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Godfrey CM, Shipe ME, Welty VF, Maiga AW, Aldrich MC, Montgomery C, Crockett J, Vaszar LT, Regis S, Isbell JM, Rickman OB, Pinkerman R, Lambright ES, Nesbitt JC, Maldonado F, Blume JD, Deppen SA, Grogan EL. The Thoracic Research Evaluation and Treatment 2.0 Model: A Lung Cancer Prediction Model for Indeterminate Nodules Referred for Specialist Evaluation. Chest 2023; 164:1305-1314. [PMID: 37421973 PMCID: PMC10635839 DOI: 10.1016/j.chest.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/03/2023] [Accepted: 06/01/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Appropriate risk stratification of indeterminate pulmonary nodules (IPNs) is necessary to direct diagnostic evaluation. Currently available models were developed in populations with lower cancer prevalence than that seen in thoracic surgery and pulmonology clinics and usually do not allow for missing data. We updated and expanded the Thoracic Research Evaluation and Treatment (TREAT) model into a more generalized, robust approach for lung cancer prediction in patients referred for specialty evaluation. RESEARCH QUESTION Can clinic-level differences in nodule evaluation be incorporated to improve lung cancer prediction accuracy in patients seeking immediate specialty evaluation compared with currently available models? STUDY DESIGN AND METHODS Clinical and radiographic data on patients with IPNs from six sites (N = 1,401) were collected retrospectively and divided into groups by clinical setting: pulmonary nodule clinic (n = 374; cancer prevalence, 42%), outpatient thoracic surgery clinic (n = 553; cancer prevalence, 73%), or inpatient surgical resection (n = 474; cancer prevalence, 90%). A new prediction model was developed using a missing data-driven pattern submodel approach. Discrimination and calibration were estimated with cross-validation and were compared with the original TREAT, Mayo Clinic, Herder, and Brock models. Reclassification was assessed with bias-corrected clinical net reclassification index and reclassification plots. RESULTS Two-thirds of patients had missing data; nodule growth and fluorodeoxyglucose-PET scan avidity were missing most frequently. The TREAT version 2.0 mean area under the receiver operating characteristic curve across missingness patterns was 0.85 compared with that of the original TREAT (0.80), Herder (0.73), Mayo Clinic (0.72), and Brock (0.68) models with improved calibration. The bias-corrected clinical net reclassification index was 0.23. INTERPRETATION The TREAT 2.0 model is more accurate and better calibrated for predicting lung cancer in high-risk IPNs than the Mayo, Herder, or Brock models. Nodule calculators such as TREAT 2.0 that account for varied lung cancer prevalence and that consider missing data may provide more accurate risk stratification for patients seeking evaluation at specialty nodule evaluation clinics.
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Affiliation(s)
- Caroline M Godfrey
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Maren E Shipe
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Valerie F Welty
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Amelia W Maiga
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Division of Thoracic Surgery, Veterans Hospital, Tennessee Valley Healthcare System, Nashville, TN
| | - Melinda C Aldrich
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jerod Crockett
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Shawn Regis
- Department of Radiation Oncology, Lahey Hospital and Medical Center, Burlington, MA
| | - James M Isbell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Otis B Rickman
- Division of Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Rhonda Pinkerman
- Division of Thoracic Surgery, Veterans Hospital, Tennessee Valley Healthcare System, Nashville, TN
| | - Eric S Lambright
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan C Nesbitt
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Division of Thoracic Surgery, Veterans Hospital, Tennessee Valley Healthcare System, Nashville, TN
| | - Fabien Maldonado
- Division of Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey D Blume
- School of Data Science, University of Virginia, Charlottesville, VA
| | - Stephen A Deppen
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Eric L Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Division of Thoracic Surgery, Veterans Hospital, Tennessee Valley Healthcare System, Nashville, TN.
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Pozzessere C, von Garnier C, Beigelman-Aubry C. Radiation Exposure to Low-Dose Computed Tomography for Lung Cancer Screening: Should We Be Concerned? Tomography 2023; 9:166-177. [PMID: 36828367 PMCID: PMC9964027 DOI: 10.3390/tomography9010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
Lung cancer screening (LCS) programs through low-dose Computed Tomography (LDCT) are being implemented in several countries worldwide. Radiation exposure of healthy individuals due to prolonged CT screening rounds and, eventually, the additional examinations required in case of suspicious findings may represent a concern, thus eventually reducing the participation in an LCS program. Therefore, the present review aims to assess the potential radiation risk from LDCT in this setting, providing estimates of cumulative dose and radiation-related risk in LCS in order to improve awareness for an informed and complete attendance to the program. After summarizing the results of the international trials on LCS to introduce the benefits coming from the implementation of a dedicated program, the screening-related and participant-related factors determining the radiation risk will be introduced and their burden assessed. Finally, future directions for a personalized screening program as well as technical improvements to reduce the delivered dose will be presented.
