Systematic Approach to the Management of the Newly Found Nodule on Screening Computed Tomography

Establishing a Pulmonary Nodule Clinic Service for Early Diagnosis of Lung Cancer - Review of International Options and Considerations for Greece

Early diagnosis of lung cancer in pulmonary nodules identified by computed tomography (CT) may be critical in reducing the epidemiological burden of the disease, particularly in countries where such a burden is considerably high and risk factors for lung cancer very prevalent. The establishment and operation of pulmonary nodule clinics (PNCs), ie, multidisciplinary services that watch and evaluate nodules found through deliberate screening efforts or as incidental findings, is increasingly becoming a key tool to implement such early-intervention, cancer-risk management policies elsewhere in the world. This review aims to research and present in a structured manner findings from published sources on options and considerations for setting up a PNC in a country such as Greece. These refer to the type of services a PNC would provide to optimize diagnosis of suspect pulmonary nodules, its structure and organization, including processes, human resources and technology infrastructure, its target audience, ie, who would be eligible to use its services, and the expected outcomes of its operation, in terms of a set of key performance indicators. Our review also revealed critical key success factors that should be considered when designing the introduction of a PNC in a health care setting, including optimal referral pathways, aligned clinical decision making and patient preferences and participation/empowerment. Our findings may inform health care systems with a high lung cancer burden and no available PNC service on options and considerations before introducing such a service in their respective settings.

Patient Experience of Managing Adherence to Repeat Lung Cancer Screening

Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients' and providers' depictions of continued screening and their understandings of patients' decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients' motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.

Multidisciplinary selection of pulmonary nodules for surgical resection: Diagnostic results and long-term outcomes

OBJECTIVE

Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported.

METHODS

All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared.

RESULTS

Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)-representing 3.3% (21/632) of all incidental nodules evaluated-than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48).

CONCLUSIONS

A unique multidisciplinary PNLCSC for incidental and lung cancer screening-detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.

[Three Dimensional Volumetric Analysis of Solid Pulmonary Nodules on Chest CT: Cancer Risk Assessment]

背景与目的

肺结节临床处理策略主要基于其恶性风险度评估，目前公认的计算机断层扫描（computed tomography, CT）影像学标准为结节直径。容积CT及三维分析软件的应用使肺结节形态学特征显示更加清晰。本研究的目的是评估肺结节的容积及三维形态特征（边缘、形状、位置）在结节恶性风险度评估中的价值。

方法

应用三维分析软件对200例直径小于3 cm实性结节的CT影像资料进行回顾性分析，恶性结节经病理或组织学确认，良性结节经病理或两年随访无增大确认。对全部结节及亚厘米结节（直径小于10 mm）分别采用Logistic回归分析计算结节三维边缘（光滑、分叶、毛刺或不规则）、形状（球体、非球体）、位置（肺实质内、血管相贴、胸膜相贴）、结节容积的似然比（odds ratios, ORs），并通过受试者工作特征（receiver operating characteristic, ROC）曲线确定结节容积评估恶性风险度的最佳阈值。

结果

纳入研究的200例中恶性78例，良性122例。对全部结节的Logistic回归分析结果显示结节容积（OR=3.3, P < 0.001）、边缘形态（分叶、毛刺或不规则的OR值分别为13.4、9.8，P均=0.001）具有预测价值，而结节的位置及三维形状不具备预测价值（P>0.05）。ROC分析显示结节容积对恶性风险度评估有价值（曲线下面积为0.928；P < 0.01，最佳阈值为666 mm³）。对亚厘米结节的分析显示仅边缘分叶、毛刺或不规则的结节恶性风险度高（OR=60.5, 75.0; P=0.003, 0.007）。

结论

结节的三维容积及边缘形态有助于判定结节的恶性风险度，容积大于666 mm³可作为恶性高危结节的阈值；边缘分叶、毛刺或不规则是亚厘米结节的唯一高危因素。

Opportunities for Patient-centered Outcomes Research in Radiology

Recently created in 2010, the Patient-Centered Outcomes Research Institute (PCORI) supports patient-centered comparative effectiveness research with a focus on prioritizing high-impact studies and improving trial design methodology. The Association of University Radiologists Radiology Research Alliance Task Force on patient-centered outcomes research in Radiology aims to review recently funded imaging-centric projects that adhere to the methodologies established by PCORI. We provide an overview of the successful application of PCORI standards to radiology topics, highlight how these methodologies differ from other forms of radiology research, and identify opportunities for new projects as well as potential barriers for involvement. Our hope is that review of specific case examples in radiology will clarify the use and value of PCORI methods mandated and supported nationally by the Affordable Care Act.