Lung Cancer Diagnosis by Fine Needle Aspiration Is Associated With Reduction in Resection of Nonmalignant Lung Nodules

Action plan for an international imaging framework for implementation of global low-dose CT screening for lung cancer

Reduction in lung cancer mortality is achievable through low dose computed tomography (LDCT) screening in high-risk individuals. Many countries are progressing from local LDCT screening studies to national screening programs. Implementation of effective large-scale screening programs is complex and requires a multi-disciplinary approach. A recent overview of the technical aspects of implementing high quality LDCT for screening resulted from the inaugural international expert meeting of the Alliance for Global Implementation of Lung and Cardiac Early Disease Detection and Treatment (AGILE). This covers the most important aspects of the CT imaging process: standardisation in CT image acquisition and interpretation, CT protocol management, technology developments and minimal requirements, integration of lung cancer biomarkers, and the role of AI in CT lung nodule detection, segmentation, and classification, and related data security issues.

Diagnostic Accuracy and Safety of Nonsurgical Biopsy for Diagnosing Pulmonary Ground-Glass Opacities: A Systematic Review and Meta-Analysis

INTRODUCTION

Previous meta-analyses have explored the diagnostic accuracy and safety of computed tomography-guided percutaneous lung biopsy of ground-glass opacities (GGOs). However, no research investigated the role of nonsurgical biopsies (including transbronchial approaches). Additionally, studies reporting the diagnostic accuracy of GGOs with different characteristics are scarce, with no quantitative assessment published to date. We performed a systematic review to explore the diagnostic accuracy and safety of nonsurgical biopsy for diagnosing GGOs, especially those with higher ground-glass components and smaller nodule sizes.

METHODS

A thorough literature search of four databases was performed to compile studies evaluating both or either of the diagnostic accuracy and complications of nonsurgical biopsy for GGOs. A bivariate random-effects model and random-effect model were utilized for data synthesis. The methodological quality of the studies was assessed according to the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

Nineteen eligible studies with a total of 1,379 biopsy-sampled lesions were analyzed, of which 1,124 were confirmed to be malignant. Nonsurgical biopsy reported a pooled sensitivity of 0.89, a specificity of 0.99, and a negative predictive value (NPV) of 60.3%. The overall sensitivity, specificity, and NPV of nonsurgical biopsy for diagnosing GGOs according to GGO component were 0.90, 0.99, and 77.2% in pure GGOs; 0.87, 0.99, and 67.2% in GG-predominant lesions; and 0.89, 1.00, and 44.1% in solid-predominant lesions, respectively. Additionally, the diagnostic sensitivity was better in lesions ≥20 mm than in small lesions (0.95 vs. 0.88). Factors that contributed to higher sensitivity were the use of a coaxial needle system and CT fluoroscopy but not the needle gauge. The summary sensitivity of core needle biopsy (CNB) was not significantly higher than fine needle aspiration (FNA) (0.92 vs. 0.84; p = 0.42); however, we found an increased incidence of hemorrhage in CNB compared with FNA (60.9 vs. 14.2%; p = 0.012).

CONCLUSION

Nonsurgical biopsy for diagnosing GGOs shows high sensitivity and specificity with an acceptably low risk of complications. However, negative biopsy results are unreliable in excluding malignancy, necessitating resampling or subsequent follow-up. The applicability of our study is limited due to significant heterogeneity, indirect comparisons, and the paucity of data on bronchoscopic approaches, restricting the generalizability of our findings to patients requiring transbronchial biopsies.

Perspective on Management of Low-Dose Computed Tomography Findings on Low-Dose Computed Tomography Examinations for Lung Cancer Screening. From the International Association for the Study of Lung Cancer Early Detection and Screening Committee

Lung cancer screening using low-dose computed tomography (LDCT) carefully implemented has been found to reduce deaths from lung cancer. Optimal management starts with selection of eligibility criteria, counseling of screenees, smoking cessation, selection of the regimen of screening which specifies the imaging protocol, and workup of LDCT findings. Coordination of clinical, radiologic, and interventional teams and ultimately treatment of diagnosed lung cancers under screening determine the benefit of LDCT screening. Ethical considerations of who should be eligible for LDCT screening programs are important to provide the benefit to as many people at risk of lung cancer as possible. Unanticipated diseases identified on LDCT may offer important benefits through early detection of leading global causes of death, such as cardiovascular diseases and chronic obstructive pulmonary disease, as the latter may result from conditions such as emphysema and bronchiectasis, which can be identified early on LDCT. This report identifies the key components of the regimen of LDCT screening for lung cancer which include the need for a management system to provide data for continuous updating of the regimen and provides quality assurance assessment of actual screenings. Multidisciplinary clinical management is needed to maximize the benefit of early detection, diagnosis, and treatment of lung cancer. Different regimens have been evolving throughout the world as the resources and needs may be different, for countries with limited resources. Sharing of results, further knowledge, and incorporation of technologic advances will continue to accelerate worldwide improvements in the diagnostic and treatment approaches.

