Imaging of the Patient with Non–Small Cell Lung Cancer

Multimodality Management of Thoracic Tumors: Initial Experience With a Multidisciplinary Thoracic Ablation Conference

BACKGROUND

This study aimed to describe lesion-specific management of thoracic tumors referred for consideration of image-guided thermal ablation (IGTA) at a newly established multidisciplinary ablation conference.

METHODS

This retrospective single-center cohort study included consecutive patients with non-small cell lung cancer (NSCLC) or thoracic metastases evaluated from June 2020 to January 2022 in a multidisciplinary conference. Outcomes included the management recommendation, treatments received (IGTA, surgical resection, stereotactic body radiation therapy [SBRT], multimodality management), and number of tumors treated per patient. Pearson's chi-square test was used to assess for a change in management, and Poisson regression was used to compare the number of tumors by treatment received.

RESULTS

The study included 172 patients (58 % female; median age, 69 years; 56 % thoracic metastases; 27 % multifocal primary lung cancer; 59 % ECOG 0 [range, 0-3]) assessed in 206 evaluations. For the patients with NSCLC, IGTA was considered the most appropriate local therapy in 12 %, equal to SBRT in 22 %, and equal to lung resection in 3 % of evaluations. For the patients with thoracic metastases, IGTA was considered the most appropriate local therapy in 22 %, equal to SBRT in 12 %, and equal to lung resection in 3 % of evaluations. Although all patients were referred for consideration of IGTA, less than one third of patients with NSCLC or thoracic metastases underwent IGTA (p < 0.001). Multimodality management allowed for treatment of more tumors per patient than single-modality management (p < 0.01).

CONCLUSIONS

Multidisciplinary evaluation of patients with thoracic tumors referred for consideration of IGTA significantly changed patient management and facilitated lesion-specific multimodality management.

Endobronchial ultrasound for T4 staging in patients with resectable NSCLC

BACKGROUND

In lung cancer patients, accurate assessment of mediastinal and vascular tumor invasion (stage T4) is crucial for optimal treatment allocation and to prevent unnecessary thoracotomies. We assessed the diagnostic accuracy of linear endobronchial ultrasound (EBUS) for T4-status in patients with centrally located lung cancer.

METHODS

This is a retrospective study among consecutive patients who underwent EBUS for diagnosis and staging of lung cancer in four hospitals in The Netherlands (Amsterdam, Leiden), Italy (Bologna) and Poland (Zakopane) between 04-2012 and 04-2019. Patients were included if the primary tumor was detected by EBUS and subsequent surgical-pathological staging was performed, which served as the reference standard. T4-status was extracted from EBUS and pathology reports. Chest CT's were re-reviewed for T4-status.

RESULTS

104 patients with lung cancer in whom EBUS detected the primary tumour, and who underwent subsequent surgical-pathological staging were included. 36 patients (35 %) had T4-status, based on vascular (n = 17), mediastinal (n = 15), both vascular and mediastinal (n = 3), or oesophageal invasion (n = 1). For EBUS, sensitivity, specificity, PPV and NPV for T4-status were (n = 104): 63.9 % (95 %CI 46.2-79.2 %), 92.6 % (83.7-97.6 %), 82.1 % (65.6-91.7 %), and 82.9 % (75.7-88.2 %), respectively. For chest CT (n = 72): 61.5 % (95 %CI 40.6-79.8 %), 37.0 % (23.2-52.5 %), 35.6 % (27.5-44.6 %), and 63.0 % (47.9-75.9 %), respectively. When combining CT and EBUS with concordant T4 status (n = 33): 90.9 % (95 %CI 58.7-99.8 %), 77.3 % (54.6-92.20 %), 66.7 % (47.5-81.6 %), and 94.4 % (721-99.1%), respectively.

CONCLUSION

Both EBUS and CT alone are inaccurate for assessing T4-status as standalone test. However, combining a negative EBUS with a negative CT may rule out T4-status with high certainty.

