Shadows in the Dark Mark H Lewy MD Chief Medical Director Guardian Life Insurance Co Goals of this talk Understand the diagnostic modalities Plain Xray Mammography Ultrasound CT Computerized Tomography Imaging ID: 598080
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Slide1
Evaluation of Breast , Pulmonary, and Thyroid Nodules
Shadows in the Dark
Mark H. Lewy, M.D.Chief Medical DirectorGuardian Life Insurance Co.Slide2
Goals of this talk
Understand the diagnostic modalitiesPlain Xray
MammographyUltrasoundCT (Computerized Tomography) ImagingMRI (Magnetic Resonance Imaging)Fine needle aspiration biopsyUnderstand the Risk Classification Systems
BI-RADS Breast Imaging and Data System (Breast)
Fleischner
Society Recommendations (Lung)ACCP recommendations (Lung)Bethesda System for Reporting Cytopathology (Thyroid)Slide3
Case #1
57 yo female, applying for 750K. 5’6”, 164 lb.Regular breast cancer screening since age 35 because her mom had breast cancer and is currently alive at 79
yo. She has had 2 biopsies in the past due to suspicious lesions, both fibroadenomas. Neither she nor her mother were tested for BRCA mutations. No history of BCP use.Her most recent mammogram 2 months ago was read as BI-RADS 3- Probably benign.
What would you do?Slide4
Breast Cancer
It is the most commonly diagnosed life threatening cancer in women.It is the second leading cause of cancer death in women after lung cancer.Approximately 1 in 8 women will develop breast cancer over the course of their lifetime.
R. Swart, MD, Breast Cancer Screening, http://emedicine.medscape.com/article/1945498-overview Slide5
Mammography Screening Guidelines
American Cancer SocietyUS Preventative Services Task ForceAmerican College of RadiologyAmerican Congress of Obstetricians and Gynecologists
National Comprehensive Care Network.Slide6
High Risk Screening
Family history, BRCA or other markersBasically start earlier with mammography and discuss risk reduction.Slide7
BI-RADS Classification
ASSESSMENT CATEGORIESCategory 0 / Need Additional Imaging Evaluation
Category 1 / Negative. Risk of malignancy 5 in 10,000Category 2 / Benign Finding . Risk 5 in 10,000
This is also a negative mammogram, but the interpreter may wish to describe a finding.
Involuting
, calcified fibroadenomas, multiple secretory calcifications, fat containing lesions such as oil cysts, lipomas, galactoceles, and mixed density hamartomas.Slide8
BI-RADS Classification
Category 3 / Probably Benign Finding - Short Interval Follow-Up Suggested. Risk <2%
A finding placed in this category should have a very high probability of being benign. It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability.
Category 4 / Suspicious Abnormality - Biopsy Should Be
Considered. Risk 25-50%
These are lesions that do not have the characteristic morphologies of breast cancer but have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy.Category 5 / Highly Suggestive of Malignancy - Appropriate Action Should Be Taken. Risk 75-99% These lesions have a high probability of being cancer
American College of Radiology. ACR Breast Imaging Reporting and Data System (BI-RADS) Web site. Available at
http://www.acr.org
. Slide9Slide10Slide11Slide12
Other breast cancer screening modalities
Ultrasound-Used as an adjunct to mammography and in diagnostic mammograms. No ionizing radiation.MRI- Used in high risk and the more dense breasts of younger
women. Also much better at detecting DCIS. Ct can also be used for these situations, but there are concerns for the increased radiation.Nuclear Imaging with technetium-99m- Not used for screening but is used in difficult or non-diagnostic cases.Tomosynthesis
- 3D breast imaging. Improved detection but double the radiation dose. Under further study.
Electrical
Impedance Imaging (T-scan)-measures electrical conduction in the breast. Approved adjunct to mammography.Slide13
Other breast cancer screening modalities
CT Laser Mammography-ExperimentalDuctal Lavage-breast cells from milk ductsThermography- no compelling evidence and currently not FDA approved
. Sensitivity significantly lower than mammography.Slide14
Case #1
57 yo female, applying for 750K. 5’6”, 164 lb.Regular breast cancer screening since age 35 because her mom had breast cancer and is currently alive at 79
yo. She has had 2 biopsies in the past due to suspicious lesions, both fibroadenomas. Neither she nor her mother were tested for BRCA mutations. No history of BCP use.Her most recent mammogram 2 months ago was read as BI-RADS 3- Probably benign.