Predicting subsolid pulmonary nodules before percutaneous needle biopsy: a comparison of artificial neural network and biopsy results

AIM

To establish an artificial neural network (ANN) model to predict subsolid nodules (SSNs) before percutaneous core-needle biopsy (PCNB). The results of the two methods were compared to provide guidance on the treatment of SSNs.

MATERIALS AND METHODS

This was a single-centre retrospective study using data from 1,459 SSNs between 2013 and 2021. The ANN was developed using data from patients who underwent surgery following computed tomography (CT) (SFC) and validated using data from patients who underwent surgery following biopsy (SFB). The prediction results of the ANN for the PCNB group and the histopathological results obtained after biopsy were compared with the histopathological results of lung nodules in the same group after surgery. Additionally, the choice of predictors for PCNB was analysed using multivariate analysis.

RESULTS

There was no significant difference between the accuracies of the ANN and PCNB in the SFB group (p=0.086). The sensitivity of PCNB was lower than that of the ANN (p=0.000), but the specificity was higher (p=0.001). PCNB had better diagnostic ability than the ANN. The incidence of precursor lesions and non-neoplastic lesions in the SFB group was lower than that in the SFC group (p=0.000). A history of malignant tumours, size (2-3 cm), volume (>400 cm3) and mean CT value (≥-450 HU) are important factors for selecting PCNB.

CONCLUSIONS

Both ANN and PCNB have comparable accuracy in diagnosing SSNs; however, PCNB has a slightly higher diagnostic ability than ANN. Selecting appropriate patients for PCNB is important for maximising the benefit to SSN patients.

Pneumothorax after percutaneous CT-guided lung nodule biopsy: a prospective, multicenter study

Background

Pneumothorax is a common complication induced by computed tomography (CT)-guided percutaneous needle biopsy, with a frequency of 17-40.4%. It remains debatable how to predict and prevent the occurrence of post-biopsy pneumothorax. In a real-world setting, we investigated the characteristics associated with pneumothorax in primary lung nodule biopsy.

Methods

This clinical registry cohort study recorded patients with newly diagnosed pulmonary nodules from 10 medical centers from April 2021 to April 2022, and the data were input into the electronic data capture (EDC) system. The eligibility criteria for participants included being within the age range of 18 to 80 years and expressing a willingness to undergo percutaneous puncture biopsy, among other requirements. Conversely, the exclusion criteria included an inability to cooperate throughout the biopsy process and the emergence of new health issues during the study duration resulting in attendance delays, among other factors. This study collected data from 924 patients, out of which 593 were included after exclusion. The essential characteristics, imaging features of pulmonary nodules, and technical factors associated with percutaneous biopsy were recorded. T-tests or one-way analysis of variance (ANOVA) were performed for continuous variables and Pearson's χ2 test, likelihood ratio, or Fisher's exact test were applied for categorical variables for comparison as appropriate, followed by multivariate logistic regression.

Results

The overall incidence of pneumothorax was 13.0% (77/593), among which timely pneumothorax was 10.3% (61/593), delayed pneumothorax was 2.7% (16/593), and the rate of chest tube placement was 3.4% (20/593). There was no significant difference in the incidence of pneumothorax in a needle size range of 16-19 G (P=0.129), but the incidence of pneumothorax was lower with 17 G needles than with 18 G. An increased morbidity of pneumothorax was correlated with age (P=0.003), emphysema (P=0.006), and operation time (P=0.002). There was no significant increase in the incidence of pneumothorax between 1 or 2 passes through the pleura (P=0.062). However, multiple pleural passes (3 times) increased the chances of pneumothorax significantly (P=0.022). These risk factors have a certain clinical value in predicting the incidence of post-biopsy pneumothorax, and the area under the curve (AUC) was 0.749.

Conclusions

The most common post-biopsy complication, pneumothorax, was managed conservatively in most cases. A maximum of two pleural passes does not increase the incidence of pneumothorax, and the 17 G needle is more suitable for percutaneous biopsy of pulmonary nodules in the real world.