[Preoperative 4D-CT Provided Helpful Evaluation of Aorta Invasion of Left Lower Lobe Lung Cancer]

A 73-year-old woman was diagnosed by bronchoscopic examination with primary left lung cancer (Adenocarcinoma, cT3N0M0, stage IIB), which was closely adjacent to the descending aorta in contrast enhanced computed tomography (CT). This CT did not reveal any invasion of a tumor into the descending aorta, and a dynamic fourth dimension CT (4D-CT) indicated that there was no invasion of the aorta by this tumor, so we decided to perform surgery. The operative procedure was a left lower lobectomy and lymph node dissection with the use of a thoracoscope. An intraoperative finding was that the tumor had not invaded the aorta. There are few reports about the evaluation of vascular invasion using the dynamic 4D-CT. We consider that the dynamic 4D-CT gave very useful information about vascular invasion.

ePAD: An Image Annotation and Analysis Platform for Quantitative Imaging

Medical imaging is critical for assessing the response of patients to new cancer therapies. Quantitative lesion assessment on images is time-consuming, and adopting new promising quantitative imaging biomarkers of response in clinical trials is challenging. The electronic Physician Annotation Device (ePAD) is a freely available web-based zero-footprint software application for viewing, annotation, and quantitative analysis of radiology images designed to meet the challenges of quantitative evaluation of cancer lesions. For imaging researchers, ePAD calculates a variety of quantitative imaging biomarkers that they can analyze and compare in ePAD to identify potential candidates as surrogate endpoints in clinical trials. For clinicians, ePAD provides clinical decision support tools for evaluating cancer response through reports summarizing changes in tumor burden based on different imaging biomarkers. As a workflow management and study oversight tool, ePAD lets clinical trial project administrators create worklists for users and oversee the progress of annotations created by research groups. To support interoperability of image annotations, ePAD writes all image annotations and results of quantitative imaging analyses in standardized file formats, and it supports migration of annotations from various propriety formats. ePAD also provides a plugin architecture supporting MATLAB server-side modules in addition to client-side plugins, permitting the community to extend the ePAD platform in various ways for new cancer use cases. We present an overview of ePAD as a platform for medical image annotation and quantitative analysis. We also discuss use cases and collaborations with different groups in the Quantitative Imaging Network and future directions.

The major thoracic vascular invasion of lung cancer

Background

We actually investigated the surgical and pathological findings in cases which tumor invasion of the major thoracic vessels was suspected based on the preoperative Computed tomography (CT) findings.

Materials and methods

We retrospectively reviewed our prospective database of all patients, who underwent lung resection for lung cancer from 2012 to 2014. 387 patients underwent lung cancer surgery. Among these patients, we analyzed 30 patients in whom pulmonary artery (PA) invasion was suspected and 11 patients in whom pulmonary vein (PV) or left atrium (LA) invasion was suspected based on the preoperative CT findings.

Results

Among the 30 patients with suspected PA invasion, there were 9 patients in whom the tumor could be peeled off the PA in actual thoracotomy. Pathological invasion of the PA was observed in 6 of these patients. The positive predictive value of the preoperative CT findings was 20%. Among the 11 patients with suspected PV or LA invasion, there were 2 patients in whom the tumor could be peeled off the PV or LA in actual thoracotomy. Pathological tumor invasion of the PV or LA was observed in 4 of these patients. The positive predictive value of the preoperative CT findings was 36%.

Conclusion

The positive predictive value of the preoperative CT findings for tumor invasion of the thoracic vessels was low. Therefore, surgical opportunities that offer the chance of a cure shouldn't be missed in advanced lung cancer patients because the tumor is located near the major thoracic vessels on preoperative CT.

•

We actually investigated tumor invasion of the major thoracic vessels.

•

We analyzed 30 patients in whom pulmonary artery (PA) invasion was suspected.

•

We analyzed 11 patients in whom pulmonary vein (PV) or left atrium (LA) invasion was suspected.

•

The positive predictive value of CT findings was low.

Clinical and radiological features driving patient selection for antiangiogenic therapy in non-small cell lung cancer (NSCLC)

BACKGROUND

The use of antiangiogenic therapy in non-small cell lung cancer (NSCLC) requires thorough evaluation of patient characteristics in order to avoid potential safety issues, particularly pulmonary haemorrhage (PH). The aim of this consensus by a panel of experts was to identify important criteria for the selection of patients with NSCLC who would benefit from antiangiogenic therapy.

METHODS

Radiologists and oncologists were selected for the expert panel. The nominal group technique (NGT) and the Delphi questionnaire were used for consensus generation. The NGT consisted of four steps, the result of which was used to set the Delphi questionnaire. A final report was generated based on the opinions of the experts from the panel.