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Affiliation(s)
- Chiara Pozzessere
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland
- Correspondence:
| | - Christophe von Garnier
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland
- Division of Pulmonology, Department of Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Catherine Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland
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Subpopulations of Circulating Cells with Morphological Features of Malignancy Are Preoperatively Detected and Have Differential Prognostic Significance in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13174488. [PMID: 34503298 PMCID: PMC8431290 DOI: 10.3390/cancers13174488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Lung cancer is by far the main cause of cancer-related deaths among both men and women. Early detection of malignant nodules and non-invasive monitoring of disease status is essential to increase the chance of cure. In this study, we analyzed the frequency and the biological features of circulating tumor cells, i.e., cells released from the tumor and in transit in the bloodstream, in patients with a diagnosis of non-small cell lung cancer undergoing surgical resection, with the aim to develop a blood-based diagnostic test and to promptly identify patients at risk of post-operative disease recurrence. Abstract Background: Non-small cell lung cancer (NSCLC) frequently presents when surgical intervention is no longer feasible. Despite local treatment with curative intent, patients might experience disease recurrence. In this context, accurate non-invasive biomarkers are urgently needed. We report the results of a pilot study on the diagnostic and prognostic role of circulating tumor cells (CTCs) in operable NSCLC. Methods: Blood samples collected from healthy volunteers (n = 10), nodule-negative high-risk individuals enrolled in a screening program (n = 7), and NSCLC patients (n = 74) before surgery were analyzed (4 mL) for the presence of cells with morphological features of malignancy enriched through the ISET® technology. Results: CTC detection was 60% in patients, while no target cells were found in lung cancer-free donors. We identified single CTCs (sCTC, 46%) and clusters of CTCs and leukocytes (heterotypic clusters, hetCLU, 31%). The prevalence of sCTC (sCTC/4 mL ≥ 2) or the presence of hetCLU predicted the risk of disease recurrence within the cohort of early-stage (I–II, n = 52) or advanced stage cases (III–IVA, n = 22), respectively, while other tumor-related factors did not inform prognosis. Conclusions: Cancer cell hematogenous dissemination occurs frequently in patients with NSCLC without clinical evidence of distant metastases, laying the foundation for the application of cell-based tests in screening programs. CTC subpopulations are fine prognostic classifiers whose clinical validity should be further investigated in larger studies.
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Novellis P, Cominesi SR, Rossetti F, Mondoni M, Gregorc V, Veronesi G. Lung cancer screening: who pays? Who receives? The European perspectives. Transl Lung Cancer Res 2021; 10:2395-2406. [PMID: 34164287 PMCID: PMC8182705 DOI: 10.21037/tlcr-20-677] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Lung cancer is the leading cause of cancer-related death worldwide, and its early detection is critical to achieving a curative treatment and to reducing mortality. Low-dose computed tomography (LDCT) is a highly sensitive technique for detecting noninvasive small lung tumors in high-risk populations. We here analyze the current status of lung cancer screening (LCS) from a European point of view. With economic burden of health care in most European countries resting on the state, it is important to reduce costs of screening and improve its effectiveness. Current cost-effectiveness analyses on LCS have indicated a favorable economic profile. The most recently published analysis reported an incremental cost-effectiveness ratio (ICER) of €3,297 per 1 life-year gained adjusted for the quality of life (QALY) and €2,944 per life-year gained, demonstrating a 90% probability of ICER being below €15,000 and a 98.1% probability of being below €25,000. Different risk models have been used to identify the target population; among these, the PLCOM2012 in particular allows for the selection of the population to be screened with high sensitivity. Risk models should also be employed to define screening intervals, which can reduce the general number of LDCT scans after the baseline round. Future perspectives of screening in a European scenario are related to the will of the policy makers to implement policy on a large scale and to improve the effectiveness of a broad screening of smoking-related disease, including cardiovascular prevention, by measuring coronary calcium score on LDCT. The employment of artificial intelligence (AI) in imaging interpretation, the use of liquid biopsies for the characterization of CT-detected undetermined nodules, and less invasive, personalized surgical treatments, will improve the effectiveness of LCS.
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Affiliation(s)
- Pierluigi Novellis
- Division of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Francesca Rossetti
- Division of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Mondoni
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Vanesa Gregorc
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Veronesi
- Division of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
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Jonas DE, Reuland DS, Reddy SM, Nagle M, Clark SD, Weber RP, Enyioha C, Malo TL, Brenner AT, Armstrong C, Coker-Schwimmer M, Middleton JC, Voisin C, Harris RP. Screening for Lung Cancer With Low-Dose Computed Tomography: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:971-987. [PMID: 33687468 DOI: 10.1001/jama.2021.0377] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Lung cancer is the leading cause of cancer-related death in the US. OBJECTIVE To review the evidence on screening for lung cancer with low-dose computed tomography (LDCT) to inform the US Preventive Services Task Force (USPSTF). DATA SOURCES MEDLINE, Cochrane Library, and trial registries through May 2019; references; experts; and literature surveillance through November 20, 2020. STUDY SELECTION English-language studies of screening with LDCT, accuracy of LDCT, risk prediction models, or treatment for early-stage lung cancer. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled because of heterogeneity of populations and screening protocols. MAIN OUTCOMES AND MEASURES Lung cancer incidence, lung cancer mortality, all-cause mortality, test accuracy, and harms. RESULTS This review included 223 publications. Seven randomized clinical trials (RCTs) (N = 86 486) evaluated lung cancer screening with LDCT; the National Lung Screening Trial (NLST, N = 53 454) and Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON, N = 15 792) were the largest RCTs. Participants were more likely to benefit than the US screening-eligible population (eg, based on life expectancy). The NLST found a reduction in lung cancer mortality (incidence rate ratio [IRR], 0.85 [95% CI, 0.75-0.96]; number needed to screen [NNS] to prevent 1 lung cancer death, 323 over 6.5 years of follow-up) with 3 rounds of annual LDCT screening compared with chest radiograph for high-risk current and former smokers aged 55 to 74 years. NELSON found a reduction in lung cancer mortality (IRR, 0.75 [95% CI, 0.61-0.90]; NNS to prevent 1 lung cancer death of 130 over 10 years of follow-up) with 4 rounds of LDCT screening with increasing intervals compared with no screening for high-risk current and former smokers aged 50 to 74 years. Harms of screening included radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress. For every 1000 persons screened in the NLST, false-positive results led to 17 invasive procedures (number needed to harm, 59) and fewer than 1 person having a major complication. Overdiagnosis estimates varied greatly (0%-67% chance that a lung cancer was overdiagnosed). Incidental findings were common, and estimates varied widely (4.4%-40.7% of persons screened). CONCLUSIONS AND RELEVANCE Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.