What would you do?Slide15
Case #2
58 yo male, applying for $500K WL. He is married with 2 adult children. 5’9”, 223lb.June 2016,
he was complaining of some chest pain. EKG and nuclear stress test were negative for ischemia. Cardiac enzymes performed in the ED were negative. As part of the evaluation for a possible pulmonary embolus a 6 mm non calcified lesion was seen in the LUL. He had not had a previous CT and did not recall even a chest xray. The ER doctor told him to follow up with regular doctor for appropriate follow up.PMH- asthma x 5 years, uses an inhaler
SH-He has been a 1 pack per day
since he was 14Slide16
Case #2 continued
Exam- negativeJuly, 2016-he followed up with his doctor. He denied any chest pains and with the previous testing the doctor did not seem concerned. It is noted that the client was to quit smoking and lose weight.
Insurance exam was not illuminating. Labs were all normal except for cotinine in the urine.Slide17
Solitary Pulmonary Nodules
A solitary pulmonary nodule is defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated with adenopathy,
atelectasis, or pleural effusion.Slide18
Solitary Pulmonary Nodule
These are the questions that clinicians and underwriters need to answer.Benign or malignant?Investigated or observed?Should it be
resected and/or biopsied?Survival rate of lung cancer is 14% at 5 yearsSlide19
Benign lung tumors
Hamartomas- mixed mature cells consisting of fat , cartilage, and muscle cells.Bronchial Adenomas- half of all benign tumorsMucous gland adenomas
Papillomas- usually arise from virusesHemangiomasSlide20
Malignant Lung Tumors
Bronchogenic carcinomaAdenocarcinomaSquamous cell carcinoma
Large cell lung cancerSmall cell lung cancerLymphomaMetastasesSlide21
Risk Factors
Factors that place the patient at high riskSMOKING, SMOKING, SMOKINGOccupational Risk or Exposure- asbestos, radon, nickel, polycyclic hydrocarbons, vinyl chloride
Factors that place the patient at low riskNot smokingSlide22
Imaging
Chest xray- not very useful with nodules less than 1 cm.CT scan- 3-4 mm size detection.PET scan- looks at metabolic activity, diagnostic accuracy, 80%
SPECT scanSlide23
Characteristics of lung nodules
Size- greater than 2 cm, 50% were malignantGrowth rate- doubling time of most cancers is 1-18 mo. Double in volume corresponds to 25% increase in diameter.
Presence of calcification- usually suggests benignancy.Border characteristics- smooth, well demarcated borders suggest benignancy.Internal characteristics
LocationSlide24
What should we accept in underwriting?
Fleischner Society RecommendationsLow riskLess than 4 mm- no further investigation
4-6 mm- CT scan at 12 months6-8 mm- 18 month follow up>8 mm- 24 month follow up 24 months follow up with enhanced scanning or biopsyHigh riskLess than 4 mm follow up at 12 months
4-6 mm- follow up to 24 months
6-8 mm follow up to 24 months
> 8 mm- follow up with enhanced scans or biopsy up to 24 months
Fleischner
Society Pulmonary Nodule Guidelines
. Radiology 2005; 237:395-400Slide25
ACCP recommendations for larger lesions >1 cm
Low risk- follow for 24 monthsIntermediate risk-PET scan or needle biopsy if amenableHigh risk- Surgical resectionSlide26
Lung Cancer ScreeningSlide27
Asif
Alavi
, MD, Solitary Pulmonary Nodule, http://emedicine.medscape.com/article/2139920-overview Slide28
Asif
Alavi
, MD, Solitary Pulmonary Nodule, http://emedicine.medscape.com/article/2139920-overview Slide29
Asif
Alavi
, MD, Solitary Pulmonary Nodule, http://emedicine.medscape.com/article/2139920-overview Slide30
Case #2
58 yo male, applying for $500K WL. He is married with 2 adult children. 5’9”, 223lb.June, 2014, he was complaining of some chest pain. EKG and nuclear stress test were negative for ischemia. Cardiac enzymes performed in the ED were negative. As part of the evaluation for a possible pulmonary embolus a 6 mm non calcified lesion was seen in the LUL. He had not had a previous CT and did not recall even a chest
xray. The ER doctor told him to follow up with regular doctor for appropriate follow up.PMH- asthma x 5 years, uses an inhaler
SH-He has been a 1 pack per day life long smokerSlide31
Case #2 continued
Exam- negativeJuly, 2014-he followed up with his doctor. He denied any chest pains and with the previous testing the doctor did not seem concerned. It is noted that the client was to quit smoking and lose weight.Insurance exam was not illuminating. Labs were all normal except for cotinine in the urine.Slide32
Discussion
AgeSexConcernsRisk factorsRecommendations
Offer- preferred, standard, low substandard, high substandard, PP/declineSlide33
Case #2 continued
He runs out immediately after receiving our decision and gets the follow-up CT of the chest and the lesion remains unchanged and he is relieved.The agent calls you and thanks you profusely for being so thorough and finding this information that his doctor missed.The client was so excited that he wants to get an additional 500K now that he knows he is OK. He is also going to quit smoking because of you.
