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Lung nodules: size still matters

Anna Rita Larici, Alessandra Farchione, Paola Franchi, Mario Ciliberto, Giuseppe Cicchetti, Lucio Calandriello, Annemilia del Ciello, Lorenzo Bonomo
European Respiratory Review 2017 26: 170025; DOI: 10.1183/16000617.0025-2017
Anna Rita Larici
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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  • For correspondence: annarita.larici@unicatt.it
Alessandra Farchione
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Paola Franchi
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Mario Ciliberto
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Giuseppe Cicchetti
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Lucio Calandriello
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Annemilia del Ciello
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Lorenzo Bonomo
Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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  • FIGURE 1
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    FIGURE 1

    Limitations of two-dimensional (2D) measurements. The axial diameter may not be the maximum one in the evaluation of lung nodules. a) A small part-solid nodule in the apico-posterior segment of the left upper lobe, with a maximum axial diameter of 12×12.2 mm; b) the sagittal multiplanar reconstruction shows that the largest diameter of the same nodule is the sagittal one of 24.7 mm. The multiplanar evaluation of nodule diameter is especially important to document asymmetrical growth of nodules. c), d) The low level of agreement when measuring small nodules: for the same nodule in the right lower lobe two different diameter values have been reported by two readers. Considering the nearest whole diameter of the two values, it results in 1 mm difference in the maximum diameter, a significant difference when considering small nodules.

  • FIGURE 2
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    FIGURE 2

    Disagreement in measuring the solid portion of a part-solid nodule when using different reconstruction algorithms and window settings. A part-solid nodule in the apical segment of left lower lobe is shown. a) By using a high-spatial frequency algorithm and the lung window, the measured maximum axial diameter of the solid portion of the nodule corresponds to 20.3 mm; b) by using a smooth algorithm and the mediastinal window, the measured maximum axial diameter of the solid portion of the nodule corresponds to 16 mm. 2D: two-dimensional.

  • FIGURE 3
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    FIGURE 3

    Volume evaluation during follow-up allows the detection of nodule growth over a shorter period of time compared to diameter estimation. a) Computed tomography (CT) axial image shows the same nodule located in the right lower lobe as reported in figure 1c; b) a 3-month follow-up axial CT image demonstrates minimal change in nodule diameters; c) conversely, nodule volume calculation using a three-dimensional (3D) volumetric method demonstrates a significant increase in volume within the range of malignancy. Histopathology revealed a carcinoid tumour. 2D: two-dimensional; TV: total volume; DT: volume doubling time; %G: volume increase; scan inter: scan interval. Squares in the nodule represent the starting points of the 3D analysis.

Tables

  • Figures
  • TABLE 1

    Relationship between nodule size, expressed as diameter and volume, and growth rate, expressed as volume doubling time (VDT), with the prevalence of malignancy

    Prevalence of malignancy %
    NELSON screening study [8]Literature review [9]
    Diameter mm
     <50.40–1
     5–101.36–28
     ≥1015.233–60
     ≥2064–82
    Volume mm3
     ≤1000.6
     100–3002.4
     ≥30016.9
    VDT days
     ≥6000.8
     400–6004
     ≤4009.9

    Data from [8, 9].

    • TABLE 2

      Technical factors that may affect volume measurement

      Effects on volumetry
      Section thicknessVolume overestimation with thick sections [40, 68, 69, 86–89]
      Overlapping reconstructionVolume overestimation with non-overlapping sections [90, 91]
      PitchLow accuracy with high pitch mode [92]
      Reconstruction algorithmsEasier nodule sampling with high spatial frequency algorithms [86, 89, 91, 93]
      Volume overestimation with high spatial frequency algorithms [90, 94, 95]
      Intravenous contrast mediumVolume overestimation [95–97]
      Scanner typeDifferences in volume estimation [50, 86, 98]
      Higher accuracy with helical CT scanner [98]
      Low radiation doseLow accuracy [76, 99, 100]
      Iterative reconstructionBetter performance [101–112]
      Manual versus semi/automated methodReduced observer variability with automated system [113, 114]
      Manual interaction reduces bias due to the software performance [55, 115]
      Software and algorithms packageDifferences in volume estimation [57, 67, 116–118]

      CT: computed tomography.

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      Lung nodules: size still matters
      Anna Rita Larici, Alessandra Farchione, Paola Franchi, Mario Ciliberto, Giuseppe Cicchetti, Lucio Calandriello, Annemilia del Ciello, Lorenzo Bonomo
      European Respiratory Review Dec 2017, 26 (146) 170025; DOI: 10.1183/16000617.0025-2017

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      Lung nodules: size still matters
      Anna Rita Larici, Alessandra Farchione, Paola Franchi, Mario Ciliberto, Giuseppe Cicchetti, Lucio Calandriello, Annemilia del Ciello, Lorenzo Bonomo
      European Respiratory Review Dec 2017, 26 (146) 170025; DOI: 10.1183/16000617.0025-2017
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      • Article
        • Abstract
        • Abstract
        • Introduction: the “size” of the problem
        • Size and malignancy
        • Size changes: the growth rate
        • Size measurements: methods and limitations
        • Factors influencing nodule measurement variations
        • Effect of measurement variations on nodule growth
        • Subsolid nodules: special considerations
        • Integrating clinical and nodule characteristics: risk prediction models
        • Size and follow-up recommendations
        • Conclusions
        • Footnotes
        • References
      • Figures & Data
      • Info & Metrics
      • PDF

      Subjects

      • Lung cancer
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