Broncograma(aéreo Calcificaciones(punteadas(o(excéntricas

NO=CRECE=o=se=resuelve

CONTROL ANUAL=POR=2=AÑOS TAC=BAJA=DOSIS

CRECE(=(Aumento(de(10%(diametro(

CRECE=

<=7=mm

CONTROL TAC=3=meses

≥=7=mm BIOPSIA Tasa(de(malignidad(de(acuerdo(al(tamaño(del(nodulo(Mayo(Clinic(Study'

Tamaño'de'la'lesión'

Tasa'de'malignidad'

<'4'mm' 0%'

4'–'7'mm' 1%'

7'–'20'mm' 15%'

>'20'mm' 81%'

NODULO=SOLIDO NO=CALCIFICADO >=10=mm

• (Factores(de(riesgo((+) • (Antecedente(personal(de(Cáncer

TAC(TORAX(CONTRASTADO

<=15=HU >=15=HU

BIOPSIA

TAC(TORAX(BAJA(DOSIS(EN(6(MESES CRECE(¡¡

Nódulos Sólidos

•  Creció=en=control=============3K6=meses

Sólido

5f8(mm

Sólido

>8(mm

PET=/=CT

SUV=<=1==============Probablemente(Benigno

Control(Anual((((((((((((((((TAC(de(baja(Dosis

Programa(Detección(Precoz

SUV=>=1===============Probablemente(Maligno

BIOPSIA

ALGORITMO(NODULOS((((NO=SOLIDOS

• Probablemente(Benignos VE(<(5(mm

•  TAC(en(((((((((((6(meses VE(5f10(mm

No=crece================================================= (o=crece=<=10%=de=su=diámetro)

CONTROL(ANUAL(TAC(TORAX(BAJA(DOSIS

CRECE=>=10% o=Aparece=componente=Sólido

BIOPSIA

ALGORITMO(NODULOS((((NO=SOLIDOS

• TAC=en=6=meses

VE(>(10(mm

• TAC=en=6=meses

Mixto((M) >(10(mm

PERSISTE=o=

Cambia=densidad

BIOPSIA

Conducta=frente=al=hallazgo=de=nódulos = 1.  Benignos:=Control(con(TAC(de(baja(dosis(a(los(12(y(24(meses.

(


Conducta=frente=al=hallazgo=de=nódulos =2.=Indeterminados:=control(de(TAC((baja(dosis(excepto(para(los(no(sólidos)(entre(3(y(6(meses(de(acuerdo(al(nivel(de(sospecha:

•  2A.(Si(no(hay(crecimiento(nuevo(control(de(TAC(a(los(12(y(24(meses((se(cuentan(desde(el(primer(TAC(indeterminado).(

•  2B.(Si(crece(sin(sobrepasar(los(7(mm(nuevo(control(de(TAC(entre(3(y(6(meses.

•  2C.(Si(crece(alcanzando((7(mm(pasa(a(categoría(de(sospechoso


Conducta=frente=al=hallazgo=de=nódulos =3.=Sospechosos 3A.=Realizar(biopsia(percutánea,(broncoscópica(o(

quirúrgica( 3B.(Realizar(TAC(con(protocolo(de(medición(de(densidad(

pre(y(post(administración(de(medio(de(contraste.   3B1.(Aumentan((<15(HU(de(densidad:(control(con(TAC(de(

baja(dosis(entre(6(y(12(meses   3B2.(Aumentan((15(HU(de(densidad:(biopsia 3C.(Realizar(PETfCT 3C1.(Sin(captación(anormal:(control(con(TAC(de(baja(dosis(entre(6(y(12(meses

3C2.(Captación(anormal:(biopsia

Conducta=frente=al=hallazgo=de=nódulos =3.=Sospechosos 3D.(Para(aquellos(nódulos(que(se(consideran(con(alta(probabilidad(de(ser(benignos:(Control(de(TAC((baja(dosis(o(alta(resolución(localizada(en(el(nódulo)(entre(3(y(6(meses(de(acuerdo(al(nivel(de(sospecha,(y(luego(a(los(12(y(24(meses(de(acuerdo(al(nivel(de(sospecha.


PROTOCOLO%ESTUDIO%NODULOS

Matías Florenzano Valdes INT/CER 2011

GRACIAS

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