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1
Department of Radiology, Division of Diagnostic Imaging, The University of
Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 057, Houston, TX
77030.
2
Department of Biostatistics, The University of Texas M. D. Anderson Cancer
Center, Houston, TX 77030.
Received July 18, 2000;
accepted after revision November 13, 2000.
Address correspondence to R. F. Munden.
Abstract
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SUBJECTS AND METHODS. A survey consisting of 13 case scenarios in which ditzels were encountered on CT examinations was mailed to the 406 members of the Society of Thoracic Radiology. Statistical analysis was performed to determine associations between responses, years of experience, location in an endemic region of granulomatous disease, and location at a lung or a general cancer center.
RESULTS. One hundred fifty-one surveys (37%) could be included in the analysis. The most common response was "short-term follow-up." As the likelihood of malignancy increased, the response of "recommend biopsy" or "considered malignant or metastatic" increased. Those radiologists located in an area considered endemic for granulomatous disease were more likely to consider an incidental ditzel benign and to recommend follow-up, whereas those in a nonendemic area were more likely to recommend biopsy. In the cases in which years of experience had an influence, the less experienced respondents were more likely to choose "nothing, considered benign" or short-term follow-up than biopsy.
CONCLUSION. The most common response was short-term follow-up, with less aggressive recommendations in cases with a lower likelihood of malignancy and more aggressive recommendations in cases with a higher likelihood of malignancy. Location in an area considered endemic for granulomatous disease and years of experience influenced decisions.
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In addition to the 13 clinical case scenarios, six questions were asked about the respondent's background and location. The respondent was asked the number of years in practice as a radiologist, the number of CT examinations performed monthly, whether the practice was located in an area endemic for granulomatous disease, and whether the practice location was a general cancer center or a lung cancer center.
In reporting the geographic distribution of respondents, the information was divided into United States and non-United States sections. The United States group was then subdivided into five geographic regions (Pacific, western, central, northeastern, and southeastern). The Pacific region included Alaska, California, Hawaii, Nevada, Oregon, and Washington. The western region consisted of Arizona, Colorado, Idaho, Kansas, Montana, Nebraska, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, Utah, and Wyoming. The central region comprised Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Ohio, and Wisconsin. The northeastern region consisted of Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. The southeastern region comprised Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Puerto Rico, South Carolina, Tennessee, Virginia, and West Virginia.
To facilitate reporting, the years of experience were grouped as 19 years or less, 20-29 years, and 30 years or more. Predetermining experience groupings (for example, <5 years; 6-15 years; and >15 years) without knowledge of appropriate separation points could result in biased reporting of the data. Therefore, the experience groupings were determined by evaluating the responses and forming group clusters on the basis of the number of years of experience. To standardize the format, group clustering by years of experience was done for all questions as a group rather than for each individual question and resulted in the grouping of 19 years or less, 20-29 years, and 30 years or more.
Independent of the experience groupings, Spearman's rank correlation coefficient tests were performed to determine the association between case responses and years of experience. Wilcoxon's rank sum tests were performed to determine the association between case responses and the respondent's location in a region with endemic disease, a cancer center, or a lung cancer center. A p value of less than 0.01 was considered statistically significant; that level was used to protect against false-positive conclusions from multiple testing.
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Of the 151 respondents, 122 respondents (81%) were from the United States and 29 (19%) were from outside the United States. Forty-eight respondents were from the northeastern region, 28 from the central, 18 from the southeastern, 18 from the western, and 10 from the Pacific region. In addition, 15 respondents were from Canada; three from the United Kingdom; two each from France, Japan, Korea, and Spain; and one each from Austria, Belgium, and Sweden.
Eighty-one respondents (54%) considered themselves to be located in an area endemic for granulomatous disease, and 70 (46%) did not. One hundred nineteen (79%) considered their practice a referral center for lung cancer, and 117 (77%) considered their practice a referral center for cancer in general.
