Lung cancer screening in China: early-stage lung cancer and minimally invasive surgery 3.0

Management of screening-detected ground glass nodules: a narrative review

Wide-scale application of low-dose computed tomography (LDCT) in lung cancer screening has led to an increased detection of ground glass nodule (GGN) lesions. However, there is still no clear management plan for these lesions after detection. Clinicians are usually faced with a dilemma in choosing the best initial management approach that not only limits overtreatment but also avoids the possibility of lesions growing into invasive carcinoma. Most current and past guidelines favor surveillance with computed tomography (CT) as the initial management approach based on the notion that the majority of GGN lesions are indolent tumors. Immediate surgery is generally considered overtreatment and is usually only recommended when the lesion grows in size, persists, or increases its solid component during follow-up CT surveillance. However, due to evolution of surgery to minimal invasive procedures, such as uniportal video-assisted thoracic surgery, and the development of enhanced recovery after thoracic surgery protocols, modern surgery is now safer and associated with less postoperative mortality. Additionally, intraoperative frozen sections can be used to guide resection, making initial management via surgery more attractive than before. Based on these developments, this review recommends that immediate surgery should be considered at the same level as follow-up CT surveillance when making multidisciplinary team decisions for screening-detected GGNs, as it provides both a diagnostic and treatment role.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Lung cancer screening with low-dose computed tomography: National expenditures and cost-effectiveness

Objective

To compare the cost-effectiveness of undertaking low-dose computed tomography (LDCT) screening for early detection of lung cancer (LC) with different frequencies within the healthcare system of China, and estimate the additional national healthcare expenditure and five-year LC mortality associated with different screening frequencies.

Material and methods

A Markov model was established using national LC epidemiological data from the Chinese Center for Disease Control and Prevention, demographic data from the Chinese Statistical Yearbook, and cost and effectiveness data mainly from the Cancer Screening Program in China. The model included thirty sex-specific screening strategies, which were classified by initial screening age (30, 35, 40, 45, and 50), and screening intervals (intervals at single time point, 1, 2, 5, 10, and 20 years). The main model outputs were incremental cost-effectiveness ratios (ICERs), additional national healthcare expenditure and five-year LC mortality.

Results

The ICERs for LDCT screening strategies vs. non-screening strategy ranged from $16,086 per quality-adjusted life-year (QALY) to $3,675,491 per QALY in the male cohort, and from $36,624 per QALY to $5,943,556 per QALY in the female cohort. The annual increment national healthcare expenditures related to LDCT screening were varied from $0.25 to $13.39 billion, with the lower cost in the cohort with older screening ages and lower screening frequencies. More frequent screening with LDCT was associated with a greater reduction in LC death: an annual LDCT screening was linked to an estimated reduction in five-year LC death by 27.27-29.07%, while a one-off screening was linked to a reduction by 5.56-5.83%.

Conclusion

Under a willingness-to-pay (WTP) threshold of three times the Chinese gross domestic product (GDP) per capita (US $37,654), annual screening with an initiating age at 50 was most cost-effective in both male and female cohorts. By taking into account both the national healthcare expenditures and the effect of LDCT screening, our study results support undertaking LDCT screening annually from 50 years old in general populations.

Community-based lung cancer screening by low-dose computed tomography in China: First round results and a meta-analysis

OBJECTIVE

To evaluate the efficiency of low-dose computed tomography (LDCT) screening for lung cancer in China by analyzing the baseline results of a community-based screening study accompanied with a meta-analysis.

METHODS

A first round of community-based lung cancer screening with LDCT was conducted in Tianjin, China, and a systematic literature search was performed to identify LDCT screening and registry-based clinical studies for lung cancer in China. Baseline results in the community-based screening study were described by participant risk level and the lung cancer detection rate was compared with the pooled rate among the screening studies. The percentage of patients per stage was compared between the community-based study and screening and clinical studies.

RESULTS

In the community-based study, 5523 participants (43.6% men) underwent LDCT. The lung cancer detection rate was 0.5% (high-risk, 1.2%; low-risk, 0.4%), with stage I disease present in 70.0% (high-risk, 50.0%; low-risk, 83.3%), and the adenocarcinoma present in 84.4% (high-risk, 61.5%; low-risk, 100%). Among all screen-detected lung cancer, women accounted for 8.3% and 66.7% in the high- and low-risk group, respectively. In the screening studies from mainland China, the lung cancer detection rate 0.6% (95 %CI: 0.3%-0.9%) for high-risk populations. The proportions with carcinoma in situ and stage I disease in the screening and clinical studies were 76.4% (95 %CI: 66.3%-85.3%) and 15.2% (95 %CI: 11.8%-18.9%), respectively.

CONCLUSIONS

The stage shift of lung cancer due to screening suggests a potential effectiveness of LDCT screening in China. Nearly 70% of screen-detected lung cancers in low-risk populations are identified in women.