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Affiliation(s)
- Daniel E Jonas
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel S Reuland
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Shivani M Reddy
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Max Nagle
- Michigan Medicine, University of Michigan, Ann Arbor
| | - Stephen D Clark
- Department of Internal Medicine, Virginia Commonwealth University, Richmond
| | - Rachel Palmieri Weber
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Chineme Enyioha
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Teri L Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Charli Armstrong
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Christiane Voisin
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Russell P Harris
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Shields LBE, Wilkett Barnes JG, Buckley C, Mikos GJ, Rogers KN, Hamm JT, Flynn JM, Hester ST, Honaker JT. Multidisciplinary approach to low-dose CT screening for lung cancer in a metropolitan community. Fam Pract 2020; 37:25-29. [PMID: 31273379 DOI: 10.1093/fampra/cmz036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lung cancer is the primary cause of cancer death in men and women in the USA, led by Kentucky. In 2015, the Centers for Medicare and Medicaid Services initiated annual lung cancer screening with a low-dose computed tomography (LDCT) scan. This observational cohort study evaluated the multidisciplinary approach to this screening in our metropolitan community. METHODS We present the prospective findings of patients who underwent a screening lung LDCT scan over a 2-year period at our institution in Kentucky. Patients who fulfilled the screening criteria were identified during an office visit with their primary care provider. RESULTS Of the 4170 patients who underwent a screening lung LDCT scan, a total of 838 (20.9%) patients had nodules >4 mm. Of the 70 patients diagnosed with lung cancer, Stage 1 non-small cell lung cancer was most commonly detected [38 cases (54.3%)]. A follow-up lung LDCT scan (n = 897), pulmonary function test (n = 157), positron emission tomography scan (n = 12) and a lung biopsy (n = 53) were performed for certain individuals who had anomalies observed on the screening lung LDCT scan. A total of 42% of patients enrolled in group tobacco cessation classes quit smoking. CONCLUSIONS This study provides a unique perspective of a lung LDCT scan screening program driven by primary care providers in a state plagued by cigarette smoking and lung cancer deaths and offers a valuable message into the prevention, high-risk screening and diagnosis of lung cancer.
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Affiliation(s)
- Lisa B E Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY
| | | | - Connie Buckley
- Norton Cancer Institute, Norton Healthcare, Louisville, KY
| | - George J Mikos
- Norton Cancer Institute, Norton Healthcare, Louisville, KY
| | - Katie N Rogers
- Norton Cancer Institute, Norton Healthcare, Louisville, KY
| | - John T Hamm
- Norton Cancer Institute, Norton Healthcare, Louisville, KY
| | - Joseph M Flynn
- Norton Cancer Institute, Norton Healthcare, Louisville, KY
| | - Steven T Hester
- Norton Medical Group, Norton Healthcare, Louisville, KY, USA
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Wood DE, Kazerooni EA, Baum SL, Eapen GA, Ettinger DS, Hou L, Jackman DM, Klippenstein D, Kumar R, Lackner RP, Leard LE, Lennes IT, Leung ANC, Makani SS, Massion PP, Mazzone P, Merritt RE, Meyers BF, Midthun DE, Pipavath S, Pratt C, Reddy C, Reid ME, Rotter AJ, Sachs PB, Schabath MB, Schiebler ML, Tong BC, Travis WD, Wei B, Yang SC, Gregory KM, Hughes M. Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 16:412-441. [PMID: 29632061 DOI: 10.6004/jnccn.2018.0020] [Citation(s) in RCA: 374] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.
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8
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Inter-observer agreement on the morphology of screening-detected lung cancer: beyond pulmonary nodules and masses. Eur Radiol 2019; 29:3862-3870. [DOI: 10.1007/s00330-019-06243-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/28/2019] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
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Grosso M, Priotto R, Ghirardo D, Talenti A, Roberto E, Bertolaccini L, Terzi A, Chauvie S. Comparison of digital tomosynthesis and computed tomography for lung nodule detection in SOS screening program. Radiol Med 2017; 122:568-574. [DOI: 10.1007/s11547-017-0765-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/10/2017] [Indexed: 12/19/2022]
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10
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Is tissue the issue? J Thorac Cardiovasc Surg 2017; 153:1598-1599. [PMID: 28526109 DOI: 10.1016/j.jtcvs.2017.03.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 11/23/2022]
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Fumagalli C, Bianchi F, Raviele PR, Vacirca D, Bertalot G, Rampinelli C, Lazzeroni M, Bonanni B, Veronesi G, Fusco N, Barberis M, Guerini-Rocco E. Circulating and tissue biomarkers in early-stage non-small cell lung cancer. Ecancermedicalscience 2017; 11:717. [PMID: 28194229 PMCID: PMC5295844 DOI: 10.3332/ecancer.2017.717] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We sought to characterise circulating and tissue tumour biomarkers of patients who developed early-stage non-small cell lung cancer (NSCLC) during long-term follow-up of a chemoprevention trial (NCT00321893). MATERIALS AND METHODS Blood and sputum samples were collected from 202 high-risk asymptomatic individuals with CT-detected stable lung nodules. Real-time PCR was performed on plasma to quantify free circulating DNA. Baseline serum was investigated with a previously validated test based on 13 circulating miRNAs (miR-Test). Promoter methylation status of p16, RASSF1a and RARβ2 and telomerase activity were assessed in sputum samples. DNA was extracted from each tumour developed during follow-up and subjected to a mutation survey using the LungCarta panel on the Sequenom MassARRAY platform. RESULTS During follow-up (9 years) six individuals underwent surgery for stage I NSCLC with a median time of disease onset of 20.5 months. MiR-Test scores were positive (range: 0.14-7.24) in four out of six baseline pre-disease onset sera. No association was identified between free circulating DNA or sputum biomarkers and disease onset. All tumours harboured at least one somatic mutation in well-known cancer genes, including KRAS (n = 4), BRAF (n = 1), and TP53 (n = 3). CONCLUSION Circulating miRNA tests may represent valuable tools to detect clinically-silent tumours. Early-stage lung adenocarcinomas harbour recurrent genetic events similar to those described in advanced-stage NSCLCs.
