Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality

The pros and cons of lung cancer screening

Several trials have shown that low-dose computed tomography-based lung cancer screening (LCS) allows a substantial reduction in lung cancer-related mortality, carrying the potential for other clinical benefits. There are, however, some uncertainties to be clarified and several aspects to be implemented to optimize advantages and minimize the potential harms of LCS. This review summarizes current evidence on LCS, discussing some of the well-established and potential benefits, including lung cancer (LC)-related mortality reduction and opportunity for smoking cessation interventions, as well as the disadvantages of LCS, such as overdiagnosis and overtreatment. CLINICAL RELEVANCE STATEMENT: Different perspectives are provided on LCS based on the updated literature. KEY POINTS: Lung cancer is a leading cancer-related cause of death and screening should reduce associated mortality. This review summarizes current evidence related to LCS. Several aspects need to be implemented to optimize benefits and minimize potential drawbacks of LCS.

Economic evaluation of low-dose computed tomography for lung cancer screening among high-risk individuals - evidence from Hungary based on the HUNCHEST-II study

BACKGROUND

Lung cancer (LC) is the leading cause of cancer-related death in Hungary. Early diagnosis of LC contributes to delivering survival benefits to patients. Low-dose computer tomography (LDCT) is an imaging technology that can be used to identify smaller nodules. The aim of this study was to investigate the cost-effectiveness of introducing organised LDCT screening in Hungary among individuals aged 50 to 74 years with high-risk for developing LC using clinical effectiveness and resource utilisation inputs based on the recent HUNCHEST-II clinical trial.

METHODS

We estimated costs and outcomes in a cost-utility analysis framework over the time horizon of 30 years to compare annual and biennial screening for LC with LDCT against standard screening. The economic evaluation simulated a cohort of current and former smokers aged 50 to 74 years with a smoking exposure of at least 25 pack-years, using data from HUNCHEST-II, a multicentre study to evaluate the impact of LDCT screening on early detection of LC. Complementary data were retrieved from published studies and interviews with local experts.

RESULTS

The results of the analysis are favourable from an economic perspective: the introduction of biennial screening for LC with LDCT yielded an incremental effectiveness of 0.031 QALYs as well as an increase in costs of 306 764 HUFs over the 30-year -time horizon when compared to standard screening. The value of the base case ICER (9 908 100 HUF/QALY) of biennial screening for LC with LDCT over standard screening was below the relevant cost-effectiveness threshold. Applying an annual screening strategy using LDCT yielded even more favourable cost-effectiveness results (ICER = 7 927 455 HUF/QALY) compared to biennial screening. Notably, the cost-effectiveness of biennial screening was extendedly dominated by annual screening.

CONCLUSIONS

Along with the mature data on its effectiveness, our analysis confirms that using LDCT for LC screening among high-risk individuals is a cost-effective alternative of standard screening in Hungary. Funding a nationwide lung screening program that uses LDCT is a justified decision in economic terms; annual screening would be the optimal strategy to maximize health benefits; however in case of limited financial resources, biennial LDCT screening could offer a cost saving alternative for marginally less health gains than annual screening.

Improving CT scan for lung cancer diagnosis with an integromic signature

Lung cancer is the leading cause of cancer-related mortality globally, making early detection crucial for reducing death rates. Low-dose computed tomography (LDCT) screening helps detect lung cancer early but often identifies indeterminate pulmonary nodules (PNs), leading to potential overtreatment. This study aimed to develop a diagnostic test that accurately differentiates malignant from benign PNs detected on LDCT scans by analyzing non-coding RNAs, DNA methylation, and bacterial DNA in patient samples. Using droplet digital polymerase chain reaction, we analyzed samples from a training set of 150 patients with malignant PNs and 250 smokers with benign PNs. Individual biomarkers in plasma and sputum showed moderate effectiveness, with sensitivities ranging from 62% to 77% and specificities from 54% to 87%. We developed an integromic signature by combining two plasma biomarkers and one sputum biomarker, along with additional clinical data, which demonstrated a sensitivity of 90% and specificity of 95%. The signature's diagnostic performance was further validated in a cohort consisting of 30 patients with malignant PNs and 50 smokers with benign PNs. The integromic signature showed high sensitivity and specificity in distinguishing malignant from benign PNs identified through LDCT. This tool has the potential to significantly lower both mortality and health-care costs associated with the overtreatment of benign nodules, offering a promising approach to improving lung cancer screening protocols.

