Interstitial lung abnormalities in a large clinical lung cancer screening cohort: association with mortality and ILD diagnosis

BACKGROUND

Interstitial lung abnormalities (ILA) are CT findings suggestive of interstitial lung disease in individuals without a prior diagnosis or suspicion of ILD. Previous studies have demonstrated that ILA are associated with clinically significant outcomes including mortality. The aim of this study was to determine the prevalence of ILA in a large CT lung cancer screening program and the association with clinically significant outcomes including mortality, hospitalizations, cancer and ILD diagnosis.

METHODS

This was a retrospective study of individuals enrolled in a CT lung cancer screening program from 2012 to 2014. Baseline and longitudinal CT scans were scored for ILA per Fleischner Society guidelines. The primary analyses examined the association between baseline ILA and mortality, all-cause hospitalization, and incidence of lung cancer. Kaplan-Meier plots were generated to visualize the associations between ILA and lung cancer and all-cause mortality. Cox regression proportional hazards models were used to test for this association in both univariate and multivariable models.

RESULTS

1699 subjects met inclusion criteria. 41 (2.4%) had ILA and 101 (5.9%) had indeterminate ILA on baseline CTs. ILD was diagnosed in 10 (24.4%) of 41 with ILA on baseline CT with a mean time from baseline CT to diagnosis of 4.47 ± 2.72 years. On multivariable modeling, the presence of ILA remained a significant predictor of death, HR 3.87 (2.07, 7.21; p < 0.001) when adjusted for age, sex, BMI, pack years and active smoking, but not of lung cancer and all-cause hospital admission. Approximately 50% with baseline ILA had progression on the longitudinal scan.

CONCLUSIONS

ILA identified on baseline lung cancer screening exams are associated with all-cause mortality. In addition, a significant proportion of patients with ILA are subsequently diagnosed with ILD and have CT progression on longitudinal scans.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov; No.: NCT04503044.

Pathologic and gene expression comparison of CT- screen detected and routinely detected stage I/0 lung adenocarcinoma in NCCN risk-matched cohorts

INTRODUCTION

Although three randomized control trials have proven mortality benefit of CT lung cancer screening (CTLS), <5% of eligible US smokers are screened. Some attribute this to fear of harm conveyed at shared decision visits, including the harm of overdiagnosis/overtreatment of indolent BAC-like adenocarcinoma.

METHODS

Since the frequency of indolent cancers has not been compared between CTLS and routinely detected cohorts, we compare pathology and RNA expression of 86 NCCN high-risk CTLS subjects to 83 high-risk (HR-R) and 51 low-risk (LR-R) routinely detected patients. Indolent adenocarcinoma was defined as previously described for low malignant potential (LMP) adenocarcinoma along with AIS/MIA. Exome RNA sequencing was performed on a subset of high-risk (CTLS and HR-R) FFPE tumor samples.

RESULTS

Indolent adenocarcinoma (AIS, MIA, and LMP) showed 100% disease-specific survival (DSS) with similar frequency in CTLS (18%) and HR-R (20%) which were comparatively lower than LR-R (33%). Despite this observation, CTLS exhibited intermediate DSS between HR-R and LR-R (5-year DSS: 88% CTLS, 82% HR-R, & 95% LR-R, p = 0.047), possibly reflecting a 0.4 cm smaller median tumor size and lower frequency of tumor necrosis compared to HR-R. WGCNA gene modules derived from TCGA lung adenocarcinoma correlated with aggressive histologic patterns, mitotic activity, and tumor invasive features, but no significant differential expression between CTLS and HR-R was observed.

CONCLUSION

CTLS subjects are at no greater risk of overdiagnosis from indolent adenocarcinoma (AIS, MIA, and LMP) than risk-matched patients whose cancers are discovered in routine clinical practice. Improved outcomes likely reflect detection and treatment at smaller size.

Change in amount smoked and readiness to quit among patients undergoing lung cancer screening

Background

There is mixed evidence regarding whether undergoing computed tomography lung cancer screening (LCS) can serve as a "teachable moment" that impacts smoking behavior and attitudes. The study aim was to assess whether the standard procedures of undergoing LCS and receiving free and low-cost evidence-based cessation resources impacted short-term smoking-related outcomes.