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Affiliation(s)
- Caterina Fumagalli
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Fabrizio Bianchi
- Institute for Stem-cell Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 1, 71013, San Giovanni Rotondo, Foggia, Italy
| | - Paola Rafaniello Raviele
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Davide Vacirca
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Giovanni Bertalot
- Molecular Medicine Programme IEO, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Cristiano Rampinelli
- Department of Radiology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Giulia Veronesi
- Division of Thoracic Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano Milan, Italy
| | - Nicola Fusco
- Division of Pathology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Massimo Barberis
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
| | - Elena Guerini-Rocco
- Division of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy
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12
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Veronesi G, Novellis P, Voulaz E, Alloisio M. Early detection and early treatment of lung cancer: risks and benefits. J Thorac Dis 2016; 8:E1060-E1062. [PMID: 27747063 DOI: 10.21037/jtd.2016.08.76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Giulia Veronesi
- Thoracic Surgery Division, Humanitas Cancer Center, Rozzano, Italy
| | | | - Emanuele Voulaz
- Thoracic Surgery Division, Humanitas Cancer Center, Rozzano, Italy
| | - Marco Alloisio
- Thoracic Surgery Division, Humanitas Cancer Center, Rozzano, Italy
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13
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Rampinelli C, Calloni SF, Minotti M, Bellomi M. Spectrum of early lung cancer presentation in low-dose screening CT: a pictorial review. Insights Imaging 2016; 7:449-59. [PMID: 27188380 PMCID: PMC4877352 DOI: 10.1007/s13244-016-0487-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/20/2016] [Accepted: 03/18/2016] [Indexed: 12/14/2022] Open
Abstract
The typical presentation of early stage lung cancers on low-dose CT screening are non-calcified pulmonary nodules. However, there is a wide spectrum of unusual focal abnormalities that can be early presentations of lung cancer. These abnormalities include, for example, cancers associated with 'cystic airspaces' or scar-like cancers. The detection of lung cancer with low-dose CT can be affected by the absence of intravenous contrast medium. As a consequence, endobronchial and central lesions can be difficult to recognize, raising the potential for missed cancers. Focal lesions arising within pre-existing lung disease, such as lung fibrosis or apical scars, can also be early lung cancer manifestations and deserve particular consideration as recognition of these lesions may be hindered by the underlying disease. Furthermore, the unpredictable growth rate of lung cancer, which ranges from indolent to aggressive cancers, necessitates attention to the wide spectrum of progression in lung cancer appearance on serial low-dose CT scans. In this pictorial review we discuss the spectrum of early lung cancer presentation in low-dose CT screening, highlighting typical as well as unusual radiological features and the varied growth rates of early lung cancer. Teaching Points • There is a wide spectrum of early presentations of lung cancer on LDCT. • Low radiation dose and the absence of contrast medium injection can affect lung cancer detection. • Lung cancer growth shows various behaviours, ranging from indolent to aggressive cancers. • Familiarity with LDCT technique can improve CT screening effectiveness and avoid missed diagnosis.
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Affiliation(s)
- Cristiano Rampinelli
- Department of Medical Imaging and Radiation Sciences, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy.
| | | | - Marta Minotti
- School of Medicine, University of Milan, Milan, Italy
| | - Massimo Bellomi
- Department of Medical Imaging and Radiation Sciences, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy
- School of Medicine, University of Milan, Milan, Italy
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Parker MS, Groves RC, Fowler AA, Shepherd RW, Cassano AD, Cafaro PL, Chestnut GT. Lung cancer screening with low-dose computed tomography: an analysis of the MEDCAC decision. J Thorac Imaging 2015; 30:15-23. [PMID: 25286290 DOI: 10.1097/rti.0000000000000119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lung cancer is the leading cause of cancer death in the United States and worldwide. However, among the top 4 deadliest cancers, lung cancer is the only one not subject to routine screening. Optimism for an effective lung cancer-screening examination soared after the release of the National Lung Screening Trial results in November 2011. Since then, nearly 40 major medical societies and organizations have endorsed low-dose computed tomography (LDCT) screening. In December 2013, the United States Preventive Services Task Force also endorsed LDCT. However, the momentum for LDCT screening slowed in April 2014 when the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) panel concluded that there was not enough evidence to justify the annual use of LDCT scans for the detection of early lung cancer. This article briefly reviews the epidemiology of lung cancer, the National Lung Screening Trial study results, and the growing national endorsement of LDCT from a variety of key stakeholder organizations. We subsequently analyze and offer our evidence-based counterpoints to the major assumptions underlying the MEDCAC decision.
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Affiliation(s)
- Mark S Parker
- *Department of Diagnostic Radiology, Cardiothoracic Imaging †Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine ‡Department of Surgery, Division of Cardiothoracic Surgery ∥Department of Radiology §Department of Internal Medicine, VCU Medical Center, Richmond, VA
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Deppen SA, Blume JD, Aldrich MC, Fletcher SA, Massion PP, Walker RC, Chen HC, Speroff T, Degesys CA, Pinkerman R, Lambright ES, Nesbitt JC, Putnam JB, Grogan EL. Predicting lung cancer prior to surgical resection in patients with lung nodules. J Thorac Oncol 2015; 9:1477-84. [PMID: 25170644 DOI: 10.1097/jto.0000000000000287] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Existing predictive models for lung cancer focus on improving screening or referral for biopsy in general medical populations. A predictive model calibrated for use during preoperative evaluation of suspicious lung lesions is needed to reduce unnecessary operations for a benign disease. A clinical prediction model (Thoracic Research Evaluation And Treatment [TREAT]) is proposed for this purpose. METHODS We developed and internally validated a clinical prediction model for lung cancer in a prospective cohort evaluated at our institution. Best statistical practices were used to construct, evaluate, and validate the logistic regression model in the presence of missing covariate data using bootstrap and optimism corrected techniques. The TREAT model was externally validated in a retrospectively collected Veteran Affairs population. The discrimination and calibration of the model was estimated and compared with the Mayo Clinic model in both the populations. RESULTS The TREAT model was developed in 492 patients from Vanderbilt whose lung cancer prevalence was 72% and validated among 226 Veteran Affairs patients with a lung cancer prevalence of 93%. In the development cohort, the area under the receiver operating curve (AUC) and Brier score were 0.87 (95% confidence interval [CI], 0.83-0.92) and 0.12, respectively compared with the AUC 0.89 (95% CI, 0.79-0.98) and Brier score 0.13 in the validation dataset. The TREAT model had significantly higher accuracy (p < 0.001) and better calibration than the Mayo Clinic model (AUC = 0.80; 95% CI, 75-85; Brier score = 0.17). CONCLUSION The validated TREAT model had better diagnostic accuracy than the Mayo Clinic model in preoperative assessment of suspicious lung lesions in a population being evaluated for lung resection.