Current and Future Perspectives on Computed Tomography Screening for Lung Cancer: A Roadmap From 2023 to 2027 From the International Association for the Study of Lung Cancer

Low-dose computed tomography (LDCT) screening for lung cancer substantially reduces mortality from lung cancer, as revealed in randomized controlled trials and meta-analyses. This review is based on the ninth CT screening symposium of the International Association for the Study of Lung Cancer, which focuses on the major themes pertinent to the successful global implementation of LDCT screening and develops a strategy to further the implementation of lung cancer screening globally. These recommendations provide a 5-year roadmap to advance the implementation of LDCT screening globally, including the following: (1) establish universal screening program quality indicators; (2) establish evidence-based criteria to identify individuals who have never smoked but are at high-risk of developing lung cancer; (3) develop recommendations for incidentally detected lung nodule tracking and management protocols to complement programmatic lung cancer screening; (4) Integrate artificial intelligence and biomarkers to increase the prediction of malignancy in suspicious CT screen-detected lesions; and (5) standardize high-quality performance artificial intelligence protocols that lead to substantial reductions in costs, resource utilization and radiologist reporting time; (6) personalize CT screening intervals on the basis of an individual's lung cancer risk; (7) develop evidence to support clinical management and cost-effectiveness of other identified abnormalities on a lung cancer screening CT; (8) develop publicly accessible, easy-to-use geospatial tools to plan and monitor equitable access to screening services; and (9) establish a global shared education resource for lung cancer screening CT to ensure high-quality reading and reporting.

Surgical Resection of Benign Nodules in Lung Cancer Screening: Incidence and Features

Introduction

Interventions and surgical procedures are common for nonmalignant lung lesions detected on lung cancer screening (LCS). Inadvertent surgical resection of benign nodules with a clinical suspicion of lung cancer can occur, can be associated with complications, and adds to the cost of screening. The objective of this study is to assess the characteristics of surgically resected benign nodules detected on LCS computed tomography which were presumed to be lung cancers.

Methods

This retrospective study included 4798 patients who underwent LCS between June 2014 and January 2021. The benign lung nodules, surgically resected with a presumed cancer diagnosis, were identified from the LCS registry. Patient demographics, imaging characteristics, and pathologic diagnoses of benign nodules were analyzed.

Results

Of the 4798 patients who underwent LCS, 148 (3.1%) underwent surgical resection of a lung nodule, and of those who had a resection, 19 of 148 (12.8%) had a benign diagnosis (median age = 64 y, range: 56-77 y; F = 12 of 19, 63.2%; M = seven of 19, 36.8%). The median nodule size was 10 mm (range: 6-31 mm). Most nodules were solid (15 of 19, 78.9%), located in the upper lobes (11 of 19; 57.9%), and were peripheral (17 of 19, 89.5%). Most nodules (13 of 17; 76.5%) had interval growth, and four of 17 (23.5%) had increased fluorodeoxyglucose uptake. Of the 19 patients, 17 (89.5%) underwent sublobar resection (16 wedge resection and one segmentectomy), whereas two central nodules (10.5%) had lobectomies. Pathologies identified included focal areas of fibrosis or scarring (n = 8), necrotizing granulomatous inflammation (n = 3), other nonspecific inflammatory focus (n = 3), benign tumors (n = 3), reactive lymphoid hyperplasia (n = 1), and organizing pneumonia (n = 1).

Conclusions

Surgical resections of benign nodules that were presumed malignant are infrequent and may be unavoidable given overlapping imaging features of benign and malignant nodules. Knowledge of benign pathologies that can mimic malignancy may help reduce the incidence of unnecessary surgeries.

A look ahead to promote the early detection of lung cancer: technical and cost implications of a confirmed diagnosis before surgery

OBJECTIVE

To compare the costs and length of hospital stay among patients with a confirmed diagnosis of lung cancer (LC) prior to surgery versus those without confirmation.

METHODS

This retrospective, single-center study was conducted in patients who underwent a surgical procedure for LC, with or without a pathologically confirmed LC diagnosis prior to surgery, between March 2017 and December 2019. The main outcomes were costs and length of hospital stay (LOS).

RESULTS

Among the 269 patients who underwent surgery for lung cancer between March 2017 and December 2019, 203 (75.5%) patients underwent surgery due to a histopathological diagnosis, and 66 (24.5%) because of a Multidisciplinary Cancer Committee indication. The unadjusted mean cost was significantly lower in Group II (patients with surgery based on Multidisciplinary Cancer Committee criteria) (Є2,581.80 ± Є1,002.50) than in Group I (patients with histopathological diagnosis) (Є4,244.60 ± Є2,008.80), P < 0.0001. Once adjusted for covariables, there was a mean difference of -Є1,437.20 in the costs of Group II, P < 0.0001. Unadjusted mean hospital stay was significantly longer in Group I (5.6 days) than in Group II (3.5 days).