Beyond lung cancer screening, an opportunity for early detection of chronic obstructive pulmonary disease and cardiovascular diseases

BACKGROUND

Lung cancer screening programs concern smokers at risk for cardiovascular diseases (CVDs) and chronic obstructive pulmonary disease (COPD). The LUMASCAN (LUng Cancer Screening, MArkers and low-dose computed tomography SCANner) study aimed to evaluate the acceptability and feasibility of screening for these 3 diseases in a community population with centralized organization and to determine low-dose computed tomography (CT) markers associated with each disease.

METHODS

This cohort enrolled participants meeting National Comprehensive Cancer Network criteria (v1.2014) in an organized lung cancer-screening program including low-dose CT scans; spirometry; evaluations of coronary artery calcifications (CACs); and a smoking cessation plan at inclusion, 1, and 2 years; then telephone follow-up. Outcomes were the participation rate and the proportion of participants affected by lung cancer, obstructive lung disease, or CVD events. Logistic-regression models were used to identify radiological factors associated with each disease.

RESULTS

Between 2016 and 2019, a total of 302 participants were enrolled: 61% men; median age 58.8 years; 77% active smoker; 11% diabetes; 38% hypertension; and 27% taking lipid-lowering agents. Inclusion, 1-year, and 2-year participation rates were 99%, 81%, 79%, respectively. After a median follow-up of 5.81 years, screenings detected 12 (4%) lung cancer, 9 of 12 via low-dose CT (78% localized) and 3 of 12 during follow-up (all stage IV), 83 (27%) unknown obstructive lung disease, and 131 (43.4%) moderate to severe CACs warranting a cardiology consultation. Preexisting COPD and moderate to severe CACs were associated with major CVD events with odds ratios of 1.98 (95% confident interval [CI] = 1.00 to 3.88) and 3.27 (95% CI = 1.72 to 6.43), respectively.

CONCLUSION

The LUMASCAN study demonstrated the feasibility of combined screening for lung cancer, COPD, and CVD in a community population. Its centralized organization enabled high participation and coordination of healthcare practitioners.

Growth dynamics of lung nodules: implications for classification in lung cancer screening

BACKGROUND

Lung nodules observed in cancer screening are believed to grow exponentially, and their associated volume doubling time (VDT) has been proposed for nodule classification. This retrospective study aimed to elucidate the growth dynamics of lung nodules and determine the best classification as either benign or malignant.

METHODS

Data were analyzed from 180 participants (73.7% male) enrolled in the I-ELCAP screening program (140 primary lung cancer and 40 benign) with three or more annual CT examinations before resection. Attenuation, volume, mass and growth patterns (decelerated, linear, subexponential, exponential and accelerated) were assessed and compared as classification methods.

RESULTS

Most lung cancers (83/140) and few benign nodules (11/40) exhibited an accelerated, faster than exponential, growth pattern. Half (50%) of the benign nodules versus 26.4% of the malignant ones displayed decelerated growth. Differences in growth patterns allowed nodule malignancy to be classified, the most effective individual variable being the increase in volume between two-year-interval scans (ROC-AUC = 0.871). The same metric on the first two follow-ups yielded an AUC value of 0.769. Further classification into solid, part-solid or non-solid, improved results (ROC-AUC of 0.813 in the first year and 0.897 in the second year).

