Screening for lung cancer

An Interpretable Three-Dimensional Artificial Intelligence Model for Computer-Aided Diagnosis of Lung Nodules in Computed Tomography Images

Lung cancer is typically classified into small-cell carcinoma and non-small-cell carcinoma. Non-small-cell carcinoma accounts for approximately 85% of all lung cancers. Low-dose chest computed tomography (CT) can quickly and non-invasively diagnose lung cancer. In the era of deep learning, an artificial intelligence (AI) computer-aided diagnosis system can be developed for the automatic recognition of CT images of patients, creating a new form of intelligent medical service. For many years, lung cancer has been the leading cause of cancer-related deaths in Taiwan, with smoking and air pollution increasing the likelihood of developing the disease. The incidence of lung adenocarcinoma in never-smoking women has also increased significantly in recent years, resulting in an important public health problem. Early detection of lung cancer and prompt treatment can help reduce the mortality rate of patients with lung cancer. In this study, an improved 3D interpretable hierarchical semantic convolutional neural network named HSNet was developed and validated for the automatic diagnosis of lung cancer based on a collection of lung nodule images. The interpretable AI model proposed in this study, with different training strategies and adjustment of model parameters, such as cyclic learning rate and random weight averaging, demonstrated better diagnostic performance than the previous literature, with results of a four-fold cross-validation procedure showing calcification: 0.9873 ± 0.006, margin: 0.9207 ± 0.009, subtlety: 0.9026 ± 0.014, texture: 0.9685 ± 0.006, sphericity: 0.8652 ± 0.021, and malignancy: 0.9685 ± 0.006.

Determination of hexanal and heptanal in saliva samples by an adapted magnetic headspace adsorptive microextraction for diagnosis of lung cancer

In this work, an analytical method for the determination of two endogenous aldehydes (hexanal and heptanal) as lung cancer biomarkers in saliva samples is presented for the first time. The method is based on a modification of magnetic headspace adsorptive microextraction (M-HS-AME) followed by gas chromatography coupled to mass spectrometry (GC-MS). For this purpose, an external magnetic field generated by a neodymium magnet is used to hold the magnetic sorbent (i.e., CoFe₂O₄ magnetic nanoparticles embedded into a reversed-phase polymer) in the headspace of a microtube to extract the volatilized aldehydes. Subsequently, the analytes are desorbed in the appropriate solvent and the extract is injected into the GC-MS system for separation and determination. Under the optimized conditions, the method was validated and showed good analytical features in terms of linearity (at least up to 50 ng mL^-1), limits of detection (0.22 and 0.26 ng mL^-1 for hexanal and heptanal, respectively), and repeatability (RSD ≤12%). This new approach was successfully applied to saliva samples from healthy volunteers and those with lung cancer, obtaining notably differences between both groups. These results reveal the prospect of the method as potential diagnostic tool for lung cancer by saliva analysis. This work contributes to the Analytical Chemistry field presenting a double novelty: on the one hand, the use of M-HS-AME in bioanalysis is unprecedentedly proposed, thus expanding the analytical potential of this technique, and, on the other hand, the determination of hexanal and heptanal is carried out in saliva samples for the first time.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.

Staplers versus energy devices for the intersegmental plane separation in thoracoscopic segmentectomy: a comparative study

BACKGROUND

In segmentectomy, in addition to the anatomy of the segmental hilum, the identification and separation of the intersegmental plane is also an important step of the operation. Because of its simplicity and high efficiency, most thoracic surgeons choose the staplers. But the energy devices also have its unique advantages in the separation of the intersegmental plane. This study compared the clinical efficacy of staplers and energy devices in the separation of the intersegmental planes during the uniport thoracoscopic segmentectomy through the clinical data.

METHODS

Clinical data of 89 patients undergoing uniport VATS lung segmentectomy from January 2019 to October 2020 at the First Affiliated Hospital of Soochow University were analyzed retrospectively. According to the different treatment methods of intersegmental plane, the patients were divided into two groups, 55 in the stapler group and 34 in the energy device group. The clinical data of the two groups were compared and analyzed statistically. And the univariate and multivariate logistic regression were also used to explore the influencing factors of postoperative complications.

RESULTS

Lung segmentectomy was successfully operated in both groups. There were statistically significant differences in operative duration, number of staplers used, surgical expenses and postoperative complications (P < 0.05). In terms of general data, including tumor location, operative hemorrhage, drainage volume on the first postoperative day, total postoperative drainage volume, postoperative chest tube retention duration, postoperative hospital stay, postoperative blood routine indexes, and postoperative pulmonary function indexes after 3 months, no significant differences were observed (P > 0.05). Smoking history (OR 5.08, 95% CI 1.05-24.56, P = 0.043) and intersegmental plane treatment (OR 3.18, 95% CI 1.11-9.14, P = 0.031) were risk factors for postoperative complications. Patients of the energy device group had a higher incidence of postoperative complications.

CONCLUSIONS

In uniport thoracoscopic segmentectomy, the use of energy devices to treat the intersegmental plane will result in longer operative duration and higher postoperative complication rate, but it does not affect postoperative recovery and can help reduce surgical expenses. Both methods are safe and reliable. Clinically, the two methods can be reasonably selected according to the specific situation.

Value-added Opportunistic CT Screening: State of the Art

Opportunistic CT screening leverages robust imaging data embedded within abdominal and thoracic scans that are generally unrelated to the specific clinical indication and have heretofore gone largely unused. This incidental imaging information may prove beneficial to patients in terms of wellness, prevention, risk profiling, and presymptomatic detection of relevant disease. The growing interest in CT-based opportunistic screening relates to a confluence of factors: the objective and generalizable nature of CT-based body composition measures, the emergence of fully automated explainable AI solutions, the sheer volume of body CT scans performed, and the increasing emphasis on precision medicine and value-added initiatives. With a systematic approach to body composition and other useful CT markers, initial evidence suggests that their ability to help radiologists assess biologic age and predict future adverse cardiometabolic events rivals even the best available clinical reference standards. Emerging data suggest that standalone "intended" CT screening over an unorganized opportunistic approach may be justified, especially when combined with established cancer screening. This review will discuss the current status of opportunistic CT screening, including specific body composition markers and the various disease processes that may be impacted. The remaining hurdles to widespread clinical adoption include generalization to more diverse patient populations, disparate technical settings, and reimbursement.

Association of dyspnoea, mortality and resource use in hospitalised patients

As many as one in 10 patients experience dyspnoea at hospital admission but the relationship between dyspnoea and patient outcomes is unknown. We sought to determine whether dyspnoea on admission predicts outcomes.We conducted a retrospective cohort study in a single, academic medical centre. We analysed 67 362 consecutive hospital admissions with available data on dyspnoea, pain and outcomes. As part of the Initial Patient Assessment by nurses, patients rated "breathing discomfort" using a 0 to 10 scale (10="unbearable"). Patients reported dyspnoea at the time of admission and recalled dyspnoea experienced in the 24 h prior to admission. Outcomes included in-hospital mortality, 2-year mortality, length of stay, need for rapid response system activation, transfer to the intensive care unit, discharge to extended care, and 7- and 30-day all-cause readmission to the same institution.Patients who reported any dyspnoea were at an increased risk of death during that hospital stay; the greater the dyspnoea, the greater the risk of death (dyspnoea 0: 0.8% in-hospital mortality; dyspnoea 1-3: 2.5% in-hospital mortality; dyspnoea ≥4: 3.7% in-hospital mortality; p<0.001). After adjustment for patient comorbidities, demographics and severity of illness, increasing dyspnoea remained associated with inpatient mortality (dyspnoea 1-3: adjusted OR 2.1, 95% CI 1.7-2.6; dyspnoea ≥4: adjusted OR 3.1, 95% CI 2.4-3.9). Pain did not predict increased mortality. Patients reporting dyspnoea also used more hospital resources, were more likely to be readmitted and were at increased risk of death within 2 years (dyspnoea 1-3: adjusted hazard ratio 1.5, 95% CI 1.3-1.6; dyspnoea ≥4: adjusted hazard ratio 1.7, 95% CI 1.5-1.8).We found that dyspnoea of any rating was associated with an increased risk of death. Dyspnoea ratings can be rapidly collected by nursing staff, which may allow for better monitoring or interventions that could reduce mortality and morbidity.