Methods

Participants were smokers (N=87) who were registered to undergo lung screening and were enrolled in a cessation intervention trial. We conducted two phone interviews, both preceding trial randomization: the first interview was conducted prior to lung screening, and the second interview followed lung screening (median =12.5 days post-screening) and participants' receipt of their screening results. The interviews assessed demographic characteristics, interest in evidence-based cessation intervention methods, and tobacco-related characteristics, including cigarettes per day and readiness to quit. Participants received minimal evidence-based cessation resources following the pre-lung screening interview.

Results

Participants were 60.3 years old, 56.3% female, and reported a median of 40 pack-years. Participants were interested in using several evidence-based strategies, including counseling from a healthcare provider (76.7%) and receiving nicotine replacement therapy (69.8%). Pre-lung screening, 25.3% smoked ≤10 cigarettes per day, and 29.9% were ready to quit in the next 30 days. We conducted two McNemar binomial distribution tests to assess change from pre- to post-screening. At the post-lung screening assessment, approximately three-quarters reported no change on these variables. However, 23.3% reported smoking fewer cigarettes per day, whereas 4.7% reported smoking more cigarettes per day (McNemar P=0.002), and 17.2% reported increased readiness to quit, whereas 6.9% reported decreased readiness to quit (McNemar P=0.078).

Conclusions

Following receipt of cessation resources and completion of lung screening, most participants reported no change in smoking outcomes. However, there was a significant reduction in cigarettes per day, and there was a trend for increased readiness to quit. This setting may provide a potential "teachable moment" and an opportunity to assist smokers with quitting. However, more proactive and intensive interventions will be necessary to capitalize on these changes and to support abstinence in the long-term.

Qualitative coronary artery calcification scores and risk of all cause, COPD and pneumonia hospital admission in a large CT lung cancer screening cohort

BACKGROUND

Patients at high-risk for lung cancer and qualified for CT lung cancer screening (CTLS) are at risk for numerous cardio-pulmonary comorbidities. We sought to examine if qualitatively assessed coronary artery calcifications (CAC) on CTLS exams could identify patients at increased risk for non-cardiovascular events such as all cause, COPD and pneumonia related hospitalization and to verify previously reported associations between CAC and mortality and cardiovascular events.

STUDY DESIGN AND METHODS

Patients (n = 4673) from Lahey Hospital and Medical Center who underwent CTLS from January 12, 2012 through September 30, 2017 were included with clinical follow-up through September 30, 2019. CTLS exams were qualitatively scored for the presence and severity of CAC at the time of exam interpretation using a four point scale: none, mild, moderate, and marked. Multivariable Cox regression models were used to evaluate the association between CT qualitative CAC and all-cause, COPD-related, and pneumonia-related hospital admissions.

RESULTS

3631 (78%) of individuals undergoing CTLS had some degree of CAC on their baseline exam: 1308 (28.0%), 1128 (24.1%), and 1195 (25.6%) had mild, moderate and marked coronary calcification, respectively. Marked CAC was associated with all-cause hospital admission and pneumonia related admissions HR 1.48; 95% CI 1.23-1.78 and HR 2.19; 95% 1.30-3.71, respectively. Mild, moderate and marked CAC were associated with COPD-related admission HR 2.30; 95% CI 1.31-4.03, HR 2.17; 95% CI 1.20-3.91 and HR 2.27; 95% CI 1.24-4.15.

CONCLUSION

Qualitative CAC on CTLS exams identifies individuals at elevated risk for all cause, pneumonia and COPD-related hospital admissions.

Qualitative emphysema and risk of COPD hospitalization in a multicenter CT lung cancer screening cohort study

BACKGROUND

In the United States, 9 to 10 million Americans are estimated to be eligible for computed tomographic lung cancer screening (CTLS). Those meeting criteria for CTLS are at high-risk for numerous cardio-pulmonary co-morbidities. The objective of this study was to determine the association between qualitative emphysema identified on screening CTs and risk for hospital admission.