What do you offer now with this new info?Slide34
Case #3
A 49 yo female applied for $500K of term insurance. In May of 2016, s
he noticed a small lump on her trachea. She went to her primary care physician who ordered an ultrasound. The ultrasound revealed a 1.3 cm hypoechoic mass in her thyroid. Thyroid labs were noted to be normal. Thyroid radioiodine imaging showed a hot nodule. A fine needle aspiration biopsy (FNAB) was recommended but not completed.Can we offer?Slide35
Solitary Thyroid Nodules
Thyroid nodular disorders affect about 5% of the US population.Approximately 5-20% of thyroid nodules are neoplasms.
Differentiating hyperplasia from neoplasm may be difficult.Differentiating benign neoplasm from malignant neoplasm may be difficult.Evaluation requires the cooperation of the PCP, endocrinologist, radiologist, pathologist, and surgeon.Slide36
Thyroid Nodular Disease
Nodular disease is more common in women.Nodules increase in frequency with age.Look for history of neck irradiation.
Benign lesions include adenomas, cysts, thyroiditis, and hyperplasia.Thyroid cancer accounts for 1 % of all new cancers diagnosed in the US.Malignant nodules are found more often in men than in women.Cancers include follicular, papillary,
medullary
,
Hurthle, sarcoma, and lymphoma.Slide37
Differential Diagnosis
Physical exam is for the most part not helpful.Solitary nodules: Most likely to be malignant in patients older than 60 years and in patients younger than 30 years Increased rate of malignancy in males
Nodular growth Rapid growth: Ominous sign Usually painless (nontender to palpation); sudden onset of pain more strongly associated with benign disease (eg
, hemorrhage into a benign cyst,
subacute
viral thyroiditis) Hard and fixed nodules Look for molecular genetic testing to become the diagnostic test of the not to distant future.Slide38
Differential Diagnosis- Imaging
UltrasonographyUltrasonography remains the most important imaging modality in the evaluation of thyroid cancer and should be used routinely to assess the primary tumor and all associated cervical lymph node basins preoperatively.
Ultrasonographically guided fine-needle aspiration of suspicious lymph nodes may be useful in guiding the extent of surgery Radionuclide StudiesHot vs. warm vs. cold nodules
CT and MRI
Mostly helpful in staging and invasion into surrounding tissue but not in the initial differentiation of malignancy and benignancySlide39
Fine Needle Aspiration Biopsy(FNAB)
Test of choice due to accuracy, safety, and cost effectiveness. Sensitivity, specificity, and accuracy are 83%, 92%, and 95%.Very good in papillary cancers.
Not so good in follicular and Hurthle cell cancers which are frequently returned as indeterminate.Treatment of choice is usually surgical excision or RAI-131.Slide40
Bethesda System for Reporting Thyroid Cytopathology
Risk of MalignancyBenign- <1% are malignant
Atypia- 5-10% are malignantFollicular neoplasm- 20-30% are malignantSuspicious for malignancy- 50-75% are malignantMalignant- 100%
Baloch
ZW, et al.
The: National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference: a summation.
Cytojournal
. 2008;5:6. doi:10.1186/1742-6413-5-6
The Bethesda System for Reporting Thyroid Fine-Needle Aspiration Specimens
Am J Clin Pathol
2010
134
:343-Slide41
Management
For atypia-Repeat FNAB in 3-6 months or surgical consultation for those at higher clinical risk.Follicular neoplasm- Should (almost) always be referred for surgical management.
Nondiagnostic due to inadequate sampling means nondiagnostic. The test needs to be repeated in order to proceed.Slide42
Radionuclide scan
Kahn, http://emedicine.medscape.com/article/385301-overviewSlide43
Ultrasound
Kahn, http://emedicine.medscape.com/article/385301-overviewSlide44
Case #3
A 49 yo female applied for $500K of term insurance. In May of 2016, she noticed a small lump on her trachea. She went to her primary care physician who ordered an ultrasound. The ultrasound revealed a 1.3 cm hypoechoic
mass in her thyroid. Thyroid labs were noted to be normal. Thyroid radioiodine imaging showed a hot nodule. A fine needle aspiration biopsy (FNAB) was recommended but not completed.Can we offer?Slide45
Case #3
A FNAB was performed and showed atypia. Repeat was suggested in 3-6 months.Now would you offer?