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Affiliation(s)
- Stephen A Deppen
- *Department of Surgery, Tennessee Valley Healthcare System, Veterans Affairs, Nashville, Tennessee; ††Department of Thoracic Surgery, §Department of Medicine, Division of Pulmonary and Critical Care Medicine, ¶Vanderbilt-Ingram Cancer Center, and **School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; †Department of Biostatistics, Vanderbilt University, Nashville, Tennessee; and ‡Department of Critical Care Medicine, ‖Department of Radiology, and #Geriatric Research Education Clinical Center
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Diagnostic Performance of Low-Dose Computed Tomography Screening for Lung Cancer over Five Years. J Thorac Oncol 2014; 9:935-939. [DOI: 10.1097/jto.0000000000000200] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Four-Year Results of Low-Dose CT Screening and Nodule Management in the ITALUNG Trial. J Thorac Oncol 2013; 8:866-75. [DOI: 10.1097/jto.0b013e31828f68d6] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Rampinelli C, Origgi D, Bellomi M. Low-dose CT: technique, reading methods and image interpretation. Cancer Imaging 2013; 12:548-56. [PMID: 23400217 PMCID: PMC3569671 DOI: 10.1102/1470-7330.2012.0049] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The National Lung Cancer Screening Trial has recently demonstrated that screening of high-risk populations with the use of low-dose computed tomography (LDCT) reduces lung cancer mortality[1]. Based on this encouraging result, the National Comprehensive Cancer Network guidelines recommended LDCT for selected patients at high risk of lung cancer[2]. This suggests that an increasing number of CT screening examinations will be performed. The LDCT technique is relatively simple but some CT parameters are important and should be accurately defined in order to achieve good diagnostic quality and minimize the delivered dose. In addition, LDCT examinations are not as easy to read as they may initially appear; different approaches and tools are available for nodule detection and measurement. Moreover, the management of positive results can be a complex process and can differ significantly from routine clinical practice. Therefore this paper deals with the LDCT technique, reading methods and interpretation in lung cancer screening, particularly for those radiologists who have little experience of the technique.
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Couraud S, Cortot AB, Greillier L, Gounant V, Mennecier B, Girard N, Besse B, Brouchet L, Castelnau O, Frappé P, Ferretti GR, Guittet L, Khalil A, Lefebure P, Laurent F, Liebart S, Molinier O, Quoix E, Revel MP, Stach B, Souquet PJ, Thomas P, Trédaniel J, Lemarié E, Zalcman G, Barlési F, Milleron B. From randomized trials to the clinic: is it time to implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the French intergroup (IFCT) and the groupe d'Oncologie de langue francaise (GOLF). Ann Oncol 2012; 24:586-97. [PMID: 23136229 PMCID: PMC3574545 DOI: 10.1093/annonc/mds476] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Despite advances in cancer therapy, mortality is still high except in early-stage tumors, and screening remains a challenge. The randomized National Lung Screening Trial (NLST), comparing annual low-dose computed tomography (LDCT) and chest X-rays, revealed a 20% decrease in lung-cancer-specific mortality. These results raised numerous questions. The French intergroup for thoracic oncology and the French-speaking oncology group convened an expert group to provide a coherent outlook on screening modalities in France. Methods A literature review was carried out and transmitted to the expert group, which was divided into three workshops to tackle specific questions, with responses presented in a plenary session. A writing committee drafted this article. Results The multidisciplinary group favored individual screening in France, when carried out as outlined in this article and after informing subjects of the benefits and risks. The target population involves subjects aged 55–74 years, who are smokers or have a 30 pack-year smoking history. Subjects should be informed about the benefits of quitting. Screening should involve LDCT scanning with specific modalities. Criteria for CT positivity and management algorithms for positive examinations are given. Conclusions Individual screening requires rigorous assessment and precise research in order to potentially develop a lung-cancer screening policy.
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Affiliation(s)
- S Couraud
- Respiratory Diseases Department, 'Hospices Civils de Lyon' Lyon University Hospital, Pierre-Bénite
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Bach PB, Mirkin JN, Oliver TK, Azzoli CG, Berry DA, Brawley OW, Byers T, Colditz GA, Gould MK, Jett JR, Sabichi AL, Smith-Bindman R, Wood DE, Qaseem A, Detterbeck FC. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA 2012; 307:2418-29. [PMID: 22610500 PMCID: PMC3709596 DOI: 10.1001/jama.2012.5521] [Citation(s) in RCA: 871] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CONTEXT Lung cancer is the leading cause of cancer death. Most patients are diagnosed with advanced disease, resulting in a very low 5-year survival. Screening may reduce the risk of death from lung cancer. OBJECTIVE To conduct a systematic review of the evidence regarding the benefits and harms of lung cancer screening using low-dose computed tomography (LDCT). A multisociety collaborative initiative (involving the American Cancer Society, American College of Chest Physicians, American Society of Clinical Oncology, and National Comprehensive Cancer Network) was undertaken to create the foundation for development of an evidence-based clinical guideline. DATA SOURCES MEDLINE (Ovid: January 1996 to April 2012), EMBASE (Ovid: January 1996 to April 2012), and the Cochrane Library (April 2012). STUDY SELECTION Of 591 citations identified and reviewed, 8 randomized trials and 13 cohort studies of LDCT screening met criteria for inclusion. Primary outcomes were lung cancer mortality and all-cause mortality, and secondary outcomes included nodule detection, invasive procedures, follow-up tests, and smoking cessation. DATA EXTRACTION Critical appraisal using predefined criteria was conducted on individual studies and the overall body of evidence. Differences in data extracted by reviewers were adjudicated by consensus. RESULTS Three randomized studies provided evidence on the effect of LDCT screening on lung cancer mortality, of which the National Lung Screening Trial was the most informative, demonstrating that among 53,454 participants enrolled, screening resulted in significantly fewer lung cancer deaths (356 vs 443 deaths; lung cancer−specific mortality, 274 vs 309 events per 100,000 person-years for LDCT and control groups, respectively; relative risk, 0.80; 95% CI, 0.73-0.93; absolute risk reduction, 0.33%; P = .004). The other 2 smaller studies showed no such benefit. In terms of potential harms of LDCT screening, across all trials and cohorts, approximately 20% of individuals in each round of screening had positive results requiring some degree of follow-up, while approximately 1% had lung cancer. There was marked heterogeneity in this finding and in the frequency of follow-up investigations, biopsies, and percentage of surgical procedures performed in patients with benign lesions. Major complications in those with benign conditions were rare. CONCLUSION Low-dose computed tomography screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalizability of results.