STUDY DESIGN AND METHODS

We conducted a retrospective multicenter study from two CTLS cohorts: Lahey Hospital and Medical Center (LHMC) CTLS program, Burlington, MA and Mount Auburn Hospital (MAH) CTLS program, Cambridge, MA. CTLS exams were qualitatively scored by radiologists at time of screening for presence of emphysema. Multivariable Cox regression models were used to evaluate the association between CT qualitative emphysema and all-cause, COPD-related, and pneumonia-related hospital admission.

RESULTS

We included 4673 participants from the LHMC cohort and 915 from the MAH cohort. 57% and 51.9% of the LHMC and MAH cohorts had presence of CT emphysema, respectively. In the LHMC cohort, the presence of emphysema was associated with all-cause hospital admission (HR 1.15, CI 1.07-1.23; p < 0.001) and COPD-related admission (HR 1.64; 95% CI 1.14-2.36; p = 0.007), but not with pneumonia-related admission (HR 1.52; 95% CI 1.27-1.83; p < 0.001). In the MAH cohort, the presence of emphysema was only associated with COPD-related admission (HR 2.05; 95% CI 1.07-3.95; p = 0.031).

CONCLUSION

Qualitative CT assessment of emphysema is associated with COPD-related hospital admission in a CTLS population. Identification of emphysema on CLTS exams may provide an opportunity for prevention and early intervention to reduce admission risk.

Quantitative Pectoralis Muscle Area is Associated with the Development of Lung Cancer in a Large Lung Cancer Screening Cohort

BACKGROUND

Studies have demonstrated an inverse relationship between body mass index (BMI) and the risk of developing lung cancer. We conducted a retrospective cohort study evaluating baseline quantitative computed tomography (CT) measurements of body composition, specifically muscle and fat area in a large CT lung screening cohort (CTLS). We hypothesized that quantitative measurements of baseline body composition may aid in risk stratification for lung cancer.

METHODS

Patients who underwent baseline CTLS between January 1st, 2012 and September 30th, 2014 and who had an in-network primary care physician were included. All patients met NCCN Guidelines eligibility criteria for CTLS. Quantitative measurements of pectoralis muscle area (PMA) and subcutaneous fat area (SFA) were performed on a single axial slice of the CT above the aortic arch with the Chest Imaging Platform Workstation software. Cox multivariable proportional hazards model for cancer was adjusted for variables with a univariate p < 0.2. Data were dichotomized by sex and then combined to account for baseline differences between sexes.

RESULTS

One thousand six hundred and ninety six patients were included in this study. A total of 79 (4.7%) patients developed lung cancer. There was an association between the 25th percentile of PMA and the development of lung cancer [HR 1.71 (1.07, 2.75), p < 0.025] after adjusting for age, BMI, qualitative emphysema, qualitative coronary artery calcification, and baseline Lung-RADS® score.

CONCLUSIONS

Quantitative assessment of PMA on baseline CTLS was associated with the development of lung cancer. Quantitative PMA has the potential to be incorporated as a variable in future lung cancer risk models.

NCCN Guidelines as a Model of Extended Criteria for Lung Cancer Screening

Background: This review assessed the performance of patients in NCCN high-risk group 2 in a clinical CT lung screening (CTLS) program. Methods: We retrospectively reviewed screening results for all patients from our institution undergoing clinical CTLS from January 2012 through December 2016, with follow-up through June 2017. To qualify for screening, patients had to meet the NCCN Guidelines high-risk criteria for CTLS, have a physician order for screening, be asymptomatic, be lung cancer-free for 5 years, and have no known metastatic disease. We compared demographics and screening performance of NCCN high-risk groups 1 and 2 across >4 rounds of screening. Screening metrics assessed included rates of positive and suspicious examinations, significant incidental and infectious/inflammatory findings, false negatives, and cancer detection. We also compared cancer stage and histology detected in each NCCN high-risk group. Results: A total of 2,927 individuals underwent baseline screening, of which 698 (24%) were in NCCN group 2. On average, group 2 patients were younger (60.6 vs 63.1 years), smoked less (38.8 vs 50.8 pack-years), had quit longer (18.1 vs 6.3 years), and were more often former smokers (61.4% vs 44.2%). Positive and suspicious examination rates, false negatives, and rates of infectious/inflammatory findings were equivalent in groups 1 and 2 across all rounds of screening. An increased rate of cancer detection was observed in group 2 during the second annual (T2) screening round (2.7% vs 0.5%; P=.005), with no difference in the other screening rounds: baseline (T0; 2% vs 2.3%; P=.61), first annual (T1; 1.2% vs 1.7%; P=.41), and third annual and beyond (≥T3; 1.2% vs 1.1%; P=1.00). Conclusions: CTLS appears to be equally effective in both NCCN high-risk groups.