The median number of years as a radiologist was 15 (range, 2-45 years). The median number of CT examinations performed per month was 100 (range, 0-2000).
Table 1 lists the numbers and percentages of responses for the 13 case scenarios. For statistical calculations, the response considered the most aggressive was counted when more than one response was indicated. For example, if "nothing, considered benign" and "short-term follow-up" were selected, then "short-term follow-up" was used for the calculations. Only minor variations occurred in the percentages when this method was compared with that of counting each multiple-answer response individually. The largest variation was seen for case 5; in this instance, when all responses were counted, 38% of respondents chose follow-up; when only the most aggressive response was counted, 34% chose follow-up.
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Table 2 lists the responses for each case based on years of experience. Tables 3,4,5 list the responses for each case based on practice location in an area endemic for granuloma, a lung cancer center, or a general cancer center, respectively.
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Responses by Case
In every case except cases 4 and 5, shortterm follow-up was the most
frequent recommendation (31-64%) for ditzels
(Table 1). In case 4 (a patient
with bronchogenic carcinoma and a contralateral ditzel), the percentage
recommending short-term follow-up (38%) was equal to the percentage
recommending biopsy. In case 5 (previously treated bronchogenic carcinoma and
new ditzel), short-term follow-up (34%) was second to biopsy (40%). In case 6,
short-term follow-up (38%) and biopsy (37%) were recommended virtually
equally.
Years of Experience
In several cases, the recommendations varied depending on the respondents'
years of experience (Table 2).
In case 1, in which an incidental ditzel is discovered in a young patient,
there were more responses of "nothing, considered benign" (46%)
among those with less than 19 years' experience than among those with more
than 30 years of experience, most of whom chose short-term follow-up (76%).
The group with 20-29 years of experience also favored short-term follow-up
(55%). These differences were statistically significant (p = 0.001).
Similar differences were seen for case 2.
In cases with the potential for metastasis, the responses were interesting. In case 4 (a patient with lung carcinoma), respondents with 19 years' experience or less recommended shortterm follow-up, and the others favored biopsy. In case 6 (an extrathoracic malignancy), those with more than 30 years of experience chose biopsy, whereas the others chose follow-up more often; however, this difference was not statistically significant (p = 0.94). For case 11 (granulomata and a ditzel), a significant difference in response was seen for those with less than 19 years of experience and the other experience groups. The proportion of respondents choosing follow-up increased from 47% for those with less than 19 years of experience to 65% for those with 20-29 years of experience and to 62% for those with 30 or more years of experience (p = 0.0014).
Location Endemic for Granuloma
In three cases (cases 1, 2, and 7), the response was significantly more
aggressive for radiologists in nonendemic locations
(Table 3). In case 1,
radiologists in a nonendemic region chose "recommend follow-up"
56% of the time compared with 45% for radiologists in an endemic location
(p = 0.029). "Considered benign" was chosen only 27% of
the time by radiologists in nonendemic areas compared with 49% by radiologists
in endemic areas. In case 2, radiologists in a nonendemic region chose
follow-up 67% of the time; radiologists in an endemic region chose it 58% of
the time (p = 0.022). "Considered benign" was chosen only
13% of the time by radiologists in nonendemic areas compared with 30% of the
time by radiologists in endemic areas. In case 7, radiologists in a nonendemic
region chose biopsy 33% of the time compared with 27% of the time by
radiologists in an endemic location (p = 0.034). Short-term follow-up
was chosen only 36% of the time by radiologists in nonendemic areas compared
with 51% for radiologists in endemic areas.
