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Liu C, Zhao L, Wu F, Feng Y, Jiang R, Hu C. The multidisciplinary team plays an important role in the prediction of small solitary pulmonary nodules: a propensity-score-matching study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:740. [PMID: 32042756 DOI: 10.21037/atm.2019.11.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background According to guidelines, it is recommended that pulmonary nodules be discussed by a multidisciplinary team (MDT); however, the evidence for the effectiveness of MDT is sparse. To demonstrate the importance of the involvement of an MDT for the prediction of small solitary pulmonary nodules, we conducted this retrospective study. Methods The patient database of those who attended our MDT and the electronic medical record system of our hospital was used; we collected all the data from patients found with small solitary pulmonary nodules (≤2 cm), which were suspected as malignant and who received a resection of the nodules. We summarized their characteristics and analyzed them, and then compared the post-operation pathological diagnosis of the patients who attended an MDT to those who did not participate in an MDT during the same period (2017-2019.2). We also collected the follow-up data. Propensity-score-matching was utilized during the process of analysis to get a more reliable conclusion. Results Most of the qualified patients were female. Most of the small solitary pulmonary nodules (≤2 cm) were adenocarcinoma and located on the right upper lobe. There were no differences in the SUV value between malignant nodules and benign nodules. After propensity-score matching, the total positive prediction value of small solitary pulmonary nodules (≤2 cm) without an MDT was 69.4%, while that with MDT was 77.6%; the difference was not significant with a P value of 0.30. The negative predictive value of MDT was 76.2%. Conclusions In developing countries, small solitary pulmonary nodules tend to be more correctly diagnosed with MDT.
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Affiliation(s)
- Chaoyuan Liu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Lishu Zhao
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Fang Wu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Yeqian Feng
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Rong Jiang
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Chunhong Hu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
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Munden RF, Chiles C, Boiselle PM, Sicks JD, Aberle DR, Gatsonis CA. Micronodules Detected on Computed Tomography During the National Lung Screening Trial: Prevalence and Relation to Positive Studies and Lung Cancer. J Thorac Oncol 2019; 14:1538-1546. [PMID: 31295576 PMCID: PMC6708760 DOI: 10.1016/j.jtho.2019.05.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 03/22/2019] [Accepted: 05/23/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In the National Lung Screening Trial (NLST) all cases with a 4-mm nodule (micronodule) and no other findings were classified as a negative study. The prevalence and malignant potential of micronodules in the NLST is evaluated to understand if this classification was appropriate. METHODS AND MATERIALS In the NLST a total of 53,452 participants were enrolled with 26,722 undergoing low-dose computed tomography (CT) screening. To determine whether a micronodule developed into a lung cancer, a list from the NLST database of those participants who developed lung cancer and had a micronodule recorded was selected. The CT images of this subset were reviewed by experienced, fellowship-trained thoracic radiologists (R.F.M., C.C., P.M.B., and D.R.A.), all of whom participated as readers in the NLST. RESULTS There were 26,722 participants who underwent CT in the NLST, of which 11,326 (42%) participants had at least one CT with a micronodule. Five thousand five hundred sixty (49%) of these participants had at least one positive CT examination, of which 409 (3.6%) subsequently were diagnosed with lung cancer. Of the 409 lung cancer cases with a micronodule recorded, there were 13 cases in which a micronodule developed into lung cancer. Considering the 13 cases, they represent 1.2% (13 of 1089) of the lung cancers diagnosed in the CT arm of the NLST and 0.11% (13 of 11,326) of the total micronodule cases. Additionally they represent 0.23% (13 of 5560) of the micronodule and at least one positive CT examination cases and 3.2% (13 of 409) of the micronodule cases diagnosed with lung cancer. The average size of the nodule at baseline (recorded as maximum diameter by perpendicular diameter) was 3.0 × 2.5 mm (ranges 2 x 4 mm and 2 x 4 mm) and at the positive CT the nodule was 11.1 × 8.6 mm (ranges, 6 x 20 mm and 5 x 14 mm); a difference of average change in size of 8.1 × 6.1 mm. The average number of days from first CT with a micronodule recorded to positive CT was 459 days (range, 338 - 723 days), the mean time from first CT with micronodule to lung cancer diagnosis was 617 days (range, 380 - 1140 days) and the mean time from positive CT to lung cancer diagnosis was 160 days (range, 18 - 417 days). Histologically, there was one small cell carcinoma and 12 non-small cell with stages of IA in 8 (62%), stage IB in 2 (15%), and 1 each stage IIIA, IIIB, and IV. The overall survival of NSCLC cases with a micronodule was not significantly different than the survival of the CT subset diagnosed with NSCL (p = 0.36). CONCLUSIONS Micronodules are common among lung cancer-screened participants and are capable of developing into lung cancer; however, following micronodules by annual CT screening surveillance is appropriate and does not impact overall survival or outcome.