Comparative proteomic analysis of exhaled breath condensate between lung adenocarcinoma and CT-detected benign pulmonary nodule patients

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. The collection of exhaled breath condensate (EBC) is a non-invasive method that may have enormous potential as a biomarker for the early detection of lung cancer.

OBJECTIVE

To investigate the proteomic differences of EBC between lung cancer and CT-detected benign nodule patients, and determine whether these proteins could be potential biomarkers.

METHODS

Proteomic analysis was performed on individual samples from 10 lung cancer patients and 10 CT-detected benign nodule patients using data-independent acquisition (DIA) mass spectrometry.

RESULTS

A total of 1,254 proteins were identified, and 21 proteins were differentially expressed in the lung adenocarcinoma group compared to the benign nodule group (p< 0.05). The GO analysis showed that most of these proteins were involved in neutrophil-related biological processes, and the KEGG analysis showed these proteins were mostly annotated to pyruvate and propanoate metabolism. Through protein-protein interactions (PPIs) analysis, ME1 and LDHB contributed most to the interaction-network of these proteins.

CONCLUSION

Significantly differentially expressed proteins were detected between lung cancer and the CT-detected benign nodule group from EBC samples, and these proteins might serve as potential novel biomarkers of EBC for early lung cancer detection.

Should sublobar resection be offered for screening-detected lung nodules?

The increasing use of low-dose CT for screening for lung cancer will inevitably identify many small, asymptomatic lung nodules and ground-glass opacities (GGOs). Current guidelines for the management of screening-detected lesions tend to advise a conservative approach based on serial imaging and intervention only if ‘suspicious’ features emerge. However, more recent developments in thoracic surgery and in the understanding of the screening-detected lesions themselves prompt some pertinent questions over this conservatism. Is CT surveillance sufficiently reliable to exclude malignancy? Is it really necessary to hold back on operative biopsy and resection given modern surgical safety and efficacy? Is the option for early surgical therapy a viable one—especially with the availability of sublobar resection today? Modern data suggests that the risk of inaction for some screening-detected lesions may be higher than expected, whereas the potential harm of surgical intervention may be substantially reduced by sublobar resection and the latest minimally invasive surgical techniques. A more pro-active approach towards offering surgery for screening-detected lesions should now be considered.

LncRNA MACC1-AS1 Promotes Lung Adenocarcinoma Cell Proliferation by Downregulating PTEN

Background: MACC1-AS1 is an oncogenic lncRNA in gastric cancer, which interacts with AMP-activated protein kinase (AMPK) to promote cancer development. AMPK is known to interact with phosphatase and tensin homolog (PTEN). Therefore, MACC1-AS1 may also have associations with PTEN. This study aimed to investigate the interactions between MACC1-AS1 and PTEN in lung adenocarcinoma (LUAD). Materials and Methods: This study recruited 64 LUAD patients admitted to The First People's Hospital of Wenling City. Gene and protein expression levels were determined by qPCR and western blot, respectively. Cell transfections were performed to assess gene interactions. Cell proliferation was evaluated by CCK-8 assay. Results: MACC1-AS1 was upregulated in LUAD and inversely correlated with the expression of PTEN. High expression levels of MACC1-AS1 in LUAD tissues were closely correlated with poor survival rate of LUAD patients. In LUAD cells, overexpression of MACC1-AS1 led to decreased expression of PTEN and increased proliferation rate of LUAD cells, while MACC1-AS1 silencing led to increased expression of PTEN and decreased proliferation rate of LUAD cells. Furthermore, overexpression of PTEN attenuated the effects of overexpressing MACC1-AS1. Conclusions: The authors' results demonstrated that MACC1-AS1 promoted cell proliferation by downregulating PTEN in LUAD cells.

Lung Cancer Screening with Low-Dose CT: Baseline Screening Results in Shanghai

OBJECTIVE

To report the initial baseline lung cancer screening results with low dose computed tomography (LDCT) in a multicenter study in Shanghai.

METHODS

A total of 14,506 subjects underwent LDCT lung cancer screening and completed questionnaires consisting of 13 risk factors for lung cancer in the prospective study. The positive result was defined as any size and density nodule. The nodules were classified into calcified, solid, part-solid, and nonsolid nodules. The positive rate and incidental detection rate of lung cancer and stage I lung cancer were calculated. The proportion of lung nodule and lung cancer with different density and size was analyzed.

RESULTS

The positive rate and incidental detection rate of lung cancer was 29.89% and 1.23%, respectively. The incidental detection rate of stage I lung cancer was 0.97%. The proportion of lung cancer in lung nodules and stage I in lung cancer was 3.48% and 81.09%, respectively. The ratio of nonsolid nodule, part-solid nodule, and solid nodule in lung cancer was 52.94%, 31.93%, and 15.13%, respectively. 74.88% lung nodules were less than 5 mm and 94.12% lung cancers were larger than 5mm in size.

CONCLUSION

The baseline LDCT lung cancer screening showed subsolid nodules accounted for the majority of lung cancer, and 5 mm in size would be recommended as the positive result threshold.