Oral Cancer Screening: Past, Present, and Future

Oral cancer is a major public health problem, and there is an increasing trend for oral cancer to affect young men and women. Public awareness is poor, and many patients present with late-stage disease, contributing to high mortality. Oral cancer is often preceded by a clinical premalignant phase accessible to visual inspection, and thus there are opportunities for earlier detection and to reduce morbidity and mortality. Screening asymptomatic individuals by systematic visual oral examinations to detect the disease has been shown to be feasible. A positive screen includes both oral cancer and oral potentially malignant disorders. We review key screening studies undertaken, including 1 randomized clinical trial. Screening of high-risk groups is cost-effective. Strengths and weaknesses of oral cancer screening studies are presented to help guide new research in primary care settings and invigorated by the prospect of using emerging new technologies that may help to improve discriminatory accuracy of case detection. Most national organizations, including the US Preventive Services Task Force, have so far not recommended population-based screening due a lack of sufficient evidence that screening leads to a reduction in oral cancer mortality. Where health care resources are high, opportunistic screening in dental practices is recommended, although the paucity of research in primary care is alarming. The results of surveys suggest that dentists do perform oral cancer screenings, but there is only weak evidence that screening in dental practices leads to downstaging of disease. Where health care resources are low, the feasibility of using primary health care workers for oral cancer screening has been tested, and measures indicate good outcomes. Most studies reported in the literature are based on 1 round of screening, whereas screening should be a continuous process. This review identifies a huge potential for new research directions on screening for oral cancer.

Analysis of causes of death in patients with implanted defibrillators

AIMS

Implantable cardioverter defibrillators (ICDs) are used for primary or secondary prevention of sudden cardiac death. We sought to clarify prognosis and causes of death after ICD implantation.

METHODS AND RESULTS

A total of 2743 patients with ICDs implanted during 1990-2020 were analyzed. Median age was 68.5 (59.6-74.6) years; 21% women, median left ventricular ejection fraction (LVEF) was 30 (23-35), 52% had an ischemic etiology and 77% had a primary preventive indication. Mortality rate after 10 years was 22, 44, 55, and 72% in the 1st, 2nd, 3rd, and 4^th age quartile, respectively. The calculated median sex and age adjusted loss of life years compared to the average German population was 9.7 (6.1-14.0) years. Prognosis was independently related to sex, age, LVEF, and glomerular filtration rate. 713 out of 852 deaths could be classified to a specific cause. Congestive heart failure (CHF) accounted for death in 214 (30%) and sudden death (SD) for 144 patients (20%). Postmortem interrogation of devices in 74 patients revealed VT/VF in 39 and no episodes in 35 patients. Cancer was identified as the cause of death in 121 patients (17% of cases), of which 36 were bronchial carcinomas. 73 (10%) of patients died due to infection. 67 patients (9%) died within 24 h of procedures. Compared to other causes, significantly more life years were lost associated with procedures and SD: 9.3 (5.7-12.9) versus 12.1 (7.4-15.2) and 11.9 (7.6-17.8) years.

CONCLUSION

Life expectancy of ICD patients is lower than for the general population. Mortality is predominantly due to CHF, but there is still a considerable rate of SD. The occurrence of cancers, most importantly bronchial carcinomas, and infections, warrants protective measures. Some deaths during procedures are possibly preventable. Patients with ICDs comprise a vulnerable cohort, and treatment has to be optimized in many directions to improve prognosis.

Feasibility of intraoperative diagnosis of lung adenocarcinoma in situ to avoid excessive resection

Background

Limited lung resection is generally believed to be available for lung adenocarcinoma in situ (AIS). At our institute, intraoperative hematoxylin-eosin staining of frozen-section slides is routinely performed for evaluating tumor invasiveness after partial resection to avoid excessive lung resection. This study aimed to evaluate the feasibility and usefulness of intraoperative frozen-section diagnosis of AIS.

Methods

We retrospectively reviewed 143 patients with 151 AISs diagnosed by intraoperative frozen sections between 2012 and 2019 at our institute. All patients underwent limited resection because of the result of intraoperative frozen-section diagnosis.

Results

The total concordance rate between the diagnoses of AIS by intraoperative frozen sections and postoperative paraffin-embedded sections was 82.7% for 151 nodules. Although 21 minimally invasive adenocarcinomas (MIA) and 5 invasive adenocarcinomas were diagnosed as AIS intraoperatively, no patient had tumor recurrence after resection. Among 125 pathologically proven cases of AIS postoperatively, there were 67 (53.6%) radiologically invasive tumors including ground-glass nodules (GGNs) with part-solid component or pure-solid nodules.

Conclusions

This intraoperative evaluation of frozen-section slides will help surgeons avoid excessive lung resection for AIS that was radiologically diagnosed as invasive adenocarcinoma. Intraoperative frozen-section diagnosis will provide to be clinically useful and lead to less invasive surgical treatment for lung nodules.

Multi-Window CT Based Radiological Traits for Improving Early Detection in Lung Cancer Screening

Rationale and Objectives

Evaluate ability of radiological semantic traits assessed on multi-window computed tomography (CT) to predict lung cancer risk.

Materials and Methods

A total of 199 participants were investigated, including 60 incident lung cancers and 139 benign positive controls. Twenty lung window features and 2 mediastinal window features were extracted and scored on a point scale in three screening rounds. Multivariate logistic regression analysis was used to explore the association of these radiological traits with the risk of developing lung cancer. The areas under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and positive predictive value (PPV) were computed to evaluate the best predictive model.

Results

Combining mediastinal window-specific features with the lung window features-based model significantly improves performance compared to individual window features. Model performance is consistent both at baseline and the first follow-up scan, with an AUROC increased from 0.822 to 0.871 (p = 0.009) and from 0.877 to 0.917 (p = 0.008), respectively, for single to multi-window feature models. We also find that the multi-window CT based model showed better specificity and PPV, with PPV at the second follow-up scan improved to 0.953.

Conclusion

We find combining window semantic features improves model performance in identifying cancerous nodules. We also find that lung window features are more informative compared to mediastinal features in predicting malignancy.