CONCLUSIONS

In our dataset, most lung cancers exhibited accelerated growth in contrast to their benign counterparts. A measure of volumetric growth allowed discrimination between benign and malignant nodules. Its classification power increased when adding information on nodule compactness. The combination of these two meaningful and easily obtained variables could be used to assess malignancy of lung cancer nodules.

Current Evidence for a Lung Cancer Screening Program

Background

Lung cancer screening is still in an early phase compared to other cancer screening programs, despite its high lethality particularly when diagnosed late. Achieving early diagnosis is crucial to obtain optimal outcomes.

Summary

In this review, we will address the current evidence on lung cancer screening through low-dose computed tomography (LDCT) and its impact on mortality reduction, existing screening recommendations, patient eligibility criteria, screening frequency and duration, benefits and harms, cost-effectiveness and some insights on lung cancer screening implementation and adoption. Additionally, new non-imaging, noninvasive biomarkers with high diagnostic potential are also briefly highlighted.

Key Messages

LDCT screening in a prespecified population based on age and smoking history proved to reduce lung cancer mortality. Optimization of the target population and management of LDCT pitfalls can further improve lung cancer screening efficiency and cost-effectiveness. Novel screening technologies and biomarkers being studied can potentially be game-changers in lung cancer screening and diagnosis.

Public Heterogeneous Preferences for Low-Dose Computed Tomography Lung Cancer Screening Service Delivery in Western China: A Discrete Choice Experiment

BACKGROUND

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) is an efficient method that can reduce lung cancer mortality in high-risk individuals. However, few studies have attempted to measure the preferences for LDCT LCS service delivery. This study aimed to generate quantitative information on the Chinese population's preferences for LDCT LCS service delivery.

METHODS

The general population aged 40 to 74 in the Sichuan province of China was invited to complete an online discrete choice experiment (DCE). The DCE required participants to answer 14 discrete choice questions comprising five attributes: facility levels, facility ownership, travel mode, travel time, and out-of-pocket cost. Choice data were analyzed using mixed logit and latent class logit (LCL) models.

RESULTS

The study included 2529 respondents, with 746 (29.5%) identified as being at risk for lung cancer. Mixed logit model (MLM) analysis revealed that all five attributes significantly influenced respondents' choices. Facility levels had the highest relative importance (44.4%), followed by facility ownership (28.1%), while out-of-pocket cost had the lowest importance (6.4%). The at-risk group placed relatively more importance on price and facility ownership compared to the non-risk group. LCL model identified five distinct classes with varying preferences.

CONCLUSION

This study revealed significant heterogeneity in preferences for LCS service attributes among the Chinese population, with facility level and facility ownership being the most important factors. The findings underscore the need for tailored strategies targeting different subgroup preferences to increase screening participation rates and improve early detection outcomes.

Surveillance of subsolid nodules avoids unnecessary resections in lung cancer screening: long-term results of the prospective BioMILD trial

Background

The management of subsolid nodules (SSNs) in lung cancer screening (LCS) is still a topic of debate, with no current uniform strategy to deal with these lesions at risk of overdiagnosis and overtreatment. The BioMILD LCS trial has implemented a prospective conservative approach for SSNs, managing with annual low-dose computed tomography nonsolid nodules (NSNs) and part-solid nodules (PSNs) with a solid component <5 mm, regardless of the size of the nonsolid component. The present study aims to determine the lung cancer (LC) detection and survival in BioMILD volunteers with SSNs.

Materials and methods

Eligible participants were 758 out of 4071 (18.6%) BioMILD volunteers without baseline LC and at least one SSN detected at the baseline or further low-dose computed tomography rounds. The outcomes of the study were LC detection and long-term survival.

Results

A total of 844 NSNs and 241 PSNs were included. LC detection was 3.7% (31 out of 844) in NSNs and 7.1% (17 out of 241) in PSNs, being significantly greater in prevalent than incident nodules (8.4% versus 1.3% in NSNs; 14.1% versus 2.1% in PSNs; p-value for both nodule types p<0.01). Most LCs from SSNs were stage I (42/48, 87.5%), resectable (47/48, 97.9%), and caused no deaths. The 8-year cumulative survival of volunteers with LC derived from SSNs and not derived from SSNs was 93.8% and 74.9%, respectively.