Qualitative coronary artery calcium assessment on CT lung screening exam helps predict first cardiac events

Results

A total of 1,513 individuals underwent CTLS. Downstream data, pre-test cardiac risk factors and CAC scores were available for 88.3% (1,336/1,513). The average length of follow-up was 2.64 (SD ±0.72) years. There were a total of 43 events, occurring in 1.55% (6/386) of patients with mild CAC, 3.24% (11/339) of patients with moderate CAC, and 8.90% (26/292) of patients with marked CAC. There were no events among patients with no reported CAC (0/319). Using multivariable logistic modeling, the increased odds of an initial cardiac event was 2.56 (95% CI, 1.76-3.92, P<0.001) for mild CAC, 6.57 (95% CI, 3.10-15.4, P<0.001) for moderate CAC, and 16.8 (95% CI, 5.46-60.3, P<0.001) for marked CAC, as compared to individuals with no CAC. Time to event analysis showed distinct differences among the four CAC categories (P<0.001).

Conclusions

Qualitative coronary artery calcification scoring of CTLS exams may provide a novel method to help select individuals at elevated risk for an initial cardiac event.

Adherence to Radiology Recommendations in a Clinical CT Lung Screening Program

BACKGROUND

Assess patient adherence to radiologist recommendations in a clinical CT lung cancer screening program.

METHODS

Patients undergoing CT lung cancer screening between January 12, 2012, and June 12, 2013, were included in this institutional review board-approved retrospective review. Patients referred from outside our institution were excluded. All patients met National Comprehensive Cancer Network Guidelines Lung Cancer Screening high-risk criteria. Full-time program navigators used a CT lung screening program management system to schedule patient appointments, generate patient result notification letters detailing the radiologist follow-up recommendation, and track patient and referring physician notification of missed appointments at 30, 60, and 90 days. To be considered adherent, patients could be no more than 90 days past due for their next recommended examination as of September 12, 2014. Patients who died, were diagnosed with cancer, or otherwise became ineligible for screening were considered adherent. Adherence rates were assessed across multiple variables.

RESULTS

During the study interval, 1,162 high-risk patients were screened, and 261 of 1,162 (22.5%) outside referrals were excluded. Of the remaining 901 patients, 503 (55.8%) were male, 414 (45.9%) were active smokers, 377 (41.8%) were aged 65 to 73, and >95% were white. Of the 901 patients, 772 (85.7%) were adherent. Most common reasons for nonadherence were patient refusal of follow-up exam (66.7%), inability to successfully contact the patient (20.9%), and inability to obtain the follow-up order from the referring provider (7.8%); 23 of 901 (2.6%) were discharged for other reasons.

CONCLUSIONS

High rates of adherence to radiologist recommendations are achievable for in-network patients enrolled in a clinical CT lung screening program.

Automatic Lung-RADS™ classification with a natural language processing system

Background

Our aim was to train a natural language processing (NLP) algorithm to capture imaging characteristics of lung nodules reported in a structured CT report and suggest the applicable Lung-RADS™ (LR) category.