Prediction of MiR-21-5p in Promoting the Development of Lung Adenocarcinoma via PDZD2 Regulation

BACKGROUND Lung adenocarcinoma currently accounts for the highest cancer-related mortality rate worldwide. MiR-21-5p has a vital role in various types of cancers. We have analyzed the miR-21-5p expression level, prognosis, and associated molecular pathways in lung adenocarcinoma with multiple bioinformatics databases. MATERIAL AND METHODS The Cancer Genome Atlas (TCGA) database was employed to fetch the miR-21-5p expression profile in multiple tumors. We used the UALCAN platform to assess the differential regulation of the miR-21-5p in healthy tissue and lung adenocarcinoma. Also, the survival prognosis of the miR-21-5p in each stage of lung adenocarcinoma was done by the Kaplan-Meier database. The STARBASE and UALCAN databases were employed to predict the miR-21-5p target genes, and the levels of target genes and their prognostic value were analyzed. RESULTS MiR-21-5p was overexpressed in the majority of human cancers. MiR-21-5p demonstrated escalated expression in the lung adenocarcinoma tissue in contrast to the normal tissue (P<0.05). Poor prognosis was witnessed in the miR-21-5p high expression group as compared to the low expression group (hazard ratio [HR]= 1.59, P<0.05). PDZD2 was predicted as a miR-21-5p potential target. We found a negative correlation between PDZD2 and miR-21-5p (r=-0.255, P<0.05). PDZD2 was downregulated in lung adenocarcinoma (P<0.05). Overexpression of PDZD2 was associated with a better prognosis of survival in lung adenocarcinoma patients (HR=0.45, P<0.05). CONCLUSIONS MiR-21-5p exhibits the potential to act as a biomarker for the survival prognosis of lung adenocarcinoma. It might be responsible for the onset and progression of lung adenocarcinoma through PDZD2 regulation.

Conventional Multi-Planar Reconstruction Imaging Is Insufficient to Determine the Indication for Segmentectomy

PURPOSE

The diagnostic potential of conventional multi-planar reconstruction (MPR) images, which consist of horizontal, frontal, and sagittal section, in approximating the anatomical distance between tumors and intersegmental planes remains unclear. The aim of the present study was to clarify the validity of decision-making for segmentectomy based on MPR imaging and identify a specific tumor location that is likely to result in the overestimation of the anatomical margin on MPR images.

METHODS

The study population included 33 patients who were considered eligible for segmentectomy based on the observation of MPR images, and verified using a commercially available image-analysis software whether the decision-making based on MPR images was indeed correct or not.

RESULTS

MPR image-based assessment resulted in the overestimation of the anatomical margin in as many as 8 (24%) of the 33 patients. Overestimation predominantly occurred in cases involving patients with tumors at certain segments (right S1, right S2, right S3, left S3, and left S4) that had a complex and oblique intersegmental plane.

CONCLUSION

Conventional MPR image-based assessment frequently resulted in the overestimation of the anatomical margin. We recommend using software-based assessment preoperatively in patients with tumors in the risky segments, particularly in cases involving indistinct tumors.

Exploring Novel Technologies in Lung Cancer Diagnosis: Do We Have Room for Improvement?

Lung cancer remains the leading cause of cancer-related death worldwide. Preventive strategies, mainly smoking cessation have a big impact on the reduction of lung cancer-related mortality. Screening with low dose computed tomography (LDCT) has proven to be beneficial in reducing the mortality related to lung cancer mainly based on early detection of cancer and timely initiation of treatment. Despite its beneficial effects, guideline-directed LDCT screening could lead to high false positive results, subjecting patients to harmful radiation, increase cost of healthcare and induce anxiety amongst the patients. Thus, it is imperative to look beyond the prevailing modalities of lung cancer screening and diagnosis to achieve better yield and mitigate the existent drawbacks.

Combining Plasma miRNAs and Computed Tomography Features to Differentiate the Nature of Pulmonary Nodules

Objective: The purpose of this study was to evaluate the diagnostic efficiency of combining plasma microRNAs (miRNAs) and computed tomography (CT) features in the diagnosis of pulmonary nodules. Methods: Ninety-two pulmonary nodule patients who had undergone surgery were enrolled in our study from July 2016 to March 2018 at the Sun Yat-sen University Cancer Center. A prediction model was established by combining 3 miRNAs (miRNA-146a, -200b, and -7) and CT features to identify the pulmonary nodules of these patients. We evaluated the diagnostic performance of this prediction model for pulmonary nodules using the Receiver Operating Characteristic (ROC) curve. Results: The expression levels of miRNA-146a, -200b, and -7 in early-stage non-small cell lung cancer (NSCLC) patients are significantly higher than those in benign nodule patients. We used these three miRNAs and CT features (pleural indentation and speculation) to establish a prediction model for early-stage NSCLC, with a sensitivity and specificity of 92.9%, 83.3% in the training set, respectively. For the validation process, with the sensitivity of 71.8% and the specificity of 69.2%. For ROC curve analyses, area under the curve (AUC) for tumor identification in the training stage and validation stage were 0.929 and 0.781, respectively. Conclusion: Plasma miRNA-146a, miRNA-200b, and miRNA-7 may be potential biomarkers for the early diagnosis of lung cancer. Our prediction model can help to identify the nature of pulmonary nodules with a relatively high diagnostic efficiency.

Concomitant screening of coronary artery disease and lung cancer with a new ultrafast-low-dose Computed Tomography protocol: A pilot randomised trial

We performed a pilot randomised study to assess the feasibility and radiation exposure of a new computed tomography (CT) protocol that allows screening of both coronary artery disease (CAD) and lung cancer. Current or former heavy smokers at high lung cancer risk with indication to cardiac CT for suspected or known CAD were randomised to undergo concomitant CT evaluation of either cardiac or thoracic area or cardiac CT only. Out of 129 subjects deemed eligible for the study, 110 agreed to participate and were randomised to simultaneous cardiac and lung CT (Gr.A; n = 55) or cardiac CT only (Gr.B; n = 55). The feasibility (i.e. adequate visualization of coronary artery segments) was noninferior with simultaneous cardiac and lung CT compared with the standard cardiac CT (870 of 889 segments [97%] in Gr.A vs 878/890 segments [99%] in Gr.B; mean difference 2.0% [90% confidence interval: -0.3% to 4.1%]). The safety (i.e. effective radiation dose) of the concomitant cardiac and lung CT protocol was noninferior to the standard cardiac CT (1.5 [95% confidence intervals: 1.2-1.7] vs. 1.4 [95% confidence intervals: 1.1-1.6] mSv; mean difference 0.1 mSv [90% confidence interval: -0.2 to 0.3 mSv]). In the two groups, a total of 25 significant (>70%) coronary stenoses were found at cardiac CT (9/55 cases of Gr.A vs 11/55 cases of Gr.B). Pulmonary nodules >2 mm were detected in 7 of the 55 Gr.A subjects. This pilot randomised study shows that concomitant CAD and lung cancer screening by means of a new CT protocol is both feasible and safe, thus allowing a comprehensive evaluation of both cardiac and thoracic regions during one CT scanning only. (ClinicalTrials.gov Identifier: NCT03727958).

Recommendations for lung cancer screening in Southern Africa

Lung cancer remains the leading cause of cancer-related deaths in southern Africa. Early trials of chest radiograph-based screening in males at high risk for lung cancer found no mortality benefit of a radiograph alone, or a radiograph plus sputum cytology screening strategy. Large prospective studies, including the National Lung Screening Trial, have shown an all-cause mortality benefit when low-dose computed tomography (LDCT) was used as a screening modality in patients that are at high risk of developing lung cancer. The South African Thoracic Society, based on these findings, and those from several international guidelines, recommend that annual LDCT should be offered to patients between 55-74 years of age who are current or former smokers (having quit within the preceding 15 years), with at least a 30-pack year smoking history and with no history of lung cancer. Patients should be in general good health, fit for surgery, and willing to undergo further investigations if deemed necessary. Given the high local prevalence of tuberculosis (TB) infection and post-TB lung disease, which can radiographically mimic lung cancer, a conservative threshold (nodule size ≥6 mm) should be used to determine whether the baseline LDCT screen is positive (thus nodules <6 mm require no action until the next annual screen). If a non-calcified, solid or partly solid nodule is ≥6 mm, but <10 mm with no malignant features (e.g., distinct spiculated margins), the LDCT should be repeated in 6 months. If a solid nodule or the largest component of a non-solid nodule is ≥10 or ≥6 mm and enlarging or with additional malignant features present, definitive action to exclude lung cancer is warranted. Patients should be screened annually until 15 years have elapsed from date of smoking cessation, they turn 80, become unfit for a curative operation or significant changes are observed.