Conclusion

Conservative management of SSNs in LCS enables timely diagnosis and treatment of LCs arising from SSNs while ensuring the resection of more aggressive LCs detected away from SSNs.

Lung Lesions: Differential Diagnoses Beyond Cancer

BACKGROUND Lung cancer is the most common malignant neoplasm diagnosed worldwide. Early diagnosis and treatment are of great importance for patient's prognosis. A wide variety of pulmonary conditions display clinical and radiological presentation similar to that of lung cancer, and the awareness of their existence can help in making correct diagnoses. CASE REPORT This article presents a description of 4 patients with an insidious type of lesions mimicking pulmonary carcinomas. The first patient was referred to Department with a tumor-like lesion in the right lung. After CT of the chest and core-needle biopsy, the lesion turned out to be an ectopic thyroid tissue. The second patient reported a dry cough and weight loss. A lung nodule mass was revealed in chest CT and the patient was diagnosed with pulmonary tuberculoma. The remaining 2 patients, despite the suspicion of lung cancer, were subsequently diagnosed with a post-traumatic pleural hematoma and diffuse large B cell lymphoma. CONCLUSIONS Low-dose computed tomography of the chest plays a significant role in the diagnosis of newly detected lesions in the lungs. However, due to the similarity of the image of cancer to that of other diseases, the ultimate diagnosis should be based on the interpretation of full imaging diagnostic tests, clinical presentation, and histopathological examination of the material obtained from the lesion. Analysis of cases enables us to expand our understanding of the diseases that need to be considered in differential diagnosis of a patient with a detected tumor-like lesion in the lungs.

Integrating artificial intelligence into lung cancer screening: a randomised controlled trial protocol

INTRODUCTION

Lung cancer (LC) is the most common cause of cancer-related deaths worldwide. Its early detection can be achieved with a CT scan. Two large randomised trials proved the efficacy of low-dose CT (LDCT)-based lung cancer screening (LCS) in high-risk populations. The decrease in specific mortality is 20%-25%.Nonetheless, implementing LCS on a large scale faces obstacles due to the low number of thoracic radiologists and CT scans available for the eligible population and the high frequency of false-positive screening results and the long period of indeterminacy of nodules that can reach up to 24 months, which is a source of prolonged anxiety and multiple costly examinations with possible side effects.Deep learning, an artificial intelligence solution has shown promising results in retrospective trials detecting lung nodules and characterising them. However, until now no prospective studies have demonstrated their importance in a real-life setting.

METHODS AND ANALYSIS

This open-label randomised controlled study focuses on LCS for patients aged 50-80 years, who smoked more than 20 pack-years, whether active or quit smoking less than 15 years ago. Its objective is to determine whether assisting a multidisciplinary team (MDT) with a 3D convolutional network-based analysis of screening chest CT scans accelerates the definitive classification of nodules into malignant or benign. 2722 patients will be included with the aim to demonstrate a 3-month reduction in the delay between lung nodule detection and its definitive classification into benign or malignant.

ETHICS AND DISSEMINATION

The sponsor of this study is the University Hospital of Nice. The study was approved for France by the ethical committee CPP (Comités de Protection des Personnes) Sud-Ouest et outre-mer III (No. 2022-A01543-40) and the Agence Nationale du Medicament et des produits de Santé (Ministry of Health) in December 2023. The findings of the trial will be disseminated through peer-reviewed journals and national and international conference presentations.

TRIAL REGISTRATION NUMBER

NCT05704920.

[Statement Paper on the Implementation of a National Organized Program in Germany for the Early Detection of Lung Cancer in Risk Populations Using Low-dose CT Screening Including Management of Screening Findings]

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present concrete cornerstones for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process.