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Affiliation(s)
- Reginald F Munden
- Department of Radiology, Clinical Operations and Cancer Services, Wake Forest Baptist Health and School of Medicine, Winston-Salem, North Carolina.
| | - Caroline Chiles
- Wake Forest University Health Sciences Center, Winston-Salem, North Carolina
| | - Phillip M Boiselle
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | | | - Denise R Aberle
- Department of Radiological Sciences/MII, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Constantine A Gatsonis
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island
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Althans AR, Tamer P, Brady JT, Steinhagen E, Ho VP. Surgery versus Antibiotics for Uncomplicated Appendicitis: Which Would a Medical Student Want? Surg Infect (Larchmt) 2017; 18:868-873. [PMID: 29027898 DOI: 10.1089/sur.2017.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Recent data suggest that treatment of acute, uncomplicated appendicitis (AUA) with antibiotics is as effective as surgery. A 2015 study indicated that more than 50% of patients would choose antibiotic therapy. Medical students represent a unique population of potential patients with greater medical knowledge than the general public and possibly less bias than practicing physicians. Therefore, we aimed to evaluate what the MEDICAL STUDENT'S treatment choice for AUA would be and what factors influence these decisions. METHODS We conducted a survey of current medical students at a single institution. Survey data included demographics, interest in surgery or a procedure-related specialty, knowledge of and experience with surgery and antibiotics, and concerns about treatments. A summary of the literature regarding the efficacy and safety of antibiotics and surgery was presented. Each participant was asked which treatment he or she would choose if affected by AUA. RESULTS A series of 255 medical students completed the survey (mean age 24.8 ± 2.4 y; 51.5% female). The largest number of respondents (41.2%) were second-year students, and more than half (54.2%) reported an interest in a procedure-related specialty. Nearly all (93%) reported prior antibiotic use (19% reporting adverse effects), and 50% had prior surgery (20% reporting adverse events). When asked to identify concerns about each treatment choice, "surgical complications" was selected most frequently (82%) for surgery, and "adverse events and side effects" was selected most frequently for antibiotics (57%). When asked how they would treat their own AUA, 66.3% selected surgery, 24.3% selected antibiotics, and 9.4% were unsure. Race, gender, specialty of interest, year of training, and history of adverse effects related to antibiotics or surgery were not significantly related to treatment choice (all p > 0.1). CONCLUSION When informed of the benefits and risks of surgery and antibiotics to treat AUA, medical students in our study were more likely to choose surgery.
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Affiliation(s)
- Alison R Althans
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Pierre Tamer
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Justin T Brady
- 2 Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Emily Steinhagen
- 2 Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Vanessa P Ho
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
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Managing Incidental Lung Nodules in Patients With a History of Oncologic Disease: A Survey of Thoracic Radiologists. J Thorac Imaging 2017; 32:115-120. [PMID: 27643445 DOI: 10.1097/rti.0000000000000231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to analyze the impact that a clinical history of an oncologic disease may have on the management decisions for incidentally detected lung nodules on chest computed tomographic (CT) examinations. MATERIALS AND METHODS An electronic survey was sent to all 796 members of the Society of Thoracic Radiology regarding criteria for the management of incidentally detected lung nodules in oncologic patients, as well as recommendations for nodule follow-up. Nodule characteristics and clinical parameters used by respondents were analyzed. Differences between variables were examined using the χ test. RESULTS Of the 796 Society of Thoracic Radiology members, 178 (22.36%) replied. Most respondents were subspecialized in cardiothoracic imaging (92.70%) and practiced in an "academic or teaching hospital setting" (75.28%) with a "dedicated oncology center" (94.03%). "History of oncologic disease" was the most important factor (98.87%) for management decisions. In patients with such a history, respondents most commonly used "experience and common sense" (56.74%) and reported "all incidentally found lung nodules" (65.73%, P<0.0001). "Size" and "shape" were the 2 most important nodule characteristics (33.61% and 27.05%, respectively) used to consider a nodule "clinically relevant," and "size" (44.07%) was also the most important nodule characteristic prompting recommendation for short-term CT follow-up. Follow-up CT examinations in oncologic patients were recommended by 75.84% of respondents. CONCLUSIONS In patients with a history of oncologic disease, radiologists tend to report every detected nodule and to routinely recommend follow-up CT examinations. Although most radiologists rely on "experience and common sense" in managing these nodules, greater standardization of lung nodule management in oncologic patients is needed, ideally through guidelines tailored to this patient population.