Multi-window CT based Radiomic signatures in differentiating indolent versus aggressive lung cancers in the National Lung Screening Trial: a retrospective study

Background

We retrospectively evaluated the capability of radiomic features to predict tumor growth in lung cancer screening and compared the performance of multi-window radiomic features and single window radiomic features.

Methods

One hundred fifty lung nodules among 114 screen-detected, incident lung cancer patients from the National Lung Screening Trial (NLST) were investigated. Volume double time (VDT) was calculated as the difference between continuous two scans and used to define indolent and aggressive lung cancers. Lung nodules were semi-automatically segmented using lung and mediastinal windows separately, and subtracting the mediastinal window region from the lung window region generated the difference region. 364 radiomic features were separately exacted from nodules using the lung window, the mediastinal window and the difference region. Multivariable models were conducted to identify the most predictive features in predicting tumor growth. Clinical information was also obtained from the database.

Results

Based on our definition, 26% of the cases were indolent lung cancer. The tumor growth pattern could be predicted by radiomic models constructed using features obtained in the lung window, the difference region, and by combining features obtained in both the lung window and difference regions with areas under the receiver operator characteristic (AUROCs) of 0.799, 0.819, and 0.846, respectively. The multi-window feature model showed better performance compared to single window features (P < 0.001). Incorporating clinical factors into the multi-window feature models showed improvement, yielding an accuracy of 84.67% and AUROC of 0.855 for distinguishing indolent from aggressive disease.

Conclusions

Multi-window CT based radiomics features are valuable predictors of indolent lung cancers and out performed single CT window setting. Combining clinical information improved predicting performance.

Electronic supplementary material

The online version of this article (10.1186/s40644-019-0232-6) contains supplementary material, which is available to authorized users.

The incidence of lymph node metastasis in patients with different oncogenic driver mutations among T1 non-small-cell lung cancer

OBJECTIVE

To investigate the incidence and distribution of lymph node metastasis in patients with different gene mutations among pathological T1 non-small-cell lung cancers (NSCLC).

METHODS

NSCLC cases resected in our institution between 2016 and 2018 were included. Driver mutation testing was performed in all resected tumor tissues. These patients were grouped by the type of gene mutations. On the basis of protein that mutant-genes encoded involved in the molecular pathway, the genotypes were further classified into four distinct groups: upstream receptor mutant protein (EGFR, HER2 and MET); downstream regulator mutant protein (KRAS and BRAF); fusion mutant protein (ROS1, ALK and RET) and the wild type group. The incidence of lymph node metastasis was compared among different groups.

RESULTS

Of the 1052 patients enrolled, the frequency of positive mutations was 68.0%. The incidence of lymph node metastasis were as follows: wild type (19.3%), ROS1 (72.8%), BRAF (55.5%), ALK (44.7%), HER2 (40%), RET (23.1%), KRAS (15.3%), EGFR (15.3%) and MET mutation (0%) (P < 0.001). The incidence of lymph node metastasis was significantly higher in fusion mutant protein group (45.1%) compared with others (wild type 19.3%, downstream regulator mutant protein 19.1%, upstream receptor mutant protein 15.3%, all P < 0.001). Patients with fusion genes also showed higher proportion of vascular invasion and positive lymph node ratio of greater than 0.33 compared to others.

CONCLUSION

Different genotypes of NSCLC have different propensity to develop lymph node metastasis. Cases of fusion gene mutations had a higher risk and burden of lymph node metastasis than other genotypes, which may indicate that more intensive treatment or surveillance strategies should be applied for these patients.

Awareness and interest in lung cancer screening among current and former smokers: findings from the ITC United States Survey

PURPOSE

To examine the awareness of low-dose computed tomography (LDCT) lung cancer screening among a population of current and former smokers using a nationally representative sample from the United States.

METHODS

Data for this study come from Wave 9 of the International Tobacco Control (ITC) United States Survey, conducted between 2013 and 2015. Among respondents age ≥ 40 (n = 1145), a 50% random sample were asked a series of questions pertaining to lung cancer screening. This study examines awareness and screening behaviors in relationship to demographic characteristics of respondents, health beliefs, psychosocial behaviors, and smoking behaviors. Descriptive tables and χ² tests were used to examine the association between those who were aware and unaware. Logistic regression analyses were conducted, stratified on respondents' smoking status. Data were weighed to be representative of the current smoking population in the US.

RESULTS

Overall, 52% of current and former smokers reported being aware of lung cancer screening. Among the group with no prior screening, 80.6% said they would take a lung cancer screening exam if recommended by their physician. In the multivariate models, former smokers had significantly greater awareness of lung cancer screening compared to current smokers [odds ratio 1.42 (95% confidence interval 1.03, 1.97)].

CONCLUSIONS

Awareness of LDCT lung cancer screening was lower among current smokers compared to former smokers. Most smokers who had not ever been screened said they would have lung cancer screening if it were recommended by their physician, demonstrating the need for healthcare providers to encourage those eligible for screening to take the test.

Resectable lung lesions malignancy assessment and cancer detection by ultra-deep sequencing of targeted gene mutations in plasma cell-free DNA

Background

Early detection of lung cancer to allow curative treatment remains challenging. Cell-free circulating tumour (ct) DNA (ctDNA) analysis may aid in malignancy assessment and early cancer diagnosis of lung nodules found in screening imagery.

Methods

The multicentre clinical study enrolled 192 patients with operable occupying lung diseases. Plasma ctDNA, white cell count genomic DNA (gDNA) and tumour tissue gDNA of each patient were analysed by ultra-deep sequencing to an average of 35 000× of the coding regions of 65 lung cancer-related genes.

Results

The cohort consists of a quarter of benign lung diseases and three quarters of cancer patients with all histopathology subtypes. 64% of the cancer patients are at stage I. Gene mutations detection in tissue gDNA and plasma ctDNA results in a sensitivity of 91% and specificity of 88%. When ctDNA assay was used as the test, the sensitivity was 69% and specificity 96%. As for the lung cancer patients, the assay detected 63%, 83%, 94% and 100%, for stages I, II, III and IV, respectively. In a linear discriminant analysis, combination of ctDNA, patient age and a panel of serum biomarkers boosted the overall sensitivity to 80% at a specificity of 99%. 29 out of the 65 genes harboured mutations in the patients with lung cancer with the largest number found in TP53 (30% plasma and 62% tumour tissue samples) and EGFR (20% and 40%, respectively).

Conclusion

Plasma ctDNA was analysed in lung nodule assessment and early cancer detection, while an algorithm combining clinical information enhanced the test performance.

Trial registration number

NCT03081741.

Lymph node metastasis in Chinese patients with clinical T1 non-small cell lung cancer: A multicenter real-world observational study

Background

Approximately 8.3–15.9% of patients with clinical stage I non‐small cell lung cancer are subsequently shown to have lymph node metastasis. However, the clinical characteristics of patients with lymph node metastasis in China are not fully understood.

