Natural History of Ground-Glass Lesions Among Patients With Previous Lung Cancer

Risk factors for the growth of ground-glass nodules in the lungs: A systematic review and meta-analysis

OBJECTIVE

The growth of ground-glass nodules in the lungs is an independent risk factor for the occurrence of lung cancer, which provides the basic conditions for the occurrence of lung cancer. However, risk factors for the growth of ground-glass nodules in the lungs have not been fully identified. The purpose of this meta-analysis was to assess risk factors for the growth of ground-glass nodules in the lungs.

METHODS

Computerized searches of the electronic databases of PubMed, Web of Science, Cochrane Library and Scopus for published studies on risk factors for the growth of ground-glass nodules in the lungs. The search time limit is from the establishment of the database to March 2024. Two review authors independently searched the studies according to the inclusion and exclusion criteria, and the quality of the selected studies was evaluated using the Newcastle-Ottawa Scale (NOS), and RevMan 5.4 software was used for meta-analysis. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42024499763).

RESULTS

Fourteen studies involving 2059 patients were included, and 14 statistically significant risk factors were identified. The results of meta-analysis showed that age (WMD = 4.61, 95 % CI [1.73∼7.49], p = 0.002), female (OR = 0.65, 95 % CI [0.51∼0.82], p = 0.0003), history of smoking (OR = 1.76, 95 % CI [1.07∼2.92], p = 0.03), history of malignancy (OR = 1.53, 95 % CI [1.16∼2.02], p = 0.003), lesion size (≥ 8 mm) (OR = 1.19, 95 % CI [1.12∼1.26], p < 0.00001), air bronchial sign (OR = 6.09, 95 % CI [3∼12.33], p < 0.00001), lobulation sign (OR = 2.3, 95 % CI [1.58∼3.36], p < 0.00001), spiculated sign (OR = 5.56, 95 % CI [1.39∼22.3], p = 0.02), vascular bundle sign [OR = 2.54, 95 % CI [1.85∼3.48], p < 0.00001), initial diameter (≥ 8 mm) (OR = 1.89, 95 % CI [1.34∼2.67], p = 0.0003), vacuolar sign (OR = 2.62, 95 % CI [1.46∼4.69], p = 0.001), solid nodules (OR = 4.6, 95 % CI [1.96∼10.79], p = 0.0005), solid components (OR = 13.77, 95 % CI [7.08∼26.78], p < 0.00001) and nodule roundness (OR = 2.85, 95 % CI [1.19∼6.81], p = 0.02) were risk factors for the growth of ground-glass nodules in the lungs. However, pleural adhesion (p = 0.47) and pleural retraction (p = 0.07) were not statistically significant.

CONCLUSION

This systematic review and meta-analysis showed that there are many risk factors for the growth of ground-glass nodules in the lungs, and medical staff should identify the above risk factors as early as possible in clinical work and formulate targeted interventions for precise prevention.

Managing Persistent Subsolid Nodules in Lung Cancer: Education, Decision Making, and Impact of Interval Growth Patterns

With the popularization of lung cancer screening, many persistent subsolid nodules (SSNs) have been identified clinically, especially in Asian non-smokers. However, many studies have found that SSNs exhibit heterogeneous growth trends during long-term follow ups. This article adopted a narrative approach to extensively review the available literature on the topic to explore the definitions, rationale, and clinical application of different interval growths of subsolid pulmonary nodule management and follow-up strategies. The development of SSN growth thresholds with different growth patterns could support clinical decision making with follow-up guidelines to reduce over- and delayed diagnoses. In conclusion, using different SSN growth thresholds could optimize the follow-up management and clinical decision making of SSNs in lung cancer screening programs. This could further reduce the lung cancer mortality rate and potential harm from overdiagnosis and over management.

Detecting Ground Glass Opacity Features in Patients With Lung Cancer: Automated Extraction and Longitudinal Analysis via Deep Learning-Based Natural Language Processing

BACKGROUND

Ground-glass opacities (GGOs) appearing in computed tomography (CT) scans may indicate potential lung malignancy. Proper management of GGOs based on their features can prevent the development of lung cancer. Electronic health records are rich sources of information on GGO nodules and their granular features, but most of the valuable information is embedded in unstructured clinical notes.

OBJECTIVE

We aimed to develop, test, and validate a deep learning-based natural language processing (NLP) tool that automatically extracts GGO features to inform the longitudinal trajectory of GGO status from large-scale radiology notes.

METHODS

We developed a bidirectional long short-term memory with a conditional random field-based deep-learning NLP pipeline to extract GGO and granular features of GGO retrospectively from radiology notes of 13,216 lung cancer patients. We evaluated the pipeline with quality assessments and analyzed cohort characterization of the distribution of nodule features longitudinally to assess changes in size and solidity over time.

RESULTS

Our NLP pipeline built on the GGO ontology we developed achieved between 95% and 100% precision, 89% and 100% recall, and 92% and 100% F1-scores on different GGO features. We deployed this GGO NLP model to extract and structure comprehensive characteristics of GGOs from 29,496 radiology notes of 4521 lung cancer patients. Longitudinal analysis revealed that size increased in 16.8% (240/1424) of patients, decreased in 14.6% (208/1424), and remained unchanged in 68.5% (976/1424) in their last note compared to the first note. Among 1127 patients who had longitudinal radiology notes of GGO status, 815 (72.3%) were reported to have stable status, and 259 (23%) had increased/progressed status in the subsequent notes.

CONCLUSIONS

Our deep learning-based NLP pipeline can automatically extract granular GGO features at scale from electronic health records when this information is documented in radiology notes and help inform the natural history of GGO. This will open the way for a new paradigm in lung cancer prevention and early detection.

Clinical and CT Features of Subsolid Pulmonary Nodules With Interval Growth: A Systematic Review and Meta-Analysis

Background

Establishing risk-based follow-up management strategies is crucial to the surveillance of subsolid pulmonary nodules (SSNs). However, the risk factors for SSN growth are not currently clear. This study aimed to perform a systematic review and meta-analysis to identify clinical and CT features correlated with SSN growth.

Methods

Relevant studies were retrieved from Web of Science, PubMed, Cochrane Library, and EMBASE