RESULTS

An extremely important prerequisite for the evaluation of an antiangiogenic therapeutic approach in patients with NSCLC was thorough clinical and radiological analysis of the relationships between tumour and vascular or anatomical structures (performed in close co-operation by oncologists and radiologists). The panel identified major parameters to be considered before the use of antiangiogenic treatment, collectively agreeing on the relevance of tumour cavitation, vascular infiltration, endobronchial growth and thromboembolism for chest tumour sites, and of the presence of aneurysms, extra-thoracic bleeding, brain metastases or thrombi for extra-thoracic sites. Moreover, a structured report containing information not only on the tumour but also on the general vascular status is essential to guide the treatment choice The experts agreed that tumour localization in the absence of vessel infiltration, cavitation, and the use of antiplatelet therapy are relevant parameters to be assessed, but their presence should not necessarily exclude a patient from receiving antiangiogenic therapy.

CONCLUSION

Close co-operation between oncologists and radiologists in the diagnosis, treatment selection, and assessment of response is essential for ensuring therapeutic appropriateness in the NSCLC setting. It should be noted that neither the use of antiplatelet therapy nor tumour localisation are to be considered as contraindications to antiangiogenic treatment.

Imaging after radiation therapy of thoracic tumors

Radiation-induced lung disease (RILD) is frequent after therapeutic irradiation of thoracic malignancies. Many technique-, treatment-, tumor- and patient-related factors influence the degree of injury sustained by the lung after irradiation. Based on the time interval after the completion of the treatment RILD presents as early and late features characterized by inflammatory and fibrotic changes, respectively. They are usually confined to the radiation port. Though the typical pattern of RILD is easily recognized after conventional two-dimensional radiation therapy (RT), RILD may present with atypical patterns after more recent types of three- or four-dimensional RT treatment. Three atypical patterns are reported: the modified conventional, the mass-like and the scar-like patterns. Knowledge of the various features and patterns of RILD is important for correct diagnosis and appropriate treatment. RILD should be differentiated from recurrent tumoral disease, infection and radiation-induced tumors. Due to RILD, the follow-up after RT may be difficult as response evaluation criteria in solid tumours (RECIST) criteria may be unreliable to assess tumor control particularly after stereotactic ablation RT (SABR). Long-term follow-up should be based on clinical examination and morphological and/or functional investigations including CT, PET-CT, pulmonary functional tests, MRI and PET-MRI.

Easy Diagnosis of Aortic Invasion in Patients with Lung Cancer Using Cine Magnetic Resonance Imaging

Selecting the proper treatment strategy for locally advanced lung cancer, such as T4 tumors, is difficult. Therefore, obtaining an accurate diagnosis of T4 tumors is required. It can be difficult to determine whether the tumor invades adjacent structures. We describe the case of a patient easily diagnosed to be without aortic invasion using cine magnetic resonance imaging (MRI). We herein report the case of an 80-year-old male who presented a lung tumor. The transbronchial lung washing cytology findings were consistent with those of adenocarcinoma. In addition, the computed tomography findings indicated suspected aortic invasion of the lung tumor, as the mass girdled the descending aorta beyond 120° adjoining at a length of 10 cm. However, cine MRI display clearly demonstrated a clear area of isolation between the aorta and lung tissue based on differences in the heart rhythm from the patient's respiratory movements. Therefore, the lesion was clinically diagnosed as a stage IIB (T3N0M0) tumor. Radiation was administered due to the patient's advanced age and comorbidities such as chronic obstructive pulmonary disease. He remains alive without disease progression 6 months after the therapy. Our findings, therefore, indicate the usefulness of easily diagnosing the absence of aortic invasion in patients with lung cancer using cine MRI without the need for a special software program.

Safe resection of the aortic wall infiltrated by lung cancer after placement of an endoluminal prosthesis

BACKGROUND

Few investigators have reported the results of combined resection of lung cancer infiltrating the thoracic aorta; only anecdotal accounts of off-label use of thoracic aortic endografts to facilitate resection of such tumors have been published. In this paper, we describe our experience using this innovative approach in terms of technical details and outcomes.

METHODS

We retrospectively reviewed data on 9 patients (6 men and 3 women, median age 61 years) with preoperatively suspected thoracic aorta neoplastic invasion, who were operated on after positioning of an endograft and underwent en bloc tumor resection including the aortic wall.