Methods

This is a multicenter retrospective analysis of pathological T1 non‐small cell lung cancer patients who underwent surgical resection from 2 January 2014 to 27 December 2017. Clinical and pathological information was collected with the assistance of the Large‐scale Data Analysis Center of Cancer Precision Medicine‐LinkDoc database. The clinical and pathological factors associated with lymph node metastasis were analyzed by univariate and multivariate logistic regression.

Results

A total of 10 885 participants (51.6% women; 15.3% squamous cell carcinoma) were included in the analysis. The median age was 60.0 years (range 12.9–86.6 years). A total of 1159 patients (10.6%) had metastases in mediastinal nodes (N2), and 640 patients (5.9%) had metastasis in pulmonary lymph nodes (N1). Most patients had T1b lung cancer (4766, 43.8%). Of the patients, 3260 (29.9%) were current or former smokers. The univariate and multivariate analyses showed that younger age, squamous cell carcinoma, poor differentiation, larger tumor size, carcinoembryonic antigen level ≥5 ng/mL, and vascular invasion (+) were significantly associated with higher percentages of lymph node metastases (P < 0.001 for all).

Conclusion

This real‐world study showed the significant association of lymph node metastasis with age, tumor size, histology and differentiation, carcinoembryonic antigen levels, and status of vascular invasion. Female patients with T1a adenocarcinoma in the right upper lobe barely had lymph node metastasis.

Effectiveness of Lung-RADS in Reducing False-Positive Results in a Diverse, Underserved, Urban Lung Cancer Screening Cohort

PURPOSE

The Lung CT Screening Reporting and Data System^TM (Lung-RADS^TM) was created to standardize lung cancer screening CT reporting and recommendations but has not been well validated prospectively in clinical practice. The aim of this study was to determine the effectiveness of lung cancer screening using Lung-RADS in a diverse, underserved, academic clinical screening program, focusing on whether Lung-RADS would successfully reduce the 23.3% false-positive rate found in the National Lung Screening Trial.

METHODS

Institutional review board approval was obtained to study the clinical lung cancer screening cohort. Low-dose CT results were prospectively assigned a Lung-RADS or equivalent score. The proportion of examinations in each Lung-RADS category and the corresponding lung cancer rate, subsequent imaging, interventions, mortality, and compliance were tracked. The National Death Index was queried for follow-up losses.

RESULTS

The cohort comprised 1,181 patients with 2,270 person-years of follow-up from December 2012 to December 2016. The mean age was 64 ± 16.2 years, with 51% women, 63% nonwhite, 71% current smokers, 69% overweight and obese, and multiple comorbidities. The Lung-RADS false-positive rate was 10.4% (95% confidence interval, 8.8%-12.3%). Baseline CT results were negative in 87% (n = 1,031): for Lung-RADS 1, the lung cancer rate was 0.2%, and for Lung-RADS 2, the cancer rate was 0.5%. Positive baseline examinations were Lung-RADS 3 in 10% (n = 119), 4a in 1.2% (n = 14), and 4b in 1.5% (n = 18). Corresponding cancer rates were 3.4%, 43%, and 83%, respectively. Lung cancer prevalence was 2.1%. Mortality was 40% in patients with lung cancer versus 2.5% in the remaining cohort (P < .001). Fifty-four percent of patients were overdue for first annual examinations. Eighty-four percent of patients (n = 989) had follow-up verified via electronic records or personal contact, and the remainder had vital status ascertained via the National Death Index.

CONCLUSIONS

Lung cancer screening using Lung-RADS was effective in reducing the false-positive rate compared with the National Lung Screening Trial in a diverse and underserved urban population.

Rastreamento populacional para o câncer de próstata: mais riscos que benefícios

Resumo Recentemente, inúmeras campanhas nacionais promovidas por hospitais, sociedades médicas e outras organizações têm estimulado o rastreamento do câncer de próstata, em consonância com iniciativas mundiais conhecidas como Novembro Azul. Essas campanhas aconselham a utilização do toque retal acompanhado da dosagem sérica do antígeno prostático específico em faixas etárias definidas. A motivação seria a detecção precoce da neoplasia, com redução de sua mortalidade e das complicações e impactos associados ao seu tratamento. A dosagem do PSA para fins de rastreamento é alvo de grande controvérsia, visto que a maioria dos tumores detectados pelo rastreamento é de evolução lenta e não interfeririam na sobrevida ou na qualidade de vida do paciente. O rastreamento de base populacional não é a indicação de inúmeras instituições estrangeiras e, no Brasil, o Instituto Nacional de Câncer também não recomenda à organização programas de rastreamento desse tipo. O artigo discute os riscos e benefícios associados a esse tipo de estratégia e reforça a preocupação com o uso inadequado e indiscriminado do rastreamento para o câncer de próstata.

Small low-risk pulmonary nodules on chest digital radiography: can we predict whether the nodule is benign?

AIM

To evaluate digital chest radiography (CR) performance compared to computed tomography (CT) for characterising small low-risk pulmonary nodules detected incidentally in non-oncological patients. A second aim was to assess the prevalence of calcification and possible false-positive findings mimicking nodules.

MATERIALS AND METHODS

Two hundred and seven patients who presented with a pulmonary nodule on CR and underwent CT were included prospectively. Nine radiologists blinded to the CT images reviewed the CRs assessing for the presence of nodules. Afterwards, the same radiologists evaluated the corresponding CT for the presence of nodules, dimensions, and calcification. If the nodule was not present on CT, it was considered a false-positive finding, and possible confounding factors on CR were investigated.

RESULTS

Among all 213 nodules seen on CR, 32.4% were revealed to be false-positive findings on CT, mostly due to images formed by vessels (53.6%), osseous aetiologies (30.4%), and skin lesions (13%). Most nodules <6 mm detected on radiographies had benign calcification on CT (n=90; 67.7%). Comparatively, only 41.2% of nodules ≥6 mm on the CR had benign calcification. Among all nodules <6 mm detected on CR, 95.5% were calcified or not present at CT against 81.2% for those ≥6 mm (p<0.001).

CONCLUSION

The present study demonstrated that 95.5% of pulmonary nodules smaller than 6 mm on CRs are either calcified (benign) or represent a false-positive finding on CT. These results suggest that nodule measures on CR smaller than 6 mm most likely represent a benign finding.

Screening Patterns and Mortality Differences in Patients With Lung Cancer at an Urban Underserved Community

BACKGROUND

The landmark National Lung Screening Trial demonstrated significant reduction in lung cancer-related mortality. However, European lung cancer screening (LCS) trials have not confirmed such benefit. We examined LCS patterns and determined the impact of LCS-led diagnosis on the mortality of newly diagnosed patients with lung cancer in an underserved community.

PATIENTS AND METHODS

Medical records of patients diagnosed with primary lung cancer in 2013 through 2016 (n = 855) were reviewed for primary care provider (PCP) status and LCS eligibility and completion, determined using United States Preventative Services Task Force guidelines. Univariate analyses of patient characteristics were conducted between LCS-eligible patients based on screening completion. Survival analyses were conducted using Kaplan-Meier and multivariate Cox regression.

RESULTS

In 2013 through 2016, 175 patients with primary lung cancer had an established PCP and were eligible for LCS. Among them, 19% (33/175) completed screening prior to diagnosis. LCS completion was associated with younger age (P = .02), active smoking status (P < .01), earlier stage at time of diagnosis (P < .01), follow-up in-network cancer treatment (P = .03), and surgical management (P < .01). LCS-eligible patients who underwent screening had improved all-cause mortality compared with those not screened (P < .01). Multivariate regression showed surgery (hazard ratio, 0.31; P = .04) significantly affected mortality.