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Sahovaler A, Yeh DH, Morrison D, de Ribaupierre S, Izawa J, Power A, Inculet R, Parry N, Palma DA, Landis M, Leung A, Fung K, MacNeil SD, Yoo J, Nichols AC. The incidence and management of non-head and neck incidentalomas for the head and neck surgeon. Oral Oncol 2017; 74:98-104. [PMID: 29103759 DOI: 10.1016/j.oraloncology.2017.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/16/2017] [Accepted: 09/02/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Axel Sahovaler
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - David H Yeh
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Deric Morrison
- Department of Medicine, Division of Endocrinology, Western University, London Ontario, Canada
| | - Sandrine de Ribaupierre
- Department of Clinical Neurological Science, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Jonathan Izawa
- Department of Surgery, Divisions of Urology and Surgical Oncology, Schulich School of Medicine & Dentistry Western University, Canada
| | - Adam Power
- Department of Surgery, Division of Vascular Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Richard Inculet
- Division of Thoracic Surgery, Department of Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Neil Parry
- Divisions of General Surgery and Critical Care, Departments of Surgery and Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - David A Palma
- Department of Radiation Oncology, London Regional Cancer Program, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Mark Landis
- Department of Radiology, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Andrew Leung
- Department of Radiology, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
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Du C, Wan C, Ding J, Zhang G, Zhang Y, Hu C, Ying H. Management of indeterminate pulmonary nodules (<1 cm) newly detected during the follow-up of nasopharyngeal carcinoma patients. Asia Pac J Clin Oncol 2017; 14:e15-e20. [PMID: 28792116 DOI: 10.1111/ajco.12752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 06/11/2017] [Indexed: 12/01/2022]
Abstract
AIM To investigate the management for the indeterminate pulmonary nodules newly detected during the follow-up for nasopharyngeal carcinoma (NPC) patients. METHODS Indeterminate pulmonary lesions were identified by searching medical records of NPC patients, who were followed-up with thoracic CT between April 2008 and February 2014. Indeterminate pulmonary nodules were defined as opacities that may be solitary or multiple, which were <1 cm in size and not calcified. Nodules which were followed-up for at least two years, were included into analysis. The nodules with growth were considered as metastatic lesions and those which remained stable or regressed were defined as benign. The relations between the risk of the nodules to develop into metastatic lesions and clinical features and characteristics of nodules were analyzed. RESULTS Through a median follow-up of 50 months, the majority (81 of 102, 79.4%) had no change in the size of nodules. The nodules have regressed in 11 patients. There were 10 (9.8%) cases with progression at the follow-up. The 10 patients were considered to have lung metastases, for whom continuous increases of lesions were revealed. The volume doubling time of the increasing nodules ranged from 34 to 105 days. The nodules emerging within two years after primary therapies were more likely to develop into metastatic lesions (P = 0.043). CONCLUSION Ten percent of the indeterminate pulmonary nodules represent metastatic diseases. A short-interval follow-up is recommended and if the nodules remain stable after six months follow-up, it may be proper to prolong the interval of follow-up.