RESULTS

All but one cancer were non-small cell lung carcinomas; 4 patients received neoadjuvant chemotherapy, and 7 received adjuvant therapy. Aortic endografting was performed 2 to 17 days before resection of the tumor in 7 patients and as part of a one-stage procedure in 2 patients. The proximal end of the stent graft was deployed in the aortic arch (n = 1) or the descending aorta (n = 8). Lung resections were left pneumonectomies in 4 patients and left lower lobectomies in 5. Five patients underwent additional buttressing of the aortic defect using a synthetic patch (n = 2) or the omentum (n = 3). No cardiopulmonary bypass was required. At the last follow-up, 3 patients had evidence of tumor recurrence (one local and two distant). No endograft-related complications were detected.

CONCLUSIONS

Thoracic aortic endografting allowed safe en bloc resection of tumors invading the aortic wall, avoiding the need for extracorporeal circulatory support. Such an extended indication for thoracic aortic endografts seems promising and should be considered for selected oncologic cases.

Current status of thermal ablation treatments for lung malignancies

About 75% of lung cancer patients are not surgical candidates, either due to advanced disease or medical comorbidities. Furthermore, conventional treatments that can be offered to these patients are beneficial only to a small percentage of them. Thermal ablation is a minimally invasive treatment that is commonly used in this group of patients, and which has shown promising results. Currently, the most widely used ablation techniques in the treatment of lung malignancies are radiofrequency ablation (RFA), microwave ablation, and cryoablation. Although the most studied technique is RFA, recent studies with microwave ablation and cryoablation have shown some advantages over RFA. This article reviews the application of thermal ablation in the thorax, including patient selection, basic aspects of procedure technique, imaging follow-up, treatment outcomes, and comparison of ablation techniques.

Predicting and managing the risk of pulmonary haemorrhage in patients with NSCLC treated with bevacizumab: a consensus report from a panel of experts

BACKGROUND

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor. Severe pulmonary haemorrhage (PH) is a rare but serious potential adverse event associated with bevacizumab therapy for advanced non-squamous non-small-cell lung cancer (NSCLC).

METHODS

A panel of expert oncologists, pulmonologists and radiologists reviewed the available data to identify predictive factors for PH in order to help guide physicians using bevacizumab in patients with NSCLC.

RESULTS

Patients with NSCLC are at an increased risk of PH owing to the underlying disease process. Patients with squamous histology and/or a history of grade ≥ 2 haemoptysis (≥ 2.5 ml per event) should not receive bevacizumab. No clinical or radiological features (including cavitation and central tumour location) reliably predict severe PH in bevacizumab-treated patients. Major blood vessel infiltration and bronchial vessel infiltration, encasement and abutting may predict PH; however, standardised radiological criteria for defining infiltration have not been established. Eligibility for bevacizumab is not affected by patient age, performance status or anticoagulation or antiplatelet therapy.

CONCLUSIONS

An individualised risk-benefit assessment should be undertaken in all patients with NSCLC in whom bevacizumab is being considered. Further research is required to elucidate the mechanisms underlying PH and the clinical risk factors.

Systematic review of the cost-effectiveness of positron-emission tomography in staging of non--small-cell lung cancer and management of solitary pulmonary nodules

Implementation of positron-emission tomography (PET) is variable depending on jurisdiction in part due to uncertainty about cost-effectiveness. Our objective was to perform a systematic review describing cost-effectiveness of PET in staging of non-small-cell lung cancer (NSCLC) and management of solitary pulmonary nodules (SPN). Systematic literature searches were conducted using separate search strategies for multiple databases. Our validity criteria included measurement of study quality by means of the validated Quality of Health Economic Studies (QHES) instrument. Metrics such as mean PET costs, median average cost savings per patient, incremental cost-effectiveness ratio based on life years saved and quality-adjusted life years were calculated. Eighteen studies met our inclusion criteria with average QHES scores > 75. Studies were primarily based on the national health insurance payer perspective from 10 different countries. Cost-effectiveness was assessed primarily using decision-tree modeling and sensitivity analysis to determine the effects of changing variables on expected cost and life expectancy. After adjusting for currency exchange rates and inflation to 2010 United States dollars, the mean cost of PET was $1478. The cost-effectiveness metrics used in these studies were variable depending on sensitivity and specificity of diagnostic tests used in the models, probability of malignancy, and baseline strategy. Despite observed study heterogeneity, the consensus of these studies conclude that the additional information gained from PET imaging in the staging of NSCLC and diagnosis of SPNs is worth the cost in context of proper medical indications.

Improving CT prediction of treatment response in patients with metastatic colorectal carcinoma using statistical learning theory

Background

Significant interest exists in establishing radiologic imaging as a valid biomarker for assessing the response of cancer to a variety of treatments. To address this problem, we have chosen to study patients with metastatic colorectal carcinoma to learn whether statistical learning theory can improve the performance of radiologists using CT in predicting patient treatment response to therapy compared with the more traditional RECIST (Response Evaluation Criteria in Solid Tumors) standard.