CONCLUSION

To our knowledge, this is the first study to assess LCS patterns and mortality differences on patients with screen-detected lung cancer in an urban underserved setting since the inception of United States Preventative Services Task Force guidelines. Patients with a LCS-led diagnosis had improved mortality, likely owing to cancer detection at earlier stages with curative treatment, which echoes the finding of prospective trials.

Diagnostic value of microRNAs derived from exosomes in bronchoalveolar lavage fluid of early-stage lung adenocarcinoma: A pilot study

Background

Low‐dose computed tomography can identify smaller nodules more often than chest radiography in lung screening. However, complications from invasive diagnostic procedures performed to detect nodules are common. Exosomes contain a diverse array of biomolecules that reflect the biological state of the cell from which they are released. The aim of this study was to investigate the diagnostic value of bronchoalveolar lavage (BAL) fluid exosomal microRNAs (miRNAs) for early‐stage lung adenocarcinoma.

Methods

We evaluated miRNAs (miR‐7, miR‐21, miR‐126, Let‐7a, miR‐17, and miR‐19) known to have diagnostic value for lung adenocarcinoma. Exosomes were isolated from the BAL fluid of control subjects (n = 15) and patients with lung adenocarcinoma (n = 13). Exosomal miRNA was analyzed using a commercial kit containing probes targeting six selected miRNAs. Results were validated via quantitative PCR.

Results

The presence of miRNAs was confirmed in exosomes from BAL fluid of both lung adenocarcinoma patients and control subjects. miR‐126 (P < 0.001) and Let‐7a (P = 0.015) levels were significantly higher in the BAL fluid of lung adenocarcinoma patients than in control subjects. The BAL fluid miRNA signature was confirmed using an independent set of paired adenocarcinoma and normal tissue samples (n = 4). Lung adenocarcinoma tissues showed increased expression of miR‐126 (P = 0.039) compared to normal tissue samples.

Conclusion

We identified a close correlation between BAL fluid exosomal miRNAs and tumor miRNAs. BAL fluid exosomal miRNAs obtained through noninvasive methods could serve as diagnostic biomarkers in early‐stage lung adenocarcinoma.

A novel ultrafast-low-dose computed tomography protocol allows concomitant coronary artery evaluation and lung cancer screening

BACKGROUND

Cardiac computed tomography (CT) is often performed in patients who are at high risk for lung cancer in whom screening is currently recommended. We tested diagnostic ability and radiation exposure of a novel ultra-low-dose CT protocol that allows concomitant coronary artery evaluation and lung screening.

METHODS

We studied 30 current or former heavy smoker subjects with suspected or known coronary artery disease who underwent CT assessment of both coronary arteries and thoracic area (Revolution CT, General Electric). A new ultrafast-low-dose single protocol was used for ECG-gated helical acquisition of the heart and the whole chest. A single IV iodine bolus (70-90 ml) was used. All patients with CT evidence of coronary stenosis underwent also invasive coronary angiography.

RESULTS

All the coronary segments were assessable in 28/30 (93%) patients. Only 8 coronary segments were not assessable in 2 patients due to motion artefacts (assessability: 98%; 477/485 segments). In the assessable segments, 20/21 significant stenoses (> 70% reduction of vessel diameter) were correctly diagnosed. Pulmonary nodules were detected in 5 patients, thus requiring to schedule follow-up surveillance CT thorax. Effective dose was 1.3 ± 0.9 mSv (range: 0.8-3.2 mSv). Noteworthy, no contrast or radiation dose increment was required with the new protocol as compared to conventional coronary CT protocol.

CONCLUSIONS

The novel ultrafast-low-dose CT protocol allows lung cancer screening at time of coronary artery evaluation. The new approach might enhance the cost-effectiveness of coronary CT in heavy smokers with suspected or known coronary artery disease.

Screening for early stage lung cancer and its correlation with lung nodule detection

Currently, the most effective way of reducing lung cancer mortality is early diagnosis of lung cancer. The National Lung Screening Trial has proved the efficacy of lung cancer screening using low-dose computed tomography to reduce lung cancer mortality. However, many questions remain surrounding lung cancer screening implementation, among which include how to select the optimal risk population, the personalized screening interval based different levels of risk, methods to improve diagnostic discrimination between malignant and benign disease in detected lung nodules, and the roles of biomolecular markers in stratifying risk and in guiding the management of indeterminate nodules. This review concentrates on the latest developments of lung cancer screening and provides an overview of the main unanswered questions on lung nodule detection.

Identification of a three-miRNA signature as a blood-borne diagnostic marker for early diagnosis of lung adenocarcinoma

Background

The subtypes of NSCLC have unique characteristics of pathogenic mechanism and responses to targeted therapies. Thus, non-invasive markers for diagnosis of different subtypes of NSCLC at early stage are needed.

Results

Based on the results from the screening and validation process, 3 miRNAs (miR-532, miR-628-3p and miR-425-3p) were found to display significantly different expression levels in early-stage lung adenocarcinoma, as compared to those in healthy controls. ROC analysis showed that the miRNA–based biomarker could distinguish lung adenocarcinoma from healthy controls with high AUC (0.974), sensitivity (91.5%), and specificity (97.8%). Importantly, these three miRNAs could also distinguish lung adenocarcinoma from lung benigh diseases and other subtypes of lung cancer.

Methods

Two hundreds and one early-stage lung adenocarcinoma cases and one hundreds seventy eight age- and sex-matched healthy controls were recruited to this study. We screened the differentially expressed plasma miRNAs using TaqMan Low Density Arrays (TLDA) followed by three-phase qRT-PCR validation. A risk score model was established to evaluate the diagnostic value of the plasma miRNA profiling system.

Conclusions

Taken together, these findings suggest that the 3 miRNA–based biomarker might serve as a novel non-invasive approach for diagnosis of early-stage lung adenocarcinoma.

Early Experience with Video-Assisted Thoracoscopic Anatomic Segmentectomy

BACKGROUND

Anatomic segmentectomy for stage I nonsmall cell lung cancer (NSCLC) has potential advantages such as preserving pulmonary function and reducing postoperative complications. However, many surgeons are deterred from this procedure for its anatomical complexity. Therefore, we presented our early experience with video-assisted thoracoscopic surgery (VATS) anatomic segmentectomy compared with our most recent VATS lobectomy cases.

PATIENTS AND METHODS

Forty patients with cT1aN0M0 (ground-glass opacity [GGO] rate >50%) NSCLC underwent VATS segmentectomy from January 2015 to December 2016. To compare the short-term postoperative outcomes, 47 patients, who underwent VATS lobectomy for cT1aN0M0 NSCLC (GGO rate ≤50% and pure solid nodule) during the same period, were referred to as a control group.

RESULTS

The two groups were similar in age, sex, preoperative pulmonary functional assessment, and associated comorbidities. The tumor size in the segmentectomy group was significantly smaller (median, 0.8 cm versus 1.4 cm, P < .001). Segmentectomy and lobectomy groups had similar operating time, estimated blood loss, duration of chest tube drainage, length of postoperative hospital stay, and postoperative major and minor morbidities. With regard to lymph node evaluation, lobectomy was associated with more lymph nodes (median, 12 versus 9 nodes, P < .001) and mediastinal nodal stations evaluated (median, 3 versus 3 stations, P < .001).