Methods

Our study included structured, clinical reports of consecutive CT lung screening (CTLS) exams performed from 08/2014 to 08/2015 at an ACR accredited Lung Cancer Screening Center. All patients screened were at high-risk for lung cancer according to the NCCN Guidelines^®. All exams were interpreted by one of three radiologists credentialed to read CTLS exams using LR using a standard reporting template. Training and test sets consisted of consecutive exams. Lung screening exams were divided into two groups: three training sets (500, 120, and 383 reports each) and one final evaluation set (498 reports). NLP algorithm results were compared with the gold standard of LR category assigned by the radiologist.

Results

The sensitivity/specificity of the NLP algorithm to correctly assign LR categories for suspicious nodules (LR 4) and positive nodules (LR 3/4) were 74.1%/98.6% and 75.0%/98.8% respectively. The majority of mismatches occurred in cases where pulmonary findings were present not currently addressed by LR. Misclassifications also resulted from the failure to identify exams as follow-up and the failure to completely characterize part-solid nodules. In a sub-group analysis among structured reports with standardized language, the sensitivity and specificity to detect LR 4 nodules were 87.0% and 99.5%, respectively.

Conclusions

An NLP system can accurately suggest the appropriate LR category from CTLS exam findings when standardized reporting is used.

Smoking cessation results in a clinical lung cancer screening program

BACKGROUND

Lung cancer screening may provide a "teachable moment" for promoting smoking cessation. This study assessed smoking cessation and relapse rates among individuals undergoing follow-up low-dose chest computed tomography (CT) in a clinical CT lung screening program and assessed the influence of initial screening results on smoking behavior.

METHODS

Self-reported smoking status for individuals enrolled in a clinical CT lung screening program undergoing a follow-up CT lung screening exam between 1st February, 2014 and 31st March, 2015 was retrospectively reviewed and compared to self-reported smoking status using a standardized questionnaire at program entry. Point prevalence smoking cessation and relapse rates were calculated across the entire population and compared with exam results. All individuals undergoing screening fulfilled the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Lung Cancer Screening v1.2012(®) high-risk criteria and had an order for CT lung screening.

RESULTS

A total of 1,483 individuals underwent a follow-up CT lung screening exam during the study interval. Smoking status at time of follow-up exam was available for 1,461/1,483 (98.5%). A total of 46% (678/1,461) were active smokers at program entry. The overall point prevalence smoking cessation and relapse rates were 20.8% and 9.3%, respectively. Prior positive screening exam results were not predictive of smoking cessation (OR 1.092; 95% CI, 0.715-1.693) but were predictive of reduced relapse among former smokers who had stopped smoking for 2 years or less (OR 0.330; 95% CI, 0.143-0.710). Duration of program enrollment was predictive of smoking cessation (OR 0.647; 95% CI, 0.477-0.877).

CONCLUSIONS

Smoking cessation and relapse rates in a clinical CT lung screening program rates are more favorable than those observed in the general population. Duration of participation in the screening program correlated with increased smoking cessation rates. A positive exam result correlated with reduced relapse rates among smokers recently quit smoking.

Experience With a CT Screening Program for Individuals at High Risk for Developing Lung Cancer

PURPOSE

The aim of this study was to compare results of National Comprehensive Cancer Network (NCCN) high-risk group 2 with those of NCCN high-risk group 1 in a clinical CT lung screening program.

METHODS

The results of consecutive clinical CT lung screening examinations performed from January 2012 through December 2013 were retrospectively reviewed. All examinations were interpreted by radiologists credentialed in structured CT lung screening reporting, following the NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012). Positive results required a solid nodule ≥4 mm, a ground-glass nodule ≥5 mm, or a mediastinal or hilar lymph node >1 cm, not stable for >2 years. Significant incidental findings and findings suspicious for pulmonary infection were also recorded.

RESULTS

A total of 1,760 examinations were performed (464 in group 2, 1,296 in group 1); no clinical follow-up was available in 432 patients (28%). Positive results, clinically significant incidental findings, and suspected pulmonary infection were present in 25%, 6%, and 6% in group 2 and 28.2%, 6.2%, and 6.6% in group 1, respectively. Twenty-three cases of lung cancer were diagnosed (6 in group 2, 17 in group 1), for annualized rates of malignancy of 1.8% in group 2 and 1.6% in group 1.