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Affiliation(s)
- Peter B Bach
- Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Abstract
OBJECTIVE The purpose of this article is to address the implications of invasive diagnostic procedures recommended by a lung cancer screening protocol. In particular, we assess how many invasive procedures were recommended for benign nodules. MATERIALS AND METHODS Between 2003 and 2009, 4782 high-risk current and former smokers were enrolled in a lung cancer screening study. A helical low-dose CT of the chest was performed. Morphologic features targeted were parenchymal nodules. The indication for biopsy was made according to the diagnostic algorithm provided by the International Early Lung Cancer Action Program. We recorded the time points of biopsy recommendation; shape, size, and growth of nodules; types of diagnostic procedures; complication rates; and final pathologic diagnosis. RESULTS A total of 128 diagnostic biopsies were recommended for suspicious nodules, and 127 biopsies were performed, including 110 percutaneous CT-guided fine-needle aspiration biopsies (FNABs), nine video-assisted thoracoscopic surgery (VATS) resections, seven bronchoscopies, and one ultrasound-guided biopsy of a lymph node. Of 110 FNABs, 24 had unsatisfactory results, 13 of which were referred for secondary diagnostic VATS resection. The indication for biopsy was made on the basis of shape in 48% of cases (62/128), growth on follow-up in 40% of cases (51/128), and the appearance of new nodules in 12% of cases (15/128). In total, 104 of 124 biopsies (84%) were correctly indicated (true-positive recommendation) for malignancy, 20 were benign (false-positive) (16%), and final results are pending for four cases. The overall false-positive recommendation rate was 0.42% (20/4782); 11.6% of FNABs (16/128) and 3.6% of VATS (5/128) revealed benign nodules, corresponding to an overall false-positive rate of 0.33% for FNAB (16/4782) and 0.10% for VATS (5/4782). CONCLUSION The recommended biopsy procedures for screen-detected suspicious pulmonary nodules resulted in a low intervention rate for benign nodules. This rate is minimal when we followed a research protocol that relies on shape and growth.
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Pecot CV, Li M, Zhang XJ, Rajanbabu R, Calitri C, Bungum A, Jett JR, Putnam JB, Callaway-Lane C, Deppen S, Grogan EL, Carbone DP, Worrell JA, Moons KGM, Shyr Y, Massion PP. Added value of a serum proteomic signature in the diagnostic evaluation of lung nodules. Cancer Epidemiol Biomarkers Prev 2012; 21:786-92. [PMID: 22374995 DOI: 10.1158/1055-9965.epi-11-0932] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Current management of lung nodules is complicated by nontherapeutic resections and missed chances for cure. We hypothesized that a serum proteomic signature may add diagnostic information beyond that provided by combined clinical and radiographic data. METHODS Cohort A included 265 and cohort B 114 patients. Using multivariable logistic regression analysis we calculated the area under the receiver operating characteristic curve (AUC) and quantified the added value of a previously described serum proteomic signature beyond clinical and radiographic risk factors for predicting lung cancer using the integration discrimination improvement (IDI) index. RESULTS The average computed tomography (CT) measured nodule size in cohorts A and B was 37.83 versus 23.15 mm among patients with lung cancer and 15.82 versus 17.18 mm among those without, respectively. In cohort A, the AUC increased from 0.68 to 0.86 after adding chest CT imaging variables to the clinical results, but the proteomic signature did not provide meaningful added value. In contrast, in cohort B, the AUC improved from 0.46 with clinical data alone to 0.61 when combined with chest CT imaging data and to 0.69 after adding the proteomic signature (IDI of 20% P = 0.0003). In addition, in a subgroup of 100 nodules between 5 and 20 mm in diameter, the proteomic signature added value with an IDI of 15% (P ≤ 0.0001). CONCLUSIONS The results show that this serum proteomic biomarker signature may add value to the clinical and chest CT evaluation of indeterminate lung nodules. IMPACT This study suggests a possible role of a blood biomarker in the evaluation of indeterminate lung nodules.
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Affiliation(s)
- Chad V Pecot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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The Role of the (18)F-Fluorodeoxyglucose-Positron Emission Tomography Scan in the Nederlands Leuvens Longkanker Screenings Onderzoek Lung Cancer Screening Trial. J Thorac Oncol 2011; 6:1704-12. [DOI: 10.1097/jto.0b013e3182286d0b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Computed tomographic criteria for the discrimination of subcentimeter lung nodules in patients with soft-tissue sarcomas. Clin Imaging 2011; 35:174-9. [PMID: 21513852 DOI: 10.1016/j.clinimag.2010.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 05/21/2010] [Indexed: 11/21/2022]
Abstract
The aim of this study was to identify criteria for nodule characterization on chest computed tomography in patients with soft tissue sarcomas. In 195 patients, a total of 194 benign and 117 malignant subcentimeter lung nodules were retrospectively analyzed according to lesion size, shape, margins, density, and localization. Benign lesions more frequently displayed complex shape and were of ground-glass density (P<.0001, respectively). In contrast, round shape and solid density were more frequently found in malignant lesions (P<.0001, respectively).