CONCLUSIONS

With acceptable morbidity and mortality, VATS segmentectomy may be an acceptable option for the treatment of cT1aN0M0 (GGO rate >50%) NSCLC.

Chaperonin (HSP60) and annexin-2 are candidate biomarkers for non-small cell lung carcinoma

BACKGROUND

Lung cancer is responsible of 12.4% and 17.6% of all newly diagnosed cancer cases and mortality due to cancer, respectively, and 5-year survival rate despite all improved treatment options is 15%. This survival rate reaches 66% in the Stage 1 and surgically treated patients. Early diagnosis which could not be definitely and commonly achieved yet is extremely critical in obtaining high survival rate in this disease. For this reason; proteomic differences were evaluated using matrix assisted laser desorption ionization (MALDI) mass spectrometry in the subgroups of lung adenocarcinoma and squamous cell carcinoma.

METHODS

Fresh tissue samples of 36 malignant cases involving 83.3% (n = 30) men and 16.7% (n = 6) women patients were distributed into 2 groups as early and end stage lung cancer and each group were composed of subgroups including 18 squamous cell carcinoma (9 early stage cases, 9 end stage cases) and 18 adenocarcinoma cases (9 early stage cases, 9 end stage cases). The fresh tissues obtained from the tumoral and matched normal sites after surgical intervention. The differences in protein expression levels were determined by comparing proteomic changes in each patient.

RESULTS

In the subgroups of advanced stage adenocarcinoma; tumoral tissue revealed differences in expression of 2 proteins compared with normal parenchymal tissue. Of those; difference in protein expression in heat shock protein 60 (HSP60) was found statistically significant (P = 0.0001). Subgroups of early and advanced stage squamos cell carcinoma have differed in certain 20 protein expression of normal tissue and diseased squamos cell carcinoma. Of those, increased protein expression level of only annexin-2 protein was found statistically significant (P = 0.002). No significant difference was detected in early and advanced stage protein expressions of the tumoral tissues in the subgroups of adenocarcinoma and squamous cell carcinoma.

CONCLUSIONS

We conclude that with respect to early diagnosis of lung cancer that HSP60 and annexin-2 proteins are the important biomarkers in the subgroups of adenocarcinoma and squamous cell carcinoma. We also consider that these 2 proteins are molecules which may provide critical contribution in evaluation of prognosis, metastatic potential, response to treatment, and in establishment of differential diagnosis between adenocarcinoma and squamous cell carcinoma.

Development of an Exhaled Breath Monitoring System with Semiconductive Gas Sensors, a Gas Condenser Unit, and Gas Chromatograph Columns

Various volatile organic compounds (VOCs) in breath exhaled by patients with lung cancer, healthy controls, and patients with lung cancer who underwent surgery for resection of cancer were analyzed by gas condenser-equipped gas chromatography-mass spectrometry (GC/MS) for development of an exhaled breath monitoring prototype system involving metal oxide gas sensors, a gas condenser, and gas chromatography columns. The gas condenser-GC/MS analysis identified concentrations of 56 VOCs in the breath exhaled by the test population of 136 volunteers (107 patients with lung cancer and 29 controls), and selected four target VOCs, nonanal, acetoin, acetic acid, and propanoic acid, for use with the condenser, GC, and sensor-type prototype system. The prototype system analyzed exhaled breath samples from 101 volunteers (74 patients with lung cancer and 27 controls). The prototype system exhibited a level of performance similar to that of the gas condenser-GC/MS system for breath analysis.

Efficacy of low-dose computed tomography screening for lung cancer: the current state of evidence of mortality reduction

The interim and final results of randomized controlled trials on the efficacy of lung cancer computed tomography (CT) screening have been reported recently from Western countries. The outcome of the National Lung Screening Trial (NLST) demonstrated the efficacy of low-dose thoracic CT screening for heavy smokers; however, other studies have found no apparent reduction in the mortality rate, and the outcome of the NELSON study is awaited. To date, a few studies have reported on the efficacy of lung cancer CT screening for non-/light smokers. A report from the Hitachi district, which is an ecological/time series study where non-/light smokers account for approximately half of the CT screening examinees, was published in 2012, with an outcome suggesting efficacy. Currently, a randomized controlled trial (JECS Study) is underway in Japan with non-/light smokers as the subjects, and this trial is very important in terms of cancer prevention.

Lobectomy and limited resection in small-sized peripheral non-small cell lung cancer

BACKGROUND

Although lobectomy is the standard surgical procedure for non-small cell lung cancer (NSCLC), recent studies show favorable outcomes after limited resection in patients with small-sized peripheral tumors. We conducted a randomized controlled trial of such patients to estimate postoperative outcomes and pulmonary function following these surgical techniques.

METHODS

Between 2005 and 2008, eligible patients with tumors of 2 cm or less were randomly assigned 1:1 to undergo lobectomy or limited resection; 32 and 33 NSCLC patients in each group, respectively, were analyzed. The primary end points were 5-year overall survival (OS) and disease-free survival (DFS), while the secondary end points were postoperative pulmonary function including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁).

RESULTS

The 5-year OS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.921). The 5-year DFS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.714). These rates did not differ significantly between the two resection groups. The median postoperative/preoperative FVC ratios were 84.1% and 90.0% in the lobectomy and limited resection groups, respectively, while the median postoperative/preoperative FEV₁ ratios were 81.9% and 89.1%, respectively. Both ratios were significantly higher in the limited resection group (P=0.032 and P=0.005 for FVC and FEV₁ ratios, respectively).

CONCLUSIONS

A similar outcome, with more preserved postoperative pulmonary function, was observed in patients who underwent limited resection compared to those who underwent lobectomy. Ongoing large-scale multi-institutional prospective randomized trials of lobar versus sublobar resection in patients with small peripheral NSCLCs will hopefully provide definitive information about intentional limited resection of small peripheral tumors.

Novel Methods of Intraoperative Localization and Margin Assessment of Pulmonary Nodules

Lung cancer screening has lead to frequent diagnosis of solitary pulmonary nodules, many of which require surgical biopsy for diagnosis and intervention. Subcentimeter and central nodules are particularly difficult to visualize or palpate during surgery, thus nodule localization can be a difficult problem for the thoracic surgeon. Although minimally invasive techniques including transthoracic computed tomography and bronchoscopic-guided biopsy may establish a diagnosis, these methods do not help locate nodules during surgery and can lead to inadequate tissue sampling. Therefore, surgical biopsy is often required for diagnosis and management of solitary pulmonary nodules. Additionally, after an excision, intraoperative margin assessment is important to prevent local recurrence. This is important for bronchial margins following lobectomy or parenchymal margins following sublobar resection. First, we examine methods of preoperative lesion marking, including wire placement, dye marking, ultrasound, fluoroscopy, and molecular imaging. Second, we describe the current state of the art in intraoperative margin assessment techniques.