A Prospective Observational Study of Physical Activity Levels and Physical Fitness of People at High Risk for Lung Cancer

Introduction

Physical activity (PA) is a potentially modifiable risk factor for lung cancer, with previous research revealing that people who engage in more PA have lower risk of developing lung cancer. PA levels of lung cancer screening participants have not previously been explored.

Methods

Participants at a single Australian International Lung Screen Trial site were eligible for assessment of self-reported PA levels (International Physical Activity Questionnaire and Physical Activity Scale for the Elderly) and physical assessments (6-min walk distance, hand grip muscle strength, daily step count, and body composition) at a single time point during lung cancer screening. Statistics were predominantly descriptive, with parametric data presented as mean and SD and nonparametric data presented as median and interquartile range (IQR).

Results

A total of 178 participants were enrolled in this study, with a median age of 61 years. Of the participants, 61% were men and 51% were people who currently smoke. The median total International Physical Activity Questionnaire score was 1756 MET/min/wk (IQR 689, 4049). Mean total Physical Activity Scale for the Elderly score was 160 (SD 72), higher than described in healthy sedentary adults. The median daily step count was 7237 steps (IQR 5353, 10,038) and mean 6-minute walk distance was 545 m (SD 92). Median grip strengths were within predicted normal range, with an elevated median percentage body fat and low skeletal muscle mass found on body composition.

Conclusion

Almost a quarter of International Lung Screen Trial participants assessed reported low levels of PA and have a potentially modifiable risk factor to improve health outcomes. Larger studies are needed to characterize the burden of inactivity among high-risk lung cancer screening populations.

[Statement paper on the implementation of a national organized program in Germany for the early detection of lung cancer in risk populations using low-dose CT screening including management of screening findings]

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on the early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present key points for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process. CITATION FORMAT: · Vogel-Claussen J, Blum TG, Andreas S et al. Position paper on the implementation of a nationally organized program in Germany for the early detection of lung cancer in high-risk populations using low-dose CT screening including the management of screening findings requiring further workup. Fortschr Röntgenstr 2024; 196: DOI 10.1055/a-2178-2846.

Validation of the psychosocial consequences of screening in lung cancer questionnaire in the international lung screen trial Australian cohort

BACKGROUND

Evaluation of psychosocial consequences of lung cancer screening with LDCT in high-risk populations has generally been performed using generic psychometric instruments. Such generic instruments have low coverage and low power to detect screening impacts. This study aims to validate an established lung cancer screening-specific questionnaire, Consequences Of Screening Lung Cancer (COS-LC), in Australian-English and describe early results from the baseline LDCT round of the International Lung Screen Trial (ILST).

METHODS

The Danish-version COS-LC was translated to Australian-English using the double panel method and field tested in Australian-ILST participants to examine content validity. A random sample of 200 participants were used to assess construct validity using Rasch item response theory models. Reliability was assessed using classical test theory. The COS-LC was administered to ILST participants at prespecified timepoints including at enrolment, dependent of screening results.

RESULTS

Minor linguistic alterations were made after initial translation of COS-LC to English. The COS-LC demonstrated good content validity and adequate construct validity using psychometric analysis. The four core scales fit the Rasch model, with only minor issues in five non-core scales which resolved with modification. 1129 Australian-ILST participants were included in the analysis, with minimal psychosocial impact observed shortly after baseline LDCT results.

CONCLUSION

COS-LC is the first lung cancer screening-specific questionnaire to be validated in Australia and has demonstrated excellent psychometric properties. Early results did not demonstrate significant psychosocial impacts of screening. Longer-term follow-up is awaited and will be particularly pertinent given the announcement of an Australian National Lung Cancer Screening Program.

TRIAL REGISTRATION

NCT02871856.

Atlas for the CT Syndesmophyte Score (CTSS) in patients with axial spondyloarthritis

BACKGROUND

The Computed Tomography Syndesmophyte Score (CTSS) was developed as a reliable and sensitive tool to assess syndesmophytes in low-dose CT images of the entire spine in patients with axial spondyloarthritis (axSpA). The original paper provided sparce examples of the CTSS grades.