CONCLUSIONS

The results suggest that indicating surgical resection of lung cancer based on Multidisciplinary Cancer Committee criteria, rather than performing CT-guided percutaneous lung biopsy, may result in a significant decrease in cost and length of hospital stay.

Safety profile and risk factors for bleeding in transbronchial cryobiopsy using a two-scope technique for peripheral pulmonary lesions

Background

A balloon occlusion technique is suggested for use in cryobiopsy for interstitial lung diseases because of the bleeding risk. However, it may interfere with selection of the involved bronchus for peripheral pulmonary lesions (PPLs). A two-scope technique, in which two scopes are prepared and hemostasis is started using the second scope immediately after cryobiopsy, has also been reported. This study aimed to evaluate the safety and diagnostic utility of transbronchial cryobiopsy using the two-scope technique for PPLs.

Methods

Data of patients who underwent conventional biopsy followed by cryobiopsy using the two-scope technique for PPLs from November 2019 to March 2021 were collected. The incidence of complications and risk factors for clinically significant bleeding (moderate to life-threatening) were investigated. Diagnostic yields were also compared among conventional biopsy, cryobiopsy, and the combination of them.

Results

A total of 139 patients were analyzed. Moderate bleeding occurred in 25 (18.0%) patients without severe/life-threatening bleeding. Although five cases required transbronchial instillation of thrombin, all bleeding was completely controlled using the two-scope technique. Other complications included two pneumothoraces and one asthmatic attack. On multivariable analysis, only ground-glass features (P < 0.001, odds ratio: 9.30) were associated with clinically significant bleeding. The diagnostic yields of conventional biopsy and cryobiopsy were 76.3% and 81.3%, respectively (P = 0.28). The total diagnostic yield was 89.9%, significantly higher than conventional biopsy alone (P < 0.001).

Conclusions

The two-scope technique provides useful hemostasis for safe cryobiopsy for PPLs, with a careful decision needed for ground-glass lesions.

The Prevalence of Benign Pathology Following Major Pulmonary Resection for Suspected Malignancy

BACKGROUND

In the era of lung cancer screening with low-dose computed tomography, there is concern that high false-positive rates may lead to an increase in nontherapeutic lung resection. The aim of this study is to determine the current rate of major pulmonary resection for ultimately benign pathology.

MATERIALS AND METHODS

A single-institution, retrospective analysis of all patients > 18 y who underwent major pulmonary resection between 2013 and 2018 for suspected malignancy and had benign final pathology was performed.

RESULTS

Of 394 major pulmonary resections performed for known or presumed malignancy, 10 (2.5%) were benign. Of these 10, the mean age was 61.1 y (SD 14.6). Most were current or former smokers (60%). Ninety percent underwent a fluorodeoxyglucose positron emission tomography scan. Median nodule size was 27 mm (IQR 21-35) and most were in the right middle lobe (50%). Preoperative biopsy was performed in four (40%) but were nondiagnostic. Video-assisted thoracoscopic lobectomy (70%) was the most common surgical approach. Final pathology revealed three (30%) infectious, three (30%) inflammatory, two (20%) fibrotic, and two (20%) benign neoplastic nodules. Two (20%) patients had perioperative complications, both of which were prolonged air leaks, one (10%) patient was readmitted within 30 d, and there was no mortality.

CONCLUSIONS

A small percentage of patients (2.5% in our series) may undergo major pulmonary resection for unexpectedly benign pathology. Knowledge of this rate is useful to inform shared decision-making models between surgeons and patients and evaluation of thoracic surgery program performance.

Pre-surgical assessment of mediastinal lymph node metastases in patients having ≥ 30 mm non-small-cell lung cancers

INTRODUCTION

Computed tomography (CT) and fluorodeoxyglucose-positron-emission-tomography (FDG-PET) measurements of mediastinal lymph nodes (MLNs) of patients with non-small-cell-lung-cancers (NSCLCs) ≤ 30 mm in maximum diameter are recommended for pre-surgical prediction of MLN metastases.