Results

Predictions of survival after 8 months in 38 patients with metastatic colorectal carcinoma using the Support Vector Machine (SVM) technique improved 30% when using additional information compared to WHO (World Health Organization) or RECIST measurements alone. With both Logistic Regression (LR) and SVM, there was no significant difference in performance between WHO and RECIST. The SVM and LR techniques also demonstrated that one radiologist consistently outperformed another.

Conclusions

This preliminary research study has demonstrated that SLT algorithms, properly used in a clinical setting, have the potential to address questions and criticisms associated with both RECIST and WHO scoring methods. We also propose that tumor heterogeneity, shape, etc. obtained from CT and/or MRI scans be added to the SLT feature vector for processing.

Semiquantitative visual approach to scoring lung cancer treatment response using computed tomography: a pilot study

OBJECTIVE

Our objective was to compare a newly developed semiquantitative visual scoring (SVS) method with the current standard, the Response Evaluation Criteria in Solid Tumors (RECIST) method, in the categorization of treatment response and reader agreement for patients with metastatic lung cancer followed by computed tomography.

MATERIALS AND METHODS

The 18 subjects (5 women and 13 men; mean age, 62.8 years) were from an institutional review board-approved phase 2 study that evaluated a second-line chemotherapy regimen for metastatic (stages III and IV) non-small cell lung cancer. Four radiologists, blinded to the patient outcome and each other's reads, evaluated the change in the patients' tumor burden from the baseline to the first restaging computed tomographic scan using either the RECIST or the SVS method. We compared the numbers of patients placed into the partial response, the stable disease (SD), and the progressive disease (PD) categories (Fisher exact test) and observer agreement (kappa statistic).

RESULTS

Requiring the concordance of 3 of the 4 readers resulted in the RECIST placing 17 (100%) of 17 patients in the SD category compared with the SVS placing 9 (60%) of 15 patients in the partial response, 5 (33%) of the 15 patients in the SD, and 1 (6.7%) of the 15 patients in the PD categories (P < 0.0001). Interobserver agreement was higher among the readers using the SVS method (kappa, 0.54; P < 0.0001) compared with that of the readers using the RECIST method (kappa, -0.01; P = 0.5378).

CONCLUSIONS

Using the SVS method, the readers more finely discriminated between the patient response categories with superior agreement compared with the RECIST method, which could potentially result in large differences in early treatment decisions for advanced lung cancer.

Qualitative radiology assessment of tumor response: does it measure up?

Our purpose was to assess whether a simpler qualitative evaluation of tumor response by computed tomography is as reproducible and predictive of clinical outcome as the Response Evaluation Criteria in Solid Tumors (RECIST) and World Health Organization (WHO) methods. This study was a two-reader retrospective evaluation in which qualitative assessment resulted in agreement in 21 of 23 patients with metastatic colorectal carcinoma (91.3%, kappa=0.78; 95% CI, 0.51-1.00). Hepatic metastases were classified as increased, decreased, or unchanged, compared with agreement in 20 of 23 patients (87.0%) for RECIST (kappa=0.62; 95% CI, 0.23-1.00) and WHO (kappa=0.67; 95% CI, 0.34-1.00) methods. Patients were placed into partial response, stable disease, and disease progression categories. Time to progression of disease was better predicted qualitatively than by RECIST or WHO. Our pilot data suggest that our qualitative scoring system is more reproducible and predictive of patient clinical outcome than the RECIST and WHO methods.

Lung cancer

Lung cancer is the most frequently occurring cancer in the world, and in the United States it is the second most common cancer diagnosed. Accurate staging by imaging can have a significant impact on appropriate treatment and surgical options. Familiarity with the different histologic subtypes of lung cancer and the typical and atypical appearances of lung cancer is vital. Radiologists serve a critical role in the diagnosis, staging, and follow-up of patients with lung cancer.

PET/CT in non-small cell lung cancer staging—promises and problems

Integrated positron emission tomography/computed tomography (PET/CT) has many advantages over solitary PET and CT, which has led it to become an increasingly established imaging technique in the management of many cancers. This article will review the evidence for the role of (18)F-fluorodeoxyglucose PET/CT in non-small cell lung cancer staging, examining its strengths, weaknesses and cost-effectiveness.