Cancer Referral Center
No statistically significant associations were seen between the responses
and the respondent's location at a lung cancer (n = 32,
Table 4) or general cancer
center (n = 34, Table
5). This may be because of the small number of affiliates not
associated with either type of cancer center. However, the response patterns
for case 4 (a patient with bronchogenic carcinoma) and cases 6, 7, and 10
(patients with extrathoracic malignancy) were interesting. In a patient with a
bronchogenic carcinoma, those at a lung cancer referral center were slightly
more likely to recommend short-term follow-up than were those not at a
referral center, who chose to recommend biopsy more often. A similar pattern
was also noted for patients with an extrathoracic malignancy. This pattern for
cases 6, 7, and 10 was not repeated for respondents at a general cancer
referral center. Only in case 4 (bronchogenic carcinoma) did those at a cancer
center recommend follow-up more often and those not at a cancer center
recommended biopsy more often.
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In every case except cases 4 and 5, short-term follow-up was the most frequent recommendation (31-64%) for ditzels. The recommendation of short-term follow-up occurred most often when the patient had no history of malignancy or was young (cases 1, 2, 3, 8, 9, 11, and 13). Even as the possibility for a malignant process increased as indicated in the case scenario, short-term follow-up remained a common choice. When an older patient at a higher risk of malignancy but with no prior malignancy (case 3) was considered, respondents' comments included "if smoker, would biopsy," "sometimes followed and sometimes biopsied," and "not sure what to do."
Recommending biopsy was the second most common response, with a range of 1-40%. Biopsy was recommended most often in a patient with a history of bronchogenic carcinoma and a new ditzel on follow-up CT (case 5). A comment given as the reason for recommending biopsy in this scenario was "this could represent a new primary carcinoma," which would be treated differently than metaststic disease. Biopsy was also a common answer in cases in which the ditzel could represent a metaststic lesion in a patient whose condition was newly diagnosed (cases 4 and 6). Comments regarding these cases included "if primary tumor resectable, would biopsy and if not, would follow" and "if this is the difference between stage I or not, would biopsy." Several respondents stated that the decision to biopsy rested with the referring surgeon. The survey made no mention of the method of biopsy to be recommended, and several respondents noted that they did not think a needle biopsy would be successful and that, instead of suggesting an open-lung biopsy, they would recommend follow-up. A few respondents suggested sending patients for VATS biopsy of ditzels to evaluate suspected metastatic disease.
The response, "nothing, considered benign," was most commonly given for the scenarios in which patients were at a low risk of malignancy (cases 1, 2, 8, and 11). Most comments stated that the lesion was considered a granuloma. Comments regarding these cases included "reported but encouraged to do nothing for younger patients" and "follow-up in 1 year." One respondent commented "have done VATS on these and most are benign."
Not surprisingly, when a patient with a prior malignancy developed one or more ditzels, a number of respondents considered these to be malignant or metastatic lesions. The largest percentage of respondents (26%) chose "considered malignant or metastatic, no biopsy needed" when multiple ditzels were present in a patient with a prior malignancy (case 10). In that case, several respondents commented that if the primary malignancy was breast, kidney, or thyroid carcinoma or melanoma, then the ditzels were metastatic and did not require biopsy. In cases 5 and 7, in which the patients had a previous malignancy and a new ditzel, a greater than usual percentage (17% and 15%, respectively) of respondents also considered the ditzel malignant. However, some of those who considered multiple ditzels metastatic in case 10 recommended short-term follow-up in cases 5 and 7. Those favoring biopsy commented that the choice to biopsy would depend on "age of patient" and "patient anxiety" and that "if stage I, would biopsy."
In cases 1, 2, 4, and 11, the respondents with more experience chose a more aggressive response than did the respondents having less than 19 years of experience. One can only speculate that more experienced radiologists have seen these smaller nodules develop into malignant lesions, whereas this uncommon event had not been experienced by younger radiologists. Because ditzels in patients in a region endemic for granuloma are often benign, it would be expected that respondents in such a region would be less aggressive in their management decisions regarding these lesions, and this expectation was confirmed in cases 1, 2, and 7.
Another important factor is the radiologist's location in an area considered endemic for granulomatous disease. Although a statistical difference between endemic and nonendemic location was found only for cases 1, 2, and 7, there was an overall trend for less aggressive recommendations by radiologists in an area endemic for granulomatous disease (Table 3). This is not an unexpected finding and reflects the bias resulting from the radiologist's location in these areas. Considering the influence of an endemic location will be important in future lung cancer screening studies.