CONCLUSION

NCCN group 2 results were substantively similar to those for group 1 and closely resemble those reported in the National Lung Screening Trial. Similar rates of positivity and lung cancer diagnosis in both groups suggest that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.

Performance of ACR Lung-RADS in a Clinical CT Lung Screening Program

PURPOSE

The aim of this study was to assess the effect of applying ACR Lung-RADS in a clinical CT lung screening program on the frequency of positive and false-negative findings.

METHODS

Consecutive, clinical CT lung screening examinations performed from January 2012 through May 2014 were retroactively reclassified using the new ACR Lung-RADS structured reporting system. All examinations had initially been interpreted by radiologists credentialed in structured CT lung screening reporting following the National Comprehensive Cancer Network's Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012), which incorporated positive thresholds modeled after those in the National Lung Screening Trial. The positive rate, number of false-negative findings, and positive predictive value were recalculated using the ACR Lung-RADS-specific positive solid/part-solid nodule diameter threshold of 6 mm and nonsolid (ground-glass) threshold of 2 cm. False negatives were defined as cases reclassified as benign under ACR Lung-RADS that were diagnosed with malignancies within 12 months of the baseline examination.

RESULTS

A total of 2,180 high-risk patients underwent baseline CT lung screening during the study interval; no clinical follow-up was available in 577 patients (26%). ACR Lung-RADS reduced the overall positive rate from 27.6% to 10.6%. No false negatives were present in the 152 patients with >12-month follow-up reclassified as benign. Applying ACR Lung-RADS increased the positive predictive value for diagnosed malignancy in 1,603 patients with follow-up from 6.9% to 17.3%.

CONCLUSIONS

The application of ACR Lung-RADS increased the positive predictive value in our CT lung screening cohort by a factor of 2.5, to 17.3%, without increasing the number of examinations with false-negative results.

Varian HDR surface applicators - commissioning and clinical implementation

The purpose of this study was to validate the dosimetric performance of Varian surface applicators with the source vertically positioned and develop procedures for clinical implementation. The Varian surface applicators with the source vertically positioned provide a wide range of apertures making them clinically advantageous, though the steep dose gradient in the region of 3‐4 mm prescription depth presents multiple challenges. The following commissioning tests were performed: 1) verification of functional integrity and physical dimensions; and 2) dosimetric measurements to validate data provided by Varian as well as data obtained using the Acuros algorithm for heterogeneity corrected dose calculation. A solid water (SW) phantom was scanned and the Acuros algorithm was used to compute the dose at 5 mm depth and at surface for all applicators. Two sets of reference dose measurements were performed, with the source positioned at (i) −10 mm and (ii) −15 mm from the center of the first nominal dwell position. Measurements were taken at 5 mm depth in a SW phantom and in air at the applicator surface. The results were then compared to the vendor's data and to the Acuros calculated dose. Relative dose measurements using Gafchromic films were taken at a depth of 4 mm in SW. Percent depth ionization (PDI) measurements using ion chamber were performed in SW. The profiles generated from film measurements and the PDI plots were compared with those computed using the Acuros algorithm and vendor's data, when available. Preliminary leakage tests were performed using optically stimulated luminescence dosimeters (OSLDs) and the results were compared with Acuros predictions. All applicators were found to be functional with physical dimensions within 1 mm of specifications. For scenario (ii) measurements taken in SW at 5 mm depth and in air at the surface of each applicator were within 10% and 4% agreement with vendor's data, respectively. Compared with Acuros predictions, these measurements were within 6% and 5%, respectively. Measurements taken for scenario (i) showed reduced agreement with both the vendor's data as well as the Acuros calculations, especially when using the 10 mm applicator. The full widths of the measured dose profiles were within 2 mm of those predicted by Acuros at the 90% dose level. The PDI plots and measured leakage dose were in good agreement with vendor's data and Acuros predictions. Based on the dosimetric results, a quality assurance program and procedures for clinical implementation were developed. Treatment planning will be performed using scenario (ii). The 10 mm applicator will not be released for clinical use. A prescription depth of 4 mm is recommended, to ensure full coverage at 3 mm and a minimum dose of 90% of prescribed dose at 4 mm depth.