METHODS

We reviewed all patients at Mount Sinai Health System enrolled in the Initiative for Early Lung Cancer Research on Treatment (IELCART), prospective cohort between 2016 and 2020, who had pre-surgical FDG-PET and underwent surgery with MLN resection and/or pre-operative endobronchial ultrasound (EBUS) for a first primary NSCLC ≤ 30 mm in maximum diameter on pre-surgical CT.

RESULTS

Among 470 patients, none with part-solid (n = 63) or nonsolid (n = 23) NSCLCs had MLN metastases. Solid NSCLCs were identified in 384 patients, none in typical carcinoid (n = 48) or NSCLC ≤ 10 mm in maximum diameter (n = 47, including 8 typical carcinoids) had MLN metastases. Among the remaining 297 patients with solid NSCLCs 10.1-30.0 mm, 7 (2.4%) had MLN metastases. Area-under-the-curve (AUC) for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm, using the CT maximum short-axis MLN diameter was 0.62 (95% CI:0.44-0.81, p = 0.18) and using the highest SUVmax of any MLN, AUC was 0.58 (95% CI:0.39-0.78,p = 0.41). Neither AUCs were significantly different from chance alone. Optimal cutoff for prediction of MLN metastases was ≥ 18.9 mm for CT maximum short-axis diameter [sensitivity 14.3% (95%CI:0.0%-57.9%); specificity 100.0% (95%CI:98.9%-100.0%)] and for highest SUVmax was ≥ 11.7 [sensitivity 14.3% (95%CI:0.0%-57.9%) and specificity 99.7% (95%CI:98.3%-100.0%)].

CONCLUSIONS

CT and SUVmax had low sensitivity but high specificity for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm. Clinical Stage IA NSCLCs ≤ 30 mm should be based on CT maximum tumor diameter and MLN maximum short-axis diameter ≤ 20 mm.

Pulmonary carcinomas arising in association with scar: Cytomorphologic features in histologically confirmed cases

BACKGROUND

Lung carcinoma arising in association with scar tissue is a well-reported but much debated phenomenon. Scar tissue complicates imaging and pathologic tumor measurement for cancer staging. To the best of our knowledge, the cytological findings in lung scar carcinoma (LSC) have not been described in the literature. Therefore, the aim of this study was to characterize the findings in fine-needle aspirations (FNA) from histologically confirmed LSCs.

METHODS

LSCs were identified on retrospective search. Cases with preoperative FNA material were reviewed, including non-scar cases that were used for comparison. The clinical and histopathology findings were recorded.

RESULTS

Twenty-seven cases associated with scar tissue had material for review and 35 cases not associated with scar tissue were used for comparison. The proportion of fibrosis in resection specimens ranged from 10% to 80%. Five (19%) FNA cases were hypocellular. There was no statistically significant difference between the scar and non-scar groups in terms of overall cellularity and diagnostic categories (P = .113 and P = .17, respectively). There was correlation between cytology and dominant pattern on histology in 19 (79%) adenocarcinoma cases. Spindle cells and fibrous or fibroelastotic fragments were present in 22 (81%) cases.

CONCLUSION

This is the first study describing the cytology associated with LSCs. The presence of fibrosis did not adversely impact cellularity, which is likely due to multiple excursions and selective microdissection of tumor cells by the FNA needle. The cytomorphological and histological patterns correlated in most cases. FNA is able to provide a preoperative diagnosis of carcinoma despite the presence of fibrosis.

Ex vivo thyroid fine needle aspirations as an alternative for MALDI-MSI proteomic investigation: intra-patient comparison

Fine needle aspiration (FNA) is the reference standard for the diagnosis of thyroid nodules. Matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) has been successfully used to discriminate the proteomic profiles of benign and malignant thyroid FNAs within the scope of providing support to pathologists for the classification of morphologically borderline cases. However, real FNAs provide a limited amount of material due to sample collection restrictions. Ex vivo FNAs could represent a valuable alternative, increasing sample size and the power of statistical conclusions. In this study, we compared the real and ex vivo MALDI-MSI proteomic profiles, extracted from thyrocyte containing regions of interest, of 13 patients in order to verify their similarity. Statistical analysis demonstrated the mass spectra similarity of the proteomic profiles by performing intra-patient comparison, using statistical similarity systems. In conclusion, these results show that post-surgical FNAs represent a possible alternative source of material for MALDI-MSI proteomic investigations in instances where pre-surgical samples are unavailable or the number of cells is scarce.