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Affiliation(s)
- Chengrun Du
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Caifeng Wan
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Jianhui Ding
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Guangyuan Zhang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Youwang Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Chaosu Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Hongmei Ying
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
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Yoo RE, Goo JM, Hwang EJ, Yoon SH, Lee CH, Park CM, Ahn S. Retrospective assessment of interobserver agreement and accuracy in classifications and measurements in subsolid nodules with solid components less than 8mm: which window setting is better? Eur Radiol 2016; 27:1369-1376. [DOI: 10.1007/s00330-016-4495-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 06/22/2016] [Accepted: 06/27/2016] [Indexed: 12/19/2022]
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Mets OM, de Jong PA, Chung K, Lammers JWJ, van Ginneken B, Schaefer-Prokop CM. Fleischner recommendations for the management of subsolid pulmonary nodules: high awareness but limited conformance - a survey study. Eur Radiol 2016; 26:3840-3849. [PMID: 26945759 PMCID: PMC5052295 DOI: 10.1007/s00330-016-4249-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/29/2015] [Accepted: 01/25/2016] [Indexed: 12/21/2022]
Abstract
Objectives The aim of this study was to assess awareness and conformance to the Fleischner society recommendations for the management of subsolid pulmonary nodules (SSN) in clinical practice. Methods An online questionnaire with four imaging cases was sent to 1579 associates from the European Respiratory Society and 757 from the European Society of Thoracic Imaging. Each respondent was asked to choose from several options which one they thought was the indicated management for the nodule presented. Awareness and conformance to the Fleischner recommendations (FR) were assessed and correlated to respondents characteristics. Results In total, 119 radiologists (response rate 16.0 %) and 243 pulmonologists (response rate 16.5 %) were included. Awareness of the FR was higher in radiologists than in pulmonologists (93 % vs. 70 %, p < 0.001), as was implementation in daily practice (66 % vs. 47 %, p < 0.001). Radiologists conformed to FR in rates of 31, 69, 68, and 82 %, and pulmonologists in 12, 43, 70, and 75 % for cases 1 to 4, respectively. Overmanagement was common. Conformance in SSN management was associated with awareness, working in an academic practice, larger practice size, teaching residents, and higher SSN exposure. Conclusions Although awareness of the Fleischner recommendations for SSN management is widespread, management choices in clinical practice show large heterogeneity. Key points • Guideline awareness among clinicians is widespread, but conformance shows large heterogeneity. • Awareness and conformance is significantly higher among radiologists than pulmonologists. • Overmanagement is common, which may lead to avoidable financial and physical burden. Electronic supplementary material The online version of this article (doi:10.1007/s00330-016-4249-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Onno M Mets
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kaman Chung
- Diagnostic Imaging Analysis Group, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jan-Willem J Lammers
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bram van Ginneken
- Diagnostic Imaging Analysis Group, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Cornelia M Schaefer-Prokop
- Diagnostic Imaging Analysis Group, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.,Department of Radiology, Meander Medical Center, Amersfoort, The Netherlands
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Murrmann GB, van Vollenhoven FHM, Moodley L. Approach to a solid solitary pulmonary nodule in two different settings-"Common is common, rare is rare". J Thorac Dis 2014; 6:237-48. [PMID: 24624288 DOI: 10.3978/j.issn.2072-1439.2013.11.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 11/20/2013] [Indexed: 12/19/2022]
Abstract
A new solid solitary pulmonary nodule (SPN) is a common feature in the daily practice of physicians, pulmonologists and thoracic surgeons. The etiology and consequently the diagnostic approach is very different in various parts of the world. Identification of malignant nodules is the universal goal to proceed to a potential curable therapy. In countries with a low incidence of inflammatory disease and a high incidence of lung cancer the diagnostic work up includes a positron emission tomography (PET) scan or PET-computer tomography (CT) as a main pillar. In countries with a high incidence of inflammatory and infectious disease and a low incidence in lung cancer this diagnostic work up needs to be adapted. In these settings a PET scan has a limited role and tissue diagnosis, whether with a trans-thoracic, trans-bronchial biopsy or a video-assisted wedge resection is the most targeted approach to determine or exclude malignancy. The evaluation of a solid SPN in the two different situations is outlined in our algorithm. Recommendations stress the value of clinical judgement in different settings, determination of probabilities of malignancy, cost-effective use of diagnostic tools and evaluation of various management alternatives according to the risk profile and the patients preferences.