PACS number(s): 87.55 Qr, 87.56 Da, 87.90 +y

Surgical Outcomes in a Large, Clinical, Low-Dose Computed Tomographic Lung Cancer Screening Program

BACKGROUND

Lung cancer screening with low-dose computed tomography is proven to reduce lung cancer mortality among high-risk patients. However, critics raise concern over the potential for unnecessary surgical procedures performed for benign disease as a result of screening. We reviewed our outcomes in a large clinical lung cancer screening program to assess the number of surgical procedures done for benign disease, as we believe this is an important quality metric.

METHODS

We retrospectively reviewed our surgical outcomes of consecutive patients who underwent low-dose computed tomography lung cancer screening from January 2012 through June 2014 using a prospectively collected database. All patients met the National Comprehensive Cancer Network lung cancer screening guidelines high-risk criteria.

RESULTS

There were 1,654 screened patients during the study interval with clinical follow-up at Lahey Hospital & Medical Center. Twenty-five of the 1,654 (1.5%) had surgery. Five of 25 had non-lung cancer diagnoses: 2 hamartomas, 2 necrotizing granulomas, and 1 breast cancer metastasis. The incidence of surgery for non-lung cancer diagnosis was 0.30% (5 of 1,654), and the incidence of surgery for benign disease was 0.24% (4 of 1,654). Twenty of 25 had lung cancer, 18 early stage and 2 late stage. There were no surgery-related deaths, and there was 1 major surgical complication (4%) at 30 days.

CONCLUSIONS

The incidence of surgical intervention for non-lung cancer diagnosis was low (0.30%) and is comparable to the rate reported in the National Lung Screening Trial (0.62%). Surgical intervention for benign disease was rare (0.24%) in our experience.

Implementing Lung Cancer Screening Using Low-Dose Computed Tomography: Recommendations From an Expert Panel

Implementation of effective and efficient population-based CT lung cancer screening will require involvement and coordination of stakeholders across the health care system.

Treatment planning methodology for the Miami Multichannel Applicator following the American Brachytherapy Society recently published guidelines: the Lahey Clinic experience

The objective of this study was to develop a standardized procedure from simulation to treatment delivery for the multichannel Miami applicator, in order to increase planning consistency and reduce errors. A plan is generated prior to the 1st treatment using the CT images acquired with the applicator in place, and used for all 3 fractions. To confirm the application placement before each treatment fraction, an AP image is acquired and compared with the AP baseline image taken at simulation. A preplanning table is generated using the EBRT doses and is used to compute the maximum allowable D2cc for bladder, rectum, and sigmoid, and the mean allowable dose for the upper vaginal wall per HDR brachytherapy fraction. These data are used to establish the criteria for treatment planning dose optimization. A step‐by‐step treatment planning approach was developed to ensure appropriate coverage for the tumor (D90>100% prescribed dose of 700 cGy/fraction) and the uninvolved vaginal surface (dose for the entire treatment length > 600 cGy/fraction), while keeping the organs at risk below the tolerance doses. The equivalent dose 2 Gy (EQD2) tolerances for the critical structures are based on the American Brachytherapy Society (ABS) recently published guidelines. An independent second check is performed before the 1st treatment using an in‐house Excel spreadsheet. This methodology was successfully applied for our first few cases. For these patients: the cumulative tumor dose was 74–79 EQD2 Gy10 (ABS recommended range 70–85); tumor D90 was >100% of prescribed dose (range 101%–105%); cumulative D2cc for bladder, rectum, and sigmoid were lower than the tolerances of 90, 75, and 75 EQD2 Gy3, respectively; cumulative upper vaginal wall mean dose was below the tolerance of 120 EQD2 Gy3; the second check agreement was within 5%. By using a standardized procedure the planning consistency was increased and all dosimetric criteria were met.