The Regimen of Computed Tomography Screening for Lung Cancer: Lessons Learned Over 25 Years From the International Early Lung Cancer Action Program

We learned many unanticipated and valuable lessons since we started planning our study of low-dose computed tomography (CT) screening for lung cancer in 1991. The publication of the baseline results of the Early Lung Cancer Action Project (ELCAP) in Lancet 1999 showed that CT screening could identify a high proportion of early, curable lung cancers. This stimulated large national screening studies to be quickly started. The ELCAP design, which provided evidence about screening in the context of a clinical program, was able to rapidly expand to a 12-institution study in New York State (NY-ELCAP) and to many international institutions (International-ELCAP), ultimately working with 82 institutions, all using the common I-ELCAP protocol. This expansion was possible because the investigators had developed the ELCAP Management System for screening, capturing data and CT images, and providing for quality assurance. This advanced registry and its rapid accumulation of data and images allowed continual assessment and updating of the regimen of screening as advances in knowledge and new technology emerged. For example, in the initial ELCAP study, introduction of helical CT scanners had allowed imaging of the entire lungs in a single breath, but the images were obtained in 10 mm increments resulting in about 30 images per person. Today, images are obtained in submillimeter slice thickness, resulting in around 700 images per person, which are viewed on high-resolution monitors. The regimen provides the imaging acquisition parameters, imaging interpretation, definition of positive result, and the recommendations for further workup, which now include identification of emphysema and coronary artery calcifications. Continual updating is critical to maximize the benefit of screening and to minimize potential harms. Insights were gained about the natural history of lung cancers, identification and management of nodule subtypes, increased understanding of nodule imaging and pathologic features, and measurement variability inherent in CT scanners. The registry also provides the foundation for assessment of new statistical techniques, including artificial intelligence, and integration of effective genomic and blood-based biomarkers, as they are developed.

Diagnostic utility of fine needle aspiration cytology and core biopsy histopathology with or without immunohistochemical staining in the subtyping of the non-small cell lung carcinomas: Experience from an academic centre in Turkey

INTRODUCTION

This retrospective morphological study compared the results of fine needle aspiration (FNA) cytology, haematoxylin-eosin (HE)-stained samples and immunohistochemical (IHC)-stained core needle biopsy (CNB) histology samples for primary non-small cell lung cancer (NSCLC) subtyping. We assessed the diagnostic utility of these methods to investigate the contribution of each method to NSCLC subtyping. We also identified the point at which NSCLC subtyping could be performed using histomorphology alone without IHC.

METHODOLOGY

Concurrent FNA and CNB specimens obtained via a single computed tomography-guided procedure and diagnosed as NSCLC in the Pathology Department of our university within 3 years were reviewed. The results of FNA samples, HE-stained biopsies and IHC-stained biopsies were compared according to subtype.

RESULTS

A total of 141 subjects were enrolled in the study. For subtyping, FNA provided an accurate diagnosis in 70 (55.1%) of 127 eligible subjects after the exclusion of 14 cases determined as not otherwise specified. CNB histology without IHC achieved a diagnosis in 53 (41.7%) of 127 subjects, which was a significant difference (P < .05). The compatibility rate between HE-stained biopsy samples and IHC-stained biopsy samples was 41.7% (53/127).

CONCLUSION

The diagnosis rates achieved using FNA, HE-stained CNB samples and IHC-stained CNB samples were 54.6% (77/141), 37.6% (53/141) and 90.1% (127/141), respectively. The subtype was identified in 55.1% of the subjects evaluated using FNA and 41.7% of subjects assessed using HE-stained biopsy samples without IHC. FNA provided a better result for squamous cell carcinoma than adenocarcinoma (55.1% vs 47.6%), but the diagnosing of adenocarcinoma and squamous cell carcinoma using HE-stained biopsy samples was similar (42% vs 41.7%).

Radiological-pathological correlation of negative CT biopsy results enables high negative predictive value for thoracic malignancy

AIM

To evaluate multidisciplinary team (MDT) practice of radiological-pathological correlation of non-malignant biopsy results to examine the additive effect on the predictive values of computed tomography (CT) biopsy for malignancy and their subsequent management and outcomes.

MATERIALS AND METHODS

A service evaluation of the MDT management of non-malignant lung biopsy results (May 2014- May 2017) was undertaken.