OBJECTIVES

Provide an atlas tailored to assist readers in understanding and employing the CTSS method.

METHODS

In this paper, illustrations of the different grades and views of the CTSS are presented. CTSS is used to measure bone formation in the spine of patients with axial spondyloarthritis (axSpA), in the form of syndesmophytes. In both the sagittal and coronal planes, syndesmophytes can be graded from 0 to 3 over 23 vertebral units starting at C2 and ending at S1. The CTSS ranges from 0 (absence of axSpA-related syndesmophytes) to 552 (total ankylosis of the spine).

RESULTS

The current atlas contains low-dose CT images of the spine without lesions (for reference) and all grades of syndesmophytes in different planes used in the CTSS. Examples are arranged per spinal segment (cervical, thoracic and lumbar).

CONCLUSIONS

These images can be used to assist any reader in the assessment of syndesmophytes on (low-dose) CT in patients with axSpA.

[Statement paper on the implementation of a national organized program in Germany for the early detection of lung cancer in risk populations using low-dose CT screening including management of screening findings]

The process of implementing early detection of lung cancer with low-dose CT (LDCT) in Germany has gained significant momentum in recent years. It is expected that the ordinance of the Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) on early detection of lung cancer, which has been commented on by the professional societies, will come into effect by the end of 2023. Based on this regulation, the Federal Joint Committee (G-BA) will set up a program for early lung cancer detection with LDCT in the near future. In this position paper, the specialist societies involved in lung cancer screening present concrete cornerstones for a uniform, structured and quality-assured early detection program for lung cancer in Germany to make a constructive contribution to this process.

Diagnostic value of circulating miRNA in the benign and malignant lung nodules: A systematic review and meta-analysis

BACKGROUND

Lung cancer is the leading cause of death worldwide, and its diagnosis remains a significant challenge. Identifying effective methods to differentiate benign from malignant lung nodules is of paramount importance. This meta-analysis aimed to evaluate the clinical utility of circulating microRNAs (miRNAs) for the differential diagnosis of benign and malignant lung nodules.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search was conducted across 4 electronic databases, without any temporal restrictions. The inclusion and exclusion criteria were strictly applied to assess the clinical applications of circulating miRNAs. A robust and transparent quality assessment was performed using the quality assessment of diagnostic accuracy studies-2 tool, and rigorous statistical analyses were conducted to synthesize the various diagnostic measures.

RESULTS

In the meta-analysis of 11 studies, quality assessment of diagnostic accuracy studies-2 assessment revealed < 5% high-risk methodologies, ensuring robustness. Sensitivity and Specificity were consolidated at 0.83 (95% confidence interval [CI]: 0.72-0.90) and 0.81 (95% CI: 0.73-0.88), respectively. The positive likelihood ratio and negative likelihood ratio were 4.45 (95% CI: 3.03-6.54) and 0.21 (95% CI: 0.12-0.35), respectively. The diagnostic odds ratio was 21.31 (95% CI: 10.25-44.30) and area under the receiver operating characteristic curve was 0.89 (95% CI: 0.86-0.91). Subgroup analysis highlighted significant variations in diagnostic accuracy by ethnicity and miRNA source, with non-Asian populations and serum-based tests showing higher diagnostic accuracy.

CONCLUSION

This meta-analysis demonstrated that circulating miRNAs hold substantial diagnostic value in distinguishing between benign and malignant lung nodules.