PACS numbers: 87.55‐x, 87.56 bg

Outcome of primary soft tissue sarcoma of the knee and elbow

PURPOSE

Concern is frequently raised regarding the tolerance of irradiation over a joint space. The purpose of this study was to determine the outcome in terms of relapse and potential complications in patients with knee and elbow soft tissue sarcoma treated with limb-sparing surgery with or without adjuvant radiotherapy (RT).

METHODS AND MATERIALS

A review of our prospective database between June 1982 and December 1999 identified 86 adult patients with primary soft tissue sarcoma arising from the knee (n = 65; 76%) or elbow (n = 21; 24%) treated with limb-sparing surgery. Tumors had high-grade histologic features in 72% and were >5 cm in 48% of patients. Adjuvant RT was given to 46 (54%) of 86 patients. The type of RT was postoperative external beam RT in 63% and brachytherapy in 37%. Of the 46 patients who received RT, 85% (n = 39) had deep, 78% (n = 36) high-grade, and 54% (n = 25) >5-cm tumors. Complications were assessed in terms of wound complications requiring repeated surgery, bone fracture, nerve damage, and joint stiffness.

RESULTS

With a median follow-up of 48 months (range 4-175), the 5-year actuarial rate of local control, distant control, and overall survival was 75% (95% confidence interval [CI] 64-85%), 82% (95% CI 73-91%), and 81% (95% CI 71-91%), respectively. The 5-year local control rate for patients who received RT was 80% vs. 71% for those who did not (p = 0.3). The type of RT did not significantly influence the local control rate. Patients treated with external beam RT had a 5-year local control rate of 84% compared with 73% for those treated with brachytherapy (p = 0.4). On multivariate analysis, tumor size >5 cm retained its significance as an independent predictor of poor local control (p = 0.04; relative risk 3; 95% CI 1-6). In addition, high-grade histologic features emerged as an independent predictor of local recurrence (p = 0.02; relative risk 4; 95% CI 1-20). No statistically significant difference was found between the RT and no-RT group in terms of the 5-year actuarial rate of wound reoperation (10% vs. 3%, p = 0.1), bone fracture (3% vs. 5%, p = 0.5), or nerve damage (6% vs. 3%, p = 0.5). Joint stiffness was significantly higher in the RT group (24% vs. 0%, p = 0.001), but this stiffness was severe to moderate in only 2 patients.

CONCLUSION

On the basis of the findings of this retrospective review, adjuvant RT seems to be relatively well tolerated despite the inclusion of part of the joint space in the irradiation portal. Joint stiffness was seen more frequently with adjuvant RT, but it was moderate to severe in only a small number of patients.

Efficacy of oral sildenafil in patients with erectile dysfunction after radiotherapy for carcinoma of the prostate

OBJECTIVES

To determine the efficacy of sildenafil for patients with erectile dysfunction after radiotherapy for localized prostate cancer.

METHODS

Fifty patients with erectile dysfunction after radiotherapy were treated with sildenafil. Their median age was 68 years (range 54 to 78). All were treated with a three-dimensional conformal external beam radiotherapy approach, and the median dose prescribed to the planning target volume was 75.6 Gy. Patients were initially given 50 mg of sildenafil and instructed to use the medication on at least three occasions. They were then contacted to ascertain the efficacy of and tolerance to the medication.

RESULTS

Significant improvement in the firmness of the erection after sildenafil was reported in 37 patients (74%), 2 (4%) had partial improvement, and 11 (22%) had no response. Significant improvement in the durability of the erection was reported in 33 patients (66%), 3 (6%) had partial improvement, and 14 (28%) reported no improvement. Patients with partial or moderate erectile function before using sildenafil were more likely to benefit from the medication compared with those with absent function. Among 29 patients with erections classified as partial after radiotherapy, 26 (90%) had a significant response to the medication. In contrast, only 11 (52%) of 21 with erections classified as flaccid after radiotherapy had a significant response to the medication (P = 0.007).

CONCLUSIONS

Sildenafil improved erectile function in greater than two thirds of patients with postradiotherapy impotence. Patients with less severe dysfunction are most likely to benefit from this intervention.