RESULTS

Sixty patients had a non-malignant diagnosis on initial CT biopsy. Five patients were lost to follow-up leaving 55 in the final cohort. Forty-eight of the 55 patients had biopsy results classified as potentially non-specific, of which 26 were classified as concordant with radiology (e.g., organising pneumonia with compatible CT features), and 22 were classified as discordant (e.g., non-specific inflammation and yet sufficiently suspicious CT features). Patients with concordant negative pathology showed resolution (n=19) or stability (n=6) on imaging follow-up. One lesion demonstrated growth and was proven malignant on surgical resection. Discordant lesions were managed with repeat biopsy (n=8) or surgical resection (n=13), with 12 final benign diagnoses and nine malignancies. The negative predictive value of CT biopsy alone was 44/55 (80%), following repeat biopsy was 44/50 (88%), and following radiological-pathological assessment was 32/33 (97%). No patients underwent a shift in stage from time of biopsy to resection.

CONCLUSION

Combining radiological-pathological interpretation of negative biopsy results offers superior negative predictive value for lung malignancy without delayed diagnosis of lung cancer.

Pre-surgical assessment of mediastinal lymph node metastases in Stage IA non-small-cell lung cancers

OBJECTIVE

Evaluation of sensitivity and specificity of CT and fluorodeoxyglucose-positron emission tomography for pre-surgical staging of mediastinal lymph node metastases (N2/N3) of non-small-cell-lung-cancers ≤30 mm.

METHODS

We reviewed a total of 263 patients from a prospective cohort study, who underwent resection including mediastinal lymph nodes, for first primary non-small-cell-lung-cancer ≤30 mm in maximum diameter on pre-surgical CT. Cutoff criteria for short-axis diameter on CT of the largest N2/N3 node of 10, 15, and 20 mm and positron emission uptake of 2.5, 3.0, and 4.0 were evaluated using Area-Under-the-Curve (AUC) assessment. Accuracy criterion was used to determine the optimal cutoffs.

RESULTS

Of 263 patients, 9 had nonsolid, 42 part-solid, and 212 solid non-small-cell-lung-cancers. Post-surgically, none of the 51 patients with nonsolid or part-solid cancers had mediastinal lymph node metastases. Among the 212 patients with solid cancers, 23 had N2 node metastases. For the 212 patients with solid cancers, the AUC for CT lymph node measurements was 0.67 (95% CI: 0.57-0.77), significantly higher (p = 0.001) than chance alone, while the AUC for SUVmax measurements, 0.56 (95% CI: 0.48-0.65), was not (p = 0.13). Optimal CT cutoff was >20 mm had low sensitivity of 30.4% (95% CI: 11.6%-49.2%) but high specificity of 99.5% (95% CI: 98.4%-100.0%).

CONCLUSION

Based on these results, clinical Stage IA for non-small-cell-lung-cancers with nonsolid, part-solid, or solid consistency should be based on pre-surgical CT maximum tumor diameter and lymph node short-axis measurements on CT ≤20 mm. Further prospective evaluation of these clinical Stage IA staging criteria is needed.

snoRNAs Offer Novel Insight and Promising Perspectives for Lung Cancer Understanding and Management

Small nucleolar RNAs (snoRNAs) are non-coding RNAs localized in the nucleolus, where they participate in the cleavage and chemical modification of ribosomal RNAs. Their biogenesis and molecular functions have been extensively studied since their identification in the 1960s. However, their role in cancer has only recently started to emerge. In lung cancer, efforts to profile snoRNA expression have enabled the definition of snoRNA-related signatures, not only in tissues but also in biological fluids, exposing these small RNAs as potential non-invasive biomarkers. Moreover, snoRNAs appear to be essential actors of lung cancer onset and dissemination. They affect diverse cellular functions, from regulation of the cell proliferation/death balance to promotion of cancer cell plasticity. snoRNAs display both oncogenic and tumor suppressive activities that are pivotal in lung cancer tumorigenesis and progression. Altogether, we review how further insight into snoRNAs may improve our understanding of basic lung cancer biology and the development of innovative diagnostic tools and therapies.

Pre-surgical lung biopsy in management of solitary pulmonary nodules: a cost effectiveness analysis

Objectives: Tissue diagnosis prior to thoracic surgery with curative intent is vital in thoracic lesions concerning for lung cancer. Methods of obtaining tissue diagnosis are variable within the United Kingdom.Methods: We performed a model-based analysis to identify the most efficient method of diagnosis using both a health care perspective. Our analysis concerns adults in the UK presenting with a solitary pulmonary nodule suspicious for a primary lung malignancy, patients with more advanced disease (for example lymph node spread) were not considered. Model assumptions were derived from published sources and expert reviews, cost data were obtained from healthcare research group cost estimates (2016-17). Outcomes were measured in terms of costs experienced to healthcare trusts.Results: Our results show that CT guided percutaneous lung biopsy using an ambulatory approach, is the most cost-effective method of diagnosis. Indeed, using this approach, trust experience approximately half of the cost of an approach of surgical lung biopsy performed at the time of potential resection ('frozen section').Limitations and conclusions: Whilst this analysis is limited to the specific scenario of a solitary pulmonary nodule, these findings have implications for the implementation of lung cancer screening in the UK, which is likely to result in increased numbers of patients with such early disease.