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Affiliation(s)
- Gabriele B Murrmann
- 1 Department of Surgery, 2 Department of Pulmonology, Medisch Centrum Leeuwarden, The Netherlands ; 3 Department of Cardio-Thoracic Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Femke H M van Vollenhoven
- 1 Department of Surgery, 2 Department of Pulmonology, Medisch Centrum Leeuwarden, The Netherlands ; 3 Department of Cardio-Thoracic Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Loven Moodley
- 1 Department of Surgery, 2 Department of Pulmonology, Medisch Centrum Leeuwarden, The Netherlands ; 3 Department of Cardio-Thoracic Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
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Wiener RS, Gould MK, Slatore CG, Fincke BG, Schwartz LM, Woloshin S. Resource use and guideline concordance in evaluation of pulmonary nodules for cancer: too much and too little care. JAMA Intern Med 2014; 174:871-80. [PMID: 24710850 PMCID: PMC4266552 DOI: 10.1001/jamainternmed.2014.561] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Pulmonary nodules are common, and more will be found with implementation of lung cancer screening. How potentially malignant pulmonary nodules are evaluated may affect patient outcomes, health care costs, and effectiveness of lung cancer screening programs. Guidelines for evaluating pulmonary nodules for cancer exist, but little is known about how nodules are evaluated in the usual care setting. OBJECTIVE To characterize nodule evaluation and concordance with guidelines. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted including detailed review of medical records from pulmonary nodule detection through evaluation completion, cancer diagnosis, or study end (December 31, 2012). The participants included 300 adults with pulmonary nodules from 15 Veterans Affairs hospitals. MAIN OUTCOMES AND MEASURES Resources used for evaluation at any Veterans Affairs facility and guideline-concordant evaluation served as the main outcomes. RESULTS Twenty-seven of 300 patients (9.0%) with pulmonary nodules ultimately received a diagnosis of lung cancer: 1 of 57 (1.8%) with a nodule of 4 mm or less, 4 of 134 (3.0%) with a nodule of 5 to 8 mm, and 22 of 109 (20.2%) with a nodule larger than 8 mm. Nodule evaluation entailed 1044 imaging studies, 147 consultations, 76 biopsies, 13 resections, and 21 hospitalizations. Radiographic surveillance (n = 277) lasted a median of 13 months but ranged from less than 0.5 months to 8.5 years. Forty-six patients underwent invasive procedures (range per patient, 1-4): 41.3% (19 patients) did not have cancer and 17.4% (8) experienced complications, including 1 death. Notably, 15 of the 300 (5.0%) received no purposeful evaluation and had no obvious reason for deferral, seemingly "falling through the cracks." Among 197 patients with a nodule detected after release of the Fleischner Society guidelines, 44.7% received care inconsistent with guidelines (17.8% overevaluation, 26.9% underevaluation). In multivariable analyses, the strongest predictor of guideline-inconsistent care was inappropriate radiologist recommendations (overevaluation relative risk, 4.6 [95% CI, 2.3-9.2]; underevaluation, 4.3 [2.7-6.8]). Other systems factors associated with underevaluation included receiving care at more than 1 facility (2.0 [1.5-2.7]) and nodule detection during an inpatient or preoperative visit (1.6 [1.1-2.5]). CONCLUSIONS AND RELEVANCE Pulmonary nodule evaluation is often inconsistent with guidelines, including cases with no workup and others with prolonged surveillance or unneeded procedures that may cause harm. Systems to improve quality (eg, aligning radiologist recommendations with guidelines and facilitating communication across providers) are needed before lung cancer screening is widely implemented.