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Rampinelli C, Preda L, Maniglio M, Sirica L, Travaini LL, Veronesi G, Bellomi M. Extrapulmonary malignancies detected at lung cancer screening. Radiology 2011; 261:293-9. [PMID: 21828191 DOI: 10.1148/radiol.11102231] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To retrospectively assess the detection rate, histologic characteristics, and clinical stage of screening-detected extrapulmonary malignancies in a population at high risk for lung cancer. MATERIALS AND METHODS In this institutional review board-approved study, 5201 asymptomatic heavy smokers aged 50 years or older underwent annual low-dose computed tomography (CT) for 5 consecutive years. The 5-year cumulative effective dose was 5 mSv. Subjects with at least one "potentially significant extrapulmonary incidental finding" (PS-IF) were extracted from the study database. An extrapulmonary finding was classified as potentially significant if it required further diagnostic and/or clinical evaluation. In retrospect all clinically relevant information, including findings from diagnostic work-up and final diagnosis of the PS-IF, was collected. On the basis of the information collected, only histologically proved screening-detected extrapulmonary malignancies were eventually included in this study. The percentages of volunteers with extrapulmonary malignancies were calculated, along with 95% confidence intervals (CIs), on the basis of a binomial distribution. RESULTS After 5 years of CT screening, 27 unsuspected extrapulmonary malignancies were diagnosed, representing 0.5% (27 of 5201 subjects; 95% CI: 0.34%, 0.75%) of volunteers enrolled and 6.2% (27 of 436 findings; 95% CI: 4.12%, 8.88%) of PS-IFs. Eight malignancies were diagnosed at the 1st year of screening, nine at the 2nd year, four at the 3rd year, two at the 4th year, and four at the 5th year. Twelve of the 27 extrapulmonary tumors (44%) were renal carcinomas (n = 7) or lymphomas (n = 5). Twenty-four of the 27 subjects with a malignancy were alive at the most recent follow-up. CONCLUSION A considerable number of unsuspected extrapulmonary malignancies can be detected in lung cancer screening trials. A careful evaluation of extrapulmonary structures, with particular attention to the kidneys and lymph nodes, is recommended.
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Affiliation(s)
- Cristiano Rampinelli
- Department of Radiology, European Institute of Oncology, Via Ripamonti, 435-20141 Milan, Italy.
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Mikita K, Saito H, Sakuma Y, Kondo T, Honda T, Murakami S, Oshita F, Ito H, Tsuboi M, Nakayama H, Yokose T, Kameda Y, Noda K, Yamada K. Growth rate of lung cancer recognized as small solid nodule on initial CT findings. Eur J Radiol 2011; 81:e548-53. [PMID: 21794996 DOI: 10.1016/j.ejrad.2011.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 06/07/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION To study the characteristics of lung cancer, appearing as small solid nodules on initial computed tomography (CT) findings, and to determine an appropriate follow-up duration so as to differentiate between malignancy and benign tumor. METHODS We analyzed the records of 34 patients who had undergone surgical resection of lung cancer, which appeared as small solid nodules on initial CT findings. We studied the CT findings, volume doubling times (VDT), follow-up durations, pathological and clinical findings. RESULTS VDT is classified as follows: (1) slow growth group (SGG), with a VDT of more than 700 days and (2) rapid growth group (RGG), with a VDT of less than 700 days. The median VDT of the SGG was 1083 days, and the RGG was 256 days (p<0.01). The median duration for follow-up of the SGG was 1218 days, and 179 days for the RGG. A statistical difference was noted in the follow-up durations (p<0.01). There were no statistical differences in the preoperative thin-section CT (TSCT) findings, or in the pathological findings. The RGG included more patients with smoking histories. The CT findings of RGG tended to reveal changed in base lung field such as emphysema, and lung fibrosis. CONCLUSIONS Generally, lung cancer appearing as small solid nodules on initial CT findings grew rapidly, but there were some cases which displayed slow growth patterns. These cases required follow up for over two years, before diagnosis was possible. We concluded the appropriate maximum followup duration is three years.
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Affiliation(s)
- Kei Mikita
- Department of Thoracic Oncology, Kanagawa Cancer Center, 1-1-2 Nakao, Asahi-ku, Yokohama 241-0815, Japan
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Isbell JM, Deppen S, Putnam JB, Nesbitt JC, Lambright ES, Dawes A, Massion PP, Speroff T, Jones DR, Grogan EL. Existing general population models inaccurately predict lung cancer risk in patients referred for surgical evaluation. Ann Thorac Surg 2011; 91:227-33; discussion 233. [PMID: 21172518 DOI: 10.1016/j.athoracsur.2010.08.054] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Revised: 08/23/2010] [Accepted: 08/30/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients undergoing resections for suspicious pulmonary lesions have a 9% to 55% benign rate. Validated prediction models exist to estimate the probability of malignancy in a general population and current practice guidelines recommend their use. We evaluated these models in a surgical population to determine the accuracy of existing models to predict benign or malignant disease. METHODS We conducted a retrospective review of our thoracic surgery quality improvement database (2005 to 2008) to identify patients who underwent resection of a pulmonary lesion. Patients were stratified into subgroups based on age, smoking status, and fluorodeoxyglucose positron emission tomography (PET) results. The probability of malignancy was calculated for each patient using the Mayo and solitary pulmonary nodules prediction models. Receiver operating characteristic and calibration curves were used to measure model performance. RESULTS A total of 189 patients met selection criteria; 73% were malignant. Patients with preoperative PET scans were divided into four subgroups based on age, smoking history, and nodule PET avidity. Older smokers with PET-avid lesions had a 90% malignancy rate. Patients with PET-nonavid lesions, PET-avid lesions with age less than 50 years, or never smokers of any age had a 62% malignancy rate. The area under the receiver operating characteristic curve for the Mayo and solitary pulmonary nodules models was 0.79 and 0.80, respectively; however, the models were poorly calibrated (p<0.001). CONCLUSIONS Despite improvements in diagnostic and imaging techniques, current general population models do not accurately predict lung cancer among patients referred for surgical evaluation. Prediction models with greater accuracy are needed to identify patients with benign disease to reduce nontherapeutic resections.