Ten reasons to screen women at risk of lung cancer

This opinion piece reviews major reasons for promoting lung cancer screening in at-risk women who are smokers or ex-smokers, from the age of 50. The epidemiology of lung cancer in European women is extremely worrying, with lung cancer mortality expected to surpass breast cancer mortality in most European countries. There are conflicting data as to whether women are at increased risk of developing lung cancer compared to men who have a similar tobacco exposure. The sharp increase in the incidence of lung cancer in women exceeds the increase in their smoking exposure which is in favor of greater susceptibility. Lung and breast cancer screening could be carried out simultaneously, as the screening ages largely coincide. In addition, lung cancer screening could be carried out every 2 years, as is the case for breast cancer screening, if the baseline CT scan is negative.As well as detecting early curable lung cancer, screening can also detect coronary heart disease and osteoporosis induced by smoking. This enables preventive measures to be taken in addition to smoking cessation assistance, to reduce morbidity and mortality in the female population. Key points • The epidemiology of lung cancer in European women is very worrying.• Lung cancer is becoming the leading cause of cancer mortality in European women.• Women benefit greatly from screening in terms of reduced risk of death from lung cancer.

Prevalence of subclinical lung cancer detected at autopsy: a systematic review

BACKGROUND

Lung cancer screening in high-risk populations with low-dose computed tomography is supported by international associations and recommendations. Overdiagnosis is considered a risk of screening with associated harms. The aim of this paper is to determine the prevalence of subclinical lung cancer diagnosed post-mortem to better understand the reservoir of subclinical lung cancer.

METHODS

We searched EMBASE, PubMed, and MEDLINE databases from inception until March 2022 with no language restrictions. We considered all studies with ≥100 autopsies in adults. Two reviewers independently assessed eligibility of studies, extracted data, and assessed risk of bias of included studies. We performed a meta-analysis using a random-effects model for prevalence of subclinical lung cancer diagnosed post-mortem with sensitivity and subgroup analyses.

RESULTS

A total of 13 studies with 16 730 autopsies were included. Pooled prevalence was 0.4% (95% CI 0.20 to 0.82%, I2 = 84%, tau2 = 1.19, low certainty evidence,16 730 autopsies). We performed a sensitivity analysis excluding studies which did not specify exclusion of children in their cohort, with a pooled prevalence of subclinical lung cancer of 0.87% (95% CI 0.48 to 1.57%, I2 = 71%, tau2 = 0.38, 6998 autopsies, 8 studies).

CONCLUSIONS

This is the first published systematic review to evaluate the prevalence of post-mortem subclinical lung cancer. Compared to autopsy systematic reviews in breast, prostate and thyroid cancers, the pooled prevalence is lower in lung cancer for subclinical cancer. This result should be interpreted with caution due to the included studies risk of bias and heterogeneity, with further high-quality studies required in target screening populations.

Dual targeting PET tracer [68Ga]Ga-FAPI-RGD in patients with lung neoplasms: a pilot exploratory study