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts2The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts3The Dartmouth Institute for Health Pol
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Christopher G Slatore
- Health Services Research and Development, Portland Veterans Affairs Medical Center, Portland, Oregon6Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland
| | - Benjamin G Fincke
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts7Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lisa M Schwartz
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire8Veterans Affairs Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont
| | - Steven Woloshin
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire8Veterans Affairs Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont
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11
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Zhang Z, Mao Y. [Diagnosis and management of solitary pulmonary nodules]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2013; 16:499-508. [PMID: 24034999 PMCID: PMC6000634 DOI: 10.3779/j.issn.1009-3419.2013.09.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
目前,肺癌已跃居成为我国发病率及死亡率最高的恶性肿瘤,总体5年生存率较低;早诊早治是提高肺癌患者生存率及改善预后的关键,而早期肺癌患者常无任何症状和体征,只在影像学上表现为肺孤立性结节病变。提高对孤立性肺结节良恶性的鉴别诊断能力是临床诊治过程中的难点与热点。随着各种诊治技术的发展,孤立性肺结节病变性质的诊断准确率已大大提高。
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Affiliation(s)
- Zhirong Zhang
- Department of Thoracic Surgery, Cancer Hospital, Peking Union Mediacal College & Chinese Academy of Medical Sciences, Beijing 100021, China
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Naidich DP, Bankier AA, MacMahon H, Schaefer-Prokop CM, Pistolesi M, Goo JM, Macchiarini P, Crapo JD, Herold CJ, Austin JH, Travis WD. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology 2012; 266:304-17. [PMID: 23070270 DOI: 10.1148/radiol.12120628] [Citation(s) in RCA: 702] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This report is to complement the original Fleischner Society recommendations for incidentally detected solid nodules by proposing a set of recommendations specifically aimed at subsolid nodules. The development of a standardized approach to the interpretation and management of subsolid nodules remains critically important given that peripheral adenocarcinomas represent the most common type of lung cancer, with evidence of increasing frequency. Following an initial consideration of appropriate terminology to describe subsolid nodules and a brief review of the new classification system for peripheral lung adenocarcinomas sponsored by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS), and European Respiratory Society (ERS), six specific recommendations were made, three with regard to solitary subsolid nodules and three with regard to multiple subsolid nodules. Each recommendation is followed first by the rationales underlying the recommendation and then by specific pertinent remarks. Finally, issues for which future research is needed are discussed. The recommendations are the result of careful review of the literature now available regarding subsolid nodules. Given the complexity of these lesions, the current recommendations are more varied than the original Fleischner Society guidelines for solid nodules. It cannot be overemphasized that these guidelines must be interpreted in light of an individual's clinical history. Given the frequency with which subsolid nodules are encountered in daily clinical practice, and notwithstanding continuing controversy on many of these issues, it is anticipated that further refinements and modifications to these recommendations will be forthcoming as information continues to emerge from ongoing research.
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Affiliation(s)
- David P Naidich
- Department of Radiology, New York University Medical Center, 560 First Ave, New York, NY 10016, USA.
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Quint LE, Watcharotone K, Myles JD, Gruppen LD, Mullan PB. Incidental findings at chest CT: a needs assessment survey of radiologists' knowledge. Acad Radiol 2011; 18:1500-6. [PMID: 21962546 DOI: 10.1016/j.acra.2011.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 08/15/2011] [Accepted: 08/16/2011] [Indexed: 12/21/2022]
Abstract
RATIONALE AND OBJECTIVES To assess practice patterns in evaluating incidental findings at chest computed tomography (CT) to determine the need for further education. MATERIALS AND METHODS A survey was given to 1600 radiologists, presenting four clinical case questions regarding the evaluation/significance of the following incidental findings at chest CT: thyroid lesion; enlarged mediastinal lymph nodes; asymptomatic, small pulmonary embolus; and small lung nodule. The respondents' answers were compared with "truth," as defined by the best evidence available in the medical literature. Additional questions elicited the respondents' demographics and comfort levels in addressing the findings. Analysis of variance models with a Tukey correction for post hoc comparisons and chi-square tests were used to determine if any demographic factors or comfort levels were predictive of higher correct response rates. RESULTS The overall survey response rate was 28% (445/1600). Correct case response rates ranged from 26% (115/442) to 79% (343/445). Only 6% (28/438) of respondents chose the correct answers for all cases. Up to 80% (353/440) of respondents felt comfortable in addressing findings, and only 57% (252/443) of respondents felt that they needed more training in this area. Fellowship training in cardiothoracic radiology, working in a teaching practice, and subspecialization in abdominal or cardiothoracic radiology were predictive of higher correct response rates. Except for one case question, the comfort level was not predictive of correct response rate. CONCLUSIONS There was considerable variability among radiologists and substantial deviation from best medical practice with regard to the interpretation/evaluation of incidental findings at chest CT, signifying a significant need for further education.