Assessment of Fluorodeoxyglucose F18-Labeled Positron Emission Tomography for Diagnosis of High-Risk Lung Nodules

Importance

Clinicians rely heavily on fluorodeoxyglucose F18-labeled positron emission tomography (FDG-PET) imaging to evaluate lung nodules suspicious for cancer. We evaluated the performance of FDG-PET for the diagnosis of malignancy in differing populations with varying cancer prevalence.

Objective

To determine the performance of FDG-PET/computed tomography (CT) in diagnosing lung malignancy across different populations with varying cancer prevalence.

Design, Setting, and Participants

Multicenter retrospective cohort study at 6 academic medical centers and 1 Veterans Affairs facility that comprised a total of 1188 patients with known or suspected lung cancer from 7 different cohorts from 2005 to 2015.

Exposures

18F fluorodeoxyglucose PET/CT imaging.

Main Outcome and Measures

Final diagnosis of cancer or benign disease was determined by pathological tissue diagnosis or at least 18 months of stable radiographic follow-up.

Results

Most patients were male smokers older than 60 years. Overall cancer prevalence was 81% (range by cohort, 50%-95%). The median nodule size was 22 mm (interquartile range, 15-33 mm). Positron emission tomography/CT sensitivity and specificity were 90.1% (95% CI, 88.1%-91.9%) and 39.8% (95% CI, 33.4%-46.5%), respectively. False-positive PET scans occurred in 136 of 1188 patients. Positive predictive value and negative predictive value were 86.4% (95% CI, 84.2%-88.5%) and 48.7% (95% CI, 41.3%-56.1%), respectively. On logistic regression, larger nodule size and higher population cancer prevalence were both significantly associated with PET accuracy (odds ratio, 1.027; 95% CI, 1.015-1.040 and odds ratio, 1.030; 95% CI, 1.021-1.040, respectively). As the Mayo Clinic model-predicted probability of cancer increased, the sensitivity and positive predictive value of PET/CT imaging increased, whereas the specificity and negative predictive value dropped.

Conclusions and Relevance

High false-positive rates were observed across a range of cancer prevalence. Normal PET/CT scans were not found to be reliable indicators of the absence of disease in patients with a high probability of lung cancer. In this population, aggressive tissue acquisition should be prioritized using a comprehensive lung nodule program that emphasizes advanced tissue acquisition techniques such as CT-guided fine-needle aspiration, navigational bronchoscopy, and endobronchial ultrasonography.

Transthoracic fine-needle aspiration diagnosis of solid, subsolid, and partially calcified lung nodules: A retrospective study from a single academic center

Background:

The large-scale National Lung Cancer Screening Trial demonstrated an increased detection of early-stage lung cancers using low-dose computed tomography scan in the screening population. It also demonstrated a 20% reduction of lung cancer-related deaths in these patients.

Aims:

Although both solid and subsolid lung nodules are evaluated in studies, subsolid and partially calcified lung nodules are often overlooked.

Materials and Methods:

We reviewed transthoracic fine-needle aspiration (FNA) cases from lung nodule patients in our clinics and correlated cytological diagnoses with radiologic characteristics of lesions. A computer search of the pathology archive was performed over a period of 12 months for transthoracic FNAs, including both CT- and ultrasound-guided biopsies.

Results:

A total of 111 lung nodule cases were identified. Lesions were divided into three categories: solid, subsolid, and partially calcified nodules according to radiographic findings. Of 111 cases, the average sizes of the solid (84 cases), subsolid (22 cases), and calcified (5 cases) lesions were 1.952 ± 2.225, 1.333 ± 1.827, and 1.152 ± 1.984 cm, respectively. The cytological diagnoses of three groups were compared. A diagnosis of malignancy was made in 64.28% (54 cases) in solid, 22.72% (5 cases) in subsolid, and 20% (1 case) in partially calcified nodules. Among benign lesions, eight granulomatous inflammations were identified, including one case of solid, five cases of subsolid, and two cases of calcified nodules.

Conclusions:

Our study indicates that solid nodules have the highest risk of malignancy. Furthermore, the cytological evaluation of subsolid and partially calcified nodules is crucial for the accurate diagnosis and appropriate clinical management of lung nodule patients.