Rationale: Early discovery, accurate diagnosis, and staging of lung cancer is essential for patients to receive appropriate treatment. PET/CT has become increasingly recognized as a valuable imaging modality for these patients, but there remains room for improvement in PET tracers. We aimed to evaluate the feasibility of using [⁶⁸Ga]Ga-FAPI-RGD, a dual-targeting heterodimeric PET tracer that recognizes both fibroblast activation protein (FAP) and integrin α_vβ₃ for detecting lung neoplasms, by comparing it with [¹⁸F]FDG and single-targeting tracers [⁶⁸Ga]Ga-RGD and [⁶⁸Ga]Ga-FAPI. Methods: This was a pilot exploratory study of patients with suspected lung malignancies. All 51 participants underwent [⁶⁸Ga]Ga-FAPI-RGD PET/CT, of which: 9 participants received dynamic scans, 44 participants also underwent [¹⁸F]FDG PET/CT scan within two weeks, 9 participants underwent [⁶⁸Ga]Ga-FAPI PET/CT scan and 10 participants underwent [⁶⁸Ga]Ga-RGD PET/CT scan. The final diagnosis was made based on histopathological analyses and clinical follow-up reports. Results: Among those who underwent dynamic scans, the uptake of pulmonary lesions increased over time. The optimal timepoint for a PET/CT scan was identified to be 2 h post-injection. [⁶⁸Ga]Ga-FAPI-RGD had a higher detection rate of primary lesions than [¹⁸F]FDG (91.4% vs. 77.1%, p < 0.05), higher tumor uptake (SUVmax, 6.9 ± 5.3 vs. 5.3 ± 5.4, p < 0.001) and higher tumor-to-background ratio (10.0 ± 8.4 vs. 9.0 ± 9.1, p < 0.05), demonstrated better accuracy in mediastinal lymph node evaluation (99.7% vs. 90.9%, p < 0.001), and identified more metastases (254 vs. 220). There was also a significant difference between the uptake of [⁶⁸Ga]Ga-FAPI-RGD and [⁶⁸Ga]Ga-RGD of primary lesions (SUVmax, 5.8 ± 4.4 vs. 2.3 ± 1.3, p < 0.001). Conclusion: In our small scale cohort study, [⁶⁸Ga]Ga-FAPI-RGD PET/CT gave a higher primary tumor detection rate, higher tracer uptake, and improved detection of metastases compared with [¹⁸F]FDG PET/CT, and [⁶⁸Ga]Ga-FAPI-RGD also had advantages over [⁶⁸Ga]Ga-RGD and was non-inferior to [⁶⁸Ga]Ga-FAPI. We thus provide proof-of-concept for using [⁶⁸Ga]Ga-FAPI-RGD PET/CT for diagnosing lung cancer. With the stated advantages, the dual-targeting FAPI-RGD should also be explored for therapeutic use in future studies.

[China National Lung Cancer Screening Guideline with Low-dose Computed Tomography (2023 Version)]

Lung cancer is the leading cause of cancer-related death in China. The effectiveness of low-dose computed tomography (LDCT) screening has been further validated in recent years, and significant progress has been made in research on identifying high-risk individuals, personalizing screening interval, and management of screen-detected findings. The aim of this study is to revise China national lung cancer screening guideline with LDCT (2018 version). The China Lung Cancer Early Detection and Treatment Expert Group (CLCEDTEG) designated by the China's National Health Commission, and China Lung Oncolgy Group experts, jointly participated in the revision of Chinese lung cancer screening guideline (2023 version). This revision is based on the recent advances in LDCT lung cancer screening at home and abroad, and the epidemiology of lung cancer in China. The following aspects of the guideline were revised: (1) lung cancer risk factors besides smoking were considered for the identification of high risk population; (2) LDCT scan parameters were further classified; (3) longer screening interval is recommended for individuals who had negative LDCT screening results for two consecutive rounds; (4) the follow-up interval for positive nodules was extended from 3 months to 6 months; (5) the role of multi-disciplinary treatment (MDT) in the management of positive nodules, diagnosis and treatment of lung cancer were emphasized. This revision clarifies the screening, intervention and treatment pathways, making the LDCT screening guideline more appropriate for China. Future researches based on emerging technologies, including biomarkers and artificial intelligence, are needed to optimize LDCT screening in China in the future.
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[Port-only 4-Arms Robotic Segmentectomy Under Artificial Pneumothorax]

BACKGROUND

At present, robotic surgery is widely used in thoracic surgery, which has higher maneuverability, precision, and stability, especially for small space complex operations and reconstructive surgery. The advantages of robotic lung segment resection under full orifice artificial pneumothorax are obvious.

METHODS

Based on a large number of clinical practices, we established a set of surgical methods for 4-arm robotic lung segment resection under a port-only artificial pneumothorax. 98 cases of robotic lung segment resection were performed with this method from January 2019 to August 2022. The clinical experience was summarized.

RESULTS

Robotic lung segment resection under port-only artificial pneumothorax has obvious advantages in the anatomy of lung segment vessels and bronchi. It is characterized by less bleeding, shorter operation time, adequate exposure, and flexible operation.

CONCLUSIONS

This surgical model we propose optimizes the operation mode and technique of lung segment resection, makes each step procedural, reduces collateral damage, and is easy to learn and master, which is believed to cure more lung cancer patients with less trauma.