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Doulias T, Gosney J, Elsayed H. An intra-parenchymal pulmonary lipoma with a high activity on positron emission tomography scan. Interact Cardiovasc Thorac Surg 2011; 12:843-4. [DOI: 10.1510/icvts.2010.256644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Dose reduction strategies for thoracic multidetector computed tomography: background, current issues, and recommendations. J Thorac Imaging 2011; 25:278-88. [PMID: 21042066 DOI: 10.1097/rti.0b013e3181eebc49] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This review will summarize the current background knowledge about radiation exposure related to thoracic computed tomography (CT). It will also review the historical development in this area. This will be followed by a summary of current efforts to reduce dose with respect to predefined clinical indications. Finally, the review will indicate future strategies for further dose reduction in thoracic CT imaging and give practical recommendations for everyday use.
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Munden RF, Erasmus JJ, Wahba H, Fineberg NS. Follow-Up of Small (4 mm or Less) Incidentally Detected Nodules by Computed Tomography in Oncology Patients: A Retrospective Review. J Thorac Oncol 2010; 5:1958-62. [DOI: 10.1097/jto.0b013e3181f2636e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
PURPOSE OF REVIEW In lung cancer screening with low-dose spiral computed tomography (LDCT), the proportion of stage I disease is 50-85%, and the survival rate for resected stage I disease can exceed 90%, but proof of real benefit in terms of lung cancer mortality reduction must come from the several randomized trials underway in Europe and in the USA. Our purpose is to update the readers on recent progress in medical knowledge in this field. RECENT FINDINGS Relevant novelties regarding technical and collateral aspects of lung cancer screening have been made available, covering the performance of detection systems and nodule evaluation protocols, means to increase cost-effectiveness, insight into the biology of lung cancer, promotion of minimally invasive and lung-sparing surgical options, effects of screening on smoking habits and early follow-up findings in one randomized trial of LDCT vs. clinical review. CONCLUSION Early follow-up data suggest that the effect of screening with LDCT on mortality might be smaller than expected, but definitive follow-up data are still awaited from all ongoing randomized trials. Lung cancer screening research is yielding a relevant body of medical knowledge that will be beneficial for other smoking-related diseases and contribute to a better understanding of lung cancer biology.
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Eisenberg RL, Bankier AA, Boiselle PM. Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology 2010; 255:218-24. [PMID: 20308458 DOI: 10.1148/radiol.09091556] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the familiarity of radiologists with the Fleischner Society guidelines for management of small lung nodules and to assess whether their decisions for nodule management are consistent with these recommendations. MATERIALS AND METHODS Institutional review board exemption was granted for this electronic survey, which was sent to a sample of 7000 radiologists randomly selected from the Radiological Society of North America (RSNA) directory. Three clinical scenarios for nodule management were presented. Information about policies and guidelines for nodule management, awareness of published guidelines, and respondent demographics was obtained. Associations between these parameters and management recommendations were assessed by using a chi(2) test. Respondents were also asked about tube current settings for routine chest computed tomographic examinations and those performed solely for nodule follow-up. RESULTS Of 834 respondents (response rate, 11.9%), 649 (77.8%) were aware of the Fleischner Society guidelines and 490 (58.8%) worked in practices that employed them or similar guidelines. Management selections were consistent with the Fleischner guidelines in 34.7%-60.8% of responses for the three scenarios. A significantly higher rate of concordance was associated with awareness of the Fleischner guidelines, presence of written policies based on them, a teaching practice setting, practice in a group with at least one member having chest radiology fellowship training, and fewer than 5 years of experience practicing radiology (P < .05 for all associations). The spectrum of tube current settings used was similar between the subgroups of respondents who were aware and those who were unaware of the Fleischner guidelines. CONCLUSION Among survey respondents, there was high awareness and adoption of the Fleischner guidelines, but radiologists showed varying degrees of conformance with these recommendations. Future efforts are necessary to bridge the gap between awareness and implementation of these evidence-based guidelines.
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Affiliation(s)
- Ronald L Eisenberg
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA.
