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Lower Dosage CT-guided Lung Biopsy Protocol Maintains Quality, Minimizes Exposure

Lower Dosage CT-guided Lung Biopsy Protocol Maintains Quality, Minimizes Exposure. Jeremy Collins, MD Pegah E, Lewandowski RJ, Yaghmai V, Nemcek jr AA, & Carr JC Northwestern University, Chicago, IL. Outline. Lung Cancer Epidemiology Lung Nodule Evaluation

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Lower Dosage CT-guided Lung Biopsy Protocol Maintains Quality, Minimizes Exposure

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  1. Lower Dosage CT-guided Lung Biopsy Protocol Maintains Quality, Minimizes Exposure Jeremy Collins, MD Pegah E, Lewandowski RJ, Yaghmai V, Nemcekjr AA, & Carr JC Northwestern University, Chicago, IL

  2. Outline • Lung Cancer Epidemiology • Lung Nodule Evaluation • Low Dose CT Guidance Protocol Study • Newer Techniques to Lower CT Dose • Conclusion

  3. Lung Cancer Epidemiology • Lung cancer is the 2nd most common cancer type in both genders • Leading cause of cancer mortality • Lung nodule, mass • Extrapulmonary disease • Clinical models for lung cancer risk limited • Tobacco use • Accurate screening test necessary

  4. Background • Chest x-rays initial test for lung evaluation • Inexpensive • Low radiation dose • Limited sensitivity for early disease • Screening programs provided little benefit • Chest Computed Tomography superior for lung evaluation • More expensive • Extremely sensitive for lung disease

  5. National Lung Cancer Screening Trial • National Lung Cancer Screening Trial evaluated utility of CT screening for lung cancer • Preliminary results reported August 4, 2011 • Studied asymptomatic, high-risk patients • 55 to 74 years of age • > 30 pack-year tobacco use history • Subjects randomized to annual screening with either Chest x-rays or CT • Annual screening for three years

  6. National Lung Cancer Screening Trial • 53,454 patients, enrolled at 33 centers in U.S. • Abnormal findings • 24.2% CTs vs 6.9% of Chest x-rays • Further evaluation excluded cancer • 96.4% CTs vs 94.6% of Chest x-rays • CT screening resulted in 20% reduction in lung cancer specific mortality

  7. Lung Nodules • Most common finding at CT concerning for cancer • Diagnostic imaging characteristics not definitive • Nodule size • Growth • Metabolism • Biopsy is necessary to determine etiology

  8. Biopsy Techniques • CT is commonly utilized for biopsy • Skin entry site identified • Needle advanced through lung tissue • Lesion sampled • Risks: Air leak, bleeding, radiation exposure

  9. CT Radiation Dose • CT imaging and guidance procedures associated with finite radiation exposure • Limited data to evaluate impact of small dose • Theoretical risks extrapolated from atomic bomb survivor data • Cancer risk is incremental, linear • Interventional Radiologists strive to minimize patient dose for all procedures

  10. Low Dose CT Guidance Protocol Study • Lung nodules are surrounded by air-filled lung • Readily identified at CT • Lower dose acquisitions enable safe biopsy guidance • Low dose CT guidance protocol instituted at Northwestern in August 2011 • Modifications to manufacturer provided CT guidance protocol • Applicable to any multidetector scanner

  11. Low Dose CT Guidance Protocol Study • Retrospective Analysis, single institution • 50 consecutive biopsy procedures before & after protocol change • Procedures performed by interventional radiologists • Dose metrics • Protocol adherence • Image quality • Complications evaluated

  12. Low Dose CT Guidance Protocol Study • 66% average dose reduction • 3.5 mSv (1.0 - 8.0) vs 10.3 (1.7 - 52.4) • Comparator: CxR 0.06 mSv, Chest CT 8 mSv • No difference in nodule size, biopsy difficulty • 100% adherence to new protocol • Complications were minor, similar between groups

  13. Lung Nodule Biopsy Spiral Planning Low Dose Guidance

  14. Lung Nodule Biopsy Planning Scan Guidance Scan

  15. Additional CT Dose Reduction Techniques • Automated Exposure Control • Optimization of tube current to patient size, attenuation • Iterative Reconstruction • Newer technique to improve noise characteristics • Improves image quality at lower doses • Body Mass Index Adjusted Parameters • Smaller patients

  16. Conclusion • Lung cancer leading cause of mortality, CT screening of high risk patients will likely become routine • Low-dose CT biopsy techniques are necessary to minimize risk to screening cohort • Interventional Radiologists are experts in image guided procedures & well-positioned to champion low-dose CT guided techniques for lung nodule biopsy

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