Multiple responses were more common in cases with a malignancy and ditzels (cases 4-7). Many of the comments centered on the importance of establishing metastatic disease. If surgery or therapy were to be altered on the basis of a metastatic lesion, the tendency was to proceed to biopsy.
Two letters were sent in lieu of returning the survey. The authors believed that the choice of answers provided would not accurately reflect their management of the given case scenarios. Their comments also indicated a desire for more clinical history, especially regarding the type of malignancy and its risk for metastasis to the lungs, as well as the treatment options (surgery, chemotherapy, VATS) available for a particular case.
Many respondents indicated that the management of ditzels depends on the referring physician. Comments indicating this were, "if patient is otherwise operable and resectable, these lesions are ignored by our thoracic surgeons," "our surgeon would resect dominant lesion and watch the contralateral ditzel (case 4, bronchogenic cancer), and resect if necessary," "our clinicians make the decision based on the overall situation," and "what we recommend is generally not what happens."
Some of the radiologists wrote comments about their discomfort with the survey. Several respondents expressed concern that the choices given for recommendation and management were not worded exactly as they would prefer. A few questioned the choice of recommending biopsy of a tiny nodule, stating that these nodules are "too small to biopsy." However, others noted that transthoracic needle aspiration has been performed on 5-mm nodules that proved to be malignant. Because we knew that some radiologists perform transthoracic needle aspiration of nodules this small whereas others refer them for VATS, we did not include the method of biopsy in the response choice in order to prevent bias. Similarly, the length of the short-term follow-up was not included because the time for follow-up varies among radiologists.
Overall, the comments regarding individual cases reflected the desire for more clinical information to assess the "malignant potential" of the ditzel and to know if the clinical management of the patient depended on the histology of the ditzel. One respondent wrote, "how a ditzel is managed would depend heavily on the presence or absence of other signs of metastatic disease." Other comments were "depends on the primary—if likely to go to the lung" and "depends on staging of tumor: if stage I, would chase. If stage IV, doesn't matter." Certainly, more or correct clinical information can improve a radiologist's ability to correctly interpret the radiographs. Unfortunately, for a survey to provide extensive clinical information for all case scenarios would be impractical. Also, as with this survey, in clinical practice a complete clinical history is often not provided. Radiologists can expect to struggle with similar decisions if screening for lung cancer becomes common practice because the only clinical information will be that the patient has an increased risk for lung cancer.
Finally, several radiologists disagreed with the definition of a ditzel. They thought that a ditzel is a poorly defined lesion, smaller than 5 mm, that may or may not be limited to a subpleural location. As one aptly stated, "there are ditzels and then there are ditzels." We agree, and although the term is used in conversations and may imply an unknown significance, more definitive terminology should be used in radiology reports.
In conclusion, "short-term follow-up" was the most common response for virtually all case scenarios. The less likely the patient was to have a malignant process, the more likely the response centered around follow-up or "consider benign"; and the greater the concern for metastatic disease, the more likely the response centered around biopsy or "considered metastatic." In the cases in which years of experience had an influence, the younger respondents were more likely to choose the more conservative options of "nothing, considered benign" or follow-up. Radiologists located in an area endemic for granuloma recommended follow-up more than biopsy in patients with a malignancy, whereas those in a nonendemic region recommended biopsy more often. Those in an endemic region were also more likely to consider an incidental ditzel a benign lesion that required no further evaluation than were those not in an endemic region, who were more likely to recommend short-term follow-up. No significant differences were noted if the radiologist was at a lung cancer or general cancer center.
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Acknowledgments
We thank Laura Russell for her editorial review and Lorna Phillips for her
assistance in manuscript preparation. We also thank the members of the Society
of Thoracic Radiology who participated in the survey.
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