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Affiliation(s)
- James M Isbell
- Department of Surgery, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA
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Sakamoto M, Murakawa T, Kitano K, Murayama T, Tsuchiya T, Nakajima J. Resection of solitary pulmonary lesion is beneficial to patients with a history of malignancy. Ann Thorac Surg 2011; 90:1766-71. [PMID: 21095305 DOI: 10.1016/j.athoracsur.2010.07.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 07/14/2010] [Accepted: 07/14/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Solitary pulmonary lesion poses a diagnostic challenge, especially in patients with a history of malignancy. The purpose of this study was to evaluate the characteristics of solitary pulmonary lesions and the outcome of surgical resection. METHODS We retrospectively analyzed 243 patients with a history of cancer who underwent surgery for new-found solitary pulmonary lesion between January 1998 and December 2007. RESULTS The diagnosis was primary lung cancer in 92 patients, metastasis in 133, and benign lesions in 18. The 5-year survival rate was 67.9% in all patients, 74.6% in those with primary lung cancer, 62.8% in those with metastasis, and 79.9% in those with benign lesions (p = 0.56). In metastasis patients, history of extrapulmonary recurrence and larger diameter lesion were risk factors for recurrence by multivariate analysis. History of cancers other than colorectal and bone and soft tissue sarcoma and shorter disease-free interval were indicators of poor prognosis. Pathologic stage was the only indicator of prognosis for primary lung cancer, and none of the factors concerning antecedent cancer influenced prognosis. CONCLUSIONS Surgical resection of solitary pulmonary lesion is essential in patients with a history of cancer because substantial numbers of benign lesions are included. In the case of malignancy, metastasectomy had a life-prolonging effect for selected patients, and prognosis of primary lung cancer was no worse than for the general population if treated appropriately. It is important not to hesitate to take a surgical approach for a diagnosis and to treat with standard therapy for primary lung cancer.
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Affiliation(s)
- Miki Sakamoto
- Department of Cardiothoracic Surgery, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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van Klaveren RJ, Oudkerk M, Prokop M, Scholten ET, Nackaerts K, Vernhout R, van Iersel CA, van den Bergh KAM, van 't Westeinde S, van der Aalst C, Thunnissen E, Xu DM, Wang Y, Zhao Y, Gietema HA, de Hoop BJ, Groen HJM, de Bock GH, van Ooijen P, Weenink C, Verschakelen J, Lammers JWJ, Timens W, Willebrand D, Vink A, Mali W, de Koning HJ. Management of lung nodules detected by volume CT scanning. N Engl J Med 2009; 361:2221-9. [PMID: 19955524 DOI: 10.1056/nejmoa0906085] [Citation(s) in RCA: 570] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of multidetector computed tomography (CT) in lung-cancer screening trials involving subjects with an increased risk of lung cancer has highlighted the problem for the clinician of deciding on the best course of action when noncalcified pulmonary nodules are detected by CT. METHODS A total of 7557 participants underwent CT screening in years 1, 2, and 4 of a randomized trial of lung-cancer screening. We used software to evaluate a noncalcified nodule according to its volume or volume-doubling time. Growth was defined as an increase in volume of at least 25% between two scans. The first-round screening test was considered to be negative if the volume of a nodule was less than 50 mm(3), if it was 50 to 500 mm(3) but had not grown by the time of the 3-month follow-up CT, or if, in the case of those that had grown, the volume-doubling time was 400 days or more. RESULTS In the first and second rounds of screening, 2.6% and 1.8% of the participants, respectively, had a positive test result. In round one, the sensitivity of the screen was 94.6% (95% confidence interval [CI], 86.5 to 98.0) and the negative predictive value 99.9% (95% CI, 99.9 to 100.0). In the 7361 subjects with a negative screening result in round one, 20 lung cancers were detected after 2 years of follow-up. CONCLUSIONS Among subjects at high risk for lung cancer who were screened in three rounds of CT scanning and in whom noncalcified pulmonary nodules were evaluated according to volume and volume-doubling time, the chances of finding lung cancer 1 and 2 years after a negative first-round test were 1 in 1000 and 3 in 1000, respectively. (Current Controlled Trials number, ISRCTN63545820.)
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Affiliation(s)
- Rob J van Klaveren
- Department of Pulmonology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands.
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Bellomi M, Rampinelli C, De Fiori E, Preda L, Veronesi G. Lung cancer screening update. Cancer Imaging 2009; 9 Spec No A:S122-5. [PMID: 19965303 PMCID: PMC2797473 DOI: 10.1102/1470-7330.2009.9045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Low-dose computed tomography (ld-CT) for lung cancer screening in high-risk subjects is performed within clinical trials and has started to be used in routine clinical practice. The technique is well defined, even if some methodological problems are still debated, such as the measurements of pulmonary nodules, the size to define them as clinically significant, the management of small or non-solid nodules and the best diagnostic work-up to optimize diagnostic accuracy. The data derived from an IEO observational study, started in 2000, shows a high prevalence and incidence of early stage lung cancer detected at ld-CT, demonstrating the need to prolong observation for a long period of time. The high survival rate of patients with screening-detected cancer has recently been debated in a number of papers using statistical models, but the advantage of the yearly ld-CT for the individuals is unquestionable; its benefit on the population base has still to be demonstrated by ongoing randomized trials.
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Affiliation(s)
- Massimo Bellomi
- Diagnostic Radiology, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
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