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Edey AJ, Hansell DM. Incidentally detected small pulmonary nodules on CT. Clin Radiol 2009; 64:872-84. [PMID: 19664477 DOI: 10.1016/j.crad.2009.03.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 03/25/2009] [Accepted: 03/31/2009] [Indexed: 12/21/2022]
Abstract
The widespread use of multidetector computed tomography for imaging of the chest has lead to a significant increase in the number of incidentally detected pulmonary nodules. The significance of these nodules is often uncertain and further investigations may be required. This article will review the spectrum of imaging appearances of small pulmonary nodules, and highlight the few features that allow confident characterization of a nodule as benign or malignant; current guidelines for the management of incidentally detected nodules will also be discussed.
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Affiliation(s)
- A J Edey
- Department of Radiology, Royal Brompton Hospital, London, UK
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Suda Y, Tanaka A, Hayashi K, Shindoh Y, Iijima H. A novel needle-type sampling device for flexible ultrathin bronchoscopy. TOHOKU J EXP MED 2008; 216:81-93. [PMID: 18719342 DOI: 10.1620/tjem.216.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Diagnosis of suspected cancer in the periphery of the lung is difficult. A flexible ultrathin bronchoscope has been developed for the diagnosis of peripherally located pulmonary lesions that cannot be reached with the sampling devices for standard flexible bronchoscopes. The diagnostic yield with forceps and a brush for ultrathin bronchoscopes, however, is not adequate, especially when a lesion is not exposed to the bronchial lumen. We have thus developed a novel needle-type sampling device and tested its yield in transbronchial cytology. The device consists of an elongated dental H-file (0.4 mm in diameter and 110 cm in length), a housing sheath (1.0 mm in outer diameter), and a novel handle, which enables rapid out-and-in motion of the needle. Ten consecutive patients with a peripheral pulmonary lesion who had an indication for diagnostic procedure with a flexible ultrathin bronchoscope were enrolled. The optimal bronchial route to the lesion was analyzed with virtual bronchoscopy in a data set obtained with high-resolution computed tomography, and a novel bronchial route labeling system (prior-ridge-based relative orientation nomenclature) was employed to guide insertion of the bronchoscope. Sampling with the novel needle was performed prior to use of the forceps and brush under conventional fluoroscopy. In all the cases, sampling with the needle was successful and the amount of the specimen was sufficient for cytology. Our novel sampling system with flexible ultrathin bronchoscopes may contribute to accurate and minimally invasive diagnosis of peripheral pulmonary lesions.
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Affiliation(s)
- Yuji Suda
- Department of Respiratory Medicine, Sendai City Medical Center, Sendai, Japan.
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Lee P, Sutedja TG. Lung cancer screening: has there been any progress? Computed tomography and autofluorescence bronchoscopy. Curr Opin Pulm Med 2007; 13:243-8. [PMID: 17534167 DOI: 10.1097/mcp.0b013e32818b27d3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Advances in imaging technologies are currently being explored in the attempt to reduce lung cancer morbidity and mortality by achieving stage shift. We reviewed recent important publications on lung cancer screening. RECENT FINDINGS Autofluorescence bronchoscopy has established its important role in the intervention of early central airway lesions. Multidetector computed tomography (CT) and CT-positron emission tomography may facilitate diagnosis of early parenchymal lung lesions. Practical implications of screening are reaching far beyond early diagnostic efforts per se as lead-time, length-time, overdiagnosis biases combined with low specificity of screening tests undermine its cost-effectiveness in the era of healthcare budget constraints. SUMMARY Advanced imaging technologies may allow early detection and prudent intervention in some individuals that harbour asymptomatic early lung cancer, but disproportional expenses may be required to sieve out many more individuals at risk to attain stage shift. Confounding co-morbidities and practical hurdles may reduce screening's efficacy as it is plausible that for the majority of smokers, lung cancer may not be the ultimate cause of suffering since 90% of them will not develop lung cancer. This fact remains true despite increased use of noninvasive and minimally invasive technologies for the maximum preservation of quality of life irrespective of whether early intervention is a success or failure.
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Affiliation(s)
- Pyng Lee
- Department of Pulmonary Medicine, Vrije Universiteit Academic Hospital, Amsterdam, The Netherlands
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