Jumonji domain containing 2A predicts prognosis and regulates cell growth in lung cancer depending on miR-150

Lung cancer has become the most common cancer worldwide, of which non-small cell lung cancer (NSCLC) accounts for over 80%. Previous studies have shown that the Jumonji domain containing 2A (JMJD2A) was aberrantly expressed in various tumors and involved in the regulation of tumor progression, but the role of JMJD2A on the tumorigenesis in NSCLC and the underlying mechanisms are still unclear. In the present study, we first identified the expression of JMJD2A in NSCLC tissues and cell lines through quantitative RT-PCR (qRT-PCR) and western blotting. Next, the effects of JMJD2A on the progression of NSCLC were analyzed. MTT assay was performed to measure the cell numbers and fluorescence-activated cell sorting (FACS) was adopted to evaluate cell apoptosis. Finally, the relationship between JMJD2A and miR-150 involved in NSCLC was studied. Our results suggested that JMJD2A was significantly overexpressed in NSCLC samples and cell lines. Kaplan-Meier analysis showed that high level of JMJD2A predicted a poor prognosis. Knockdown of JMJD2A inhibited tumor growth and promoted cell apoptosis in NSCLC cells. Additionally, miR-150 was upregulated in NSCLC tissues and positively related with JMJD2A expression. Significant downregulation of miR-150 was observed with JMJD2A knockdown. Furthermore, JMJD2A knockdown inhibited NSCLC cell proliferation while the silencing of miR-150 attenuated the inhibition effect on cell proliferation, suggesting that the effect of JMJD2A on NSCLC cell growth was dependent on miR-150. Thus, our findings identified that JMJD2A played an oncogenic role in NSCLC via regulating miR-150. JMJD2A could possibly serve as a prognostic factor and potential target for NSCLC therapy.

Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography

RATIONALE

Screening for lung cancer with low-dose spiral computed tomography (LDCT) has been shown to reduce lung cancer mortality by 20% compared with screening with chest X-ray (CXR) in the National Lung Screening Trial, but uncertainty remains concerning the efficacy of LDCT screening in a community setting.

OBJECTIVES

To explore the effect of LDCT screening on lung cancer mortality compared with no screening. Secondary endpoints included incidence, stage, and resectability rates.

METHODS

Male smokers of 20+ pack-years, aged 60 to 74 years, underwent a baseline CXR and sputum cytology examination and received five screening rounds with LDCT or a yearly clinical review only in a randomized fashion.

MEASUREMENTS AND MAIN RESULTS

A total of 1,264 subjects were enrolled in the LDCT arm and 1,186 in the control arm. Their median age was 64.0 years (interquartile range, 5), and median smoking exposure was 45.0 pack-years. The median follow-up was 8.35 years. One hundred four patients (8.23%) were diagnosed with lung cancer in the screening arm (66 by CT), 47 of whom (3.71%) had stage I disease; 72 control patients (6.07%) were diagnosed with lung cancer, with 16 (1.35%) being stage I cases. Lung cancer mortality was 543 per 100,000 person-years (95% confidence interval, 413-700) in the LDCT arm versus 544 per 100,000 person-years (95% CI, 410-709) in the control arm (hazard ratio, 0.993; 95% confidence interval, 0.688-1.433).

CONCLUSIONS

Because of its limited statistical power, the results of the DANTE (Detection And screening of early lung cancer with Novel imaging TEchnology) trial do not allow us to make a definitive statement about the efficacy of LDCT screening. However, they underline the importance of obtaining additional data from randomized trials with intervention-free reference arms before the implementation of population screening.

Thinking beyond the treatment effect in screening for lung cancer

In the optimism surrounding screening for lung cancer, the downsides of screening should not be ignored. The article examines the dark side of screening, which is not an unmitigated good.

Preoperative assessment of lung cancer patients: Evaluating guideline compliance (re-audit)

Background

Guidelines have been issued for the management of lung cancer patients in the United Kingdom. However, compliance with these national guidelines varies in different thoracic units in the country. We set out to evaluate our thoracic surgery practice and compliance with the national guidelines.

Methods

An initial audit in 2011 showed deficiencies in practice, thus another audit was conducted to check for improvements in guideline compliance. A retrospective study was carried out over a 12-month period from January 2013 to January 2014 and included all patients who underwent radical surgical resection for lung cancer. Data were collected from computerized records.

Results

Sixty-eight patients had radical surgery for lung cancer between January 2013 and January 2014. Four patients were excluded from the analysis due to incomplete records. Our results showed improvements in our practice compared to our initial audit. More patients underwent surgery within 4 weeks of computed tomography and positron-emission tomography scanning. An improvement was noticed in carbon monoxide transfer factor measurements. Areas for improvement include measurement of carbon monoxide transfer factor in all patients, a cardiology referral in patients at risk of cardiac complications, and the use of a global risk stratification model such as Thoracoscore.

Conclusion

Guideline-directed service delivery provision for lung cancer patients leads to improved outcomes. Our results show improvement in our practice compared to our initial audit. We aim to liaise with other thoracic surgery units to get feedback about their practice and any audits regarding adherence to the British Thoracic Society and National Institute for Health and Care Excellence guidelines.

[Lung cancer screening. What have we learnt for the practice so far?]

CLINICAL/METHODICAL ISSUE

Lung cancer is the most frequent cause of tumor-associated death and only has a good prognosis if detected at a very early tumor stage.

METHODICAL INNOVATIONS

For the first time the American National Lung Screening Trial (NLST) could prove that low-dose computed tomography (CT) screening is able to reduce lung cancer mortality by 20 %.

PERFORMANCE

To date, however, three much smaller and therefore statistically underpowered European trials could not confirm the positive results of the NLST. The results of the largest European trial NELSON are expected within the next 2 years. In addition, there are a number of open or not yet satisfactorily answered questions, such as the definition of the appropriate screening population, the management of nodules detected by screening, the effects of over-diagnosis and the risk of cumulative radiation exposure.

PRACTICAL RECOMMENDATIONS

The success of the NLST prompted several predominantly American professional societies to issue a positive recommendation about the implementation of lung cancer screening in a population at risk. However, potentially conflicting results of European studies and a number of not yet optimized issues justify caution and call for a pooled analysis of European studies in order to provide statistically sound results and to ensure a high efficiency of screening with respect to the radiation applied, mental and physical patient burden and, last but not least, the financial efforts.

Mass spectrometry-based proteomics in Chest Medicine, Gerontology, and Nephrology: subgroups omics for personalized medicine

Mass spectrometry (MS) is currently the most promising tool for studying proteomics to investigate largescale proteins in a specific proteome. Emerging MS-based proteomics is widely applied to decipher complex proteome for discovering potential biomarkers. Given its growing usage in clinical medicine for biomarker discovery to predict, diagnose and confer prognosis, MS-based proteomics can benefit study of personalized medicine. In this review we introduce some fundamental MS theory and MS-based quantitative proteomic approaches as well as several representative clinical MS-based proteomics issues in Chest Medicine, Gerontology, and Nephrology.

The mediation of social influences on smoking cessation and awareness of the early signs of lung cancer

BACKGROUND

Whilst there has been no clear consensus on the potential for earlier diagnosis of lung cancer, recent research has suggested that the time between symptom onset and consultation can be long enough to plausibly affect prognosis. In this article, we present findings from a qualitative study involving in-depth interviews with patients who had been diagnosed with lung cancer (n = 11), and people who were at heightened risk of developing the disease (n = 14).

METHODS

A grounded theory methodology was drawn upon to conduct thematic and narrative based approaches to analysis.

RESULTS

The paper focuses on three main themes which emerged from the study: i) fatalism and resignation in pathways to help-seeking and the process of diagnosis; ii) Awareness of smoking risk and response to cessation information and advice. iii) The role of social and other networks on help-seeking. Key findings included: poor awareness among participants of the symptoms of lung cancer; ambivalence about the dangers of smoking; the perception of lung cancer as part of a homogenisation of multiple illnesses; close social networks as a key trigger in help-seeking.

CONCLUSIONS

We suggest that future smoking cessation and lung cancer awareness campaigns could usefully capitalise on the influence of close social networks, and would benefit from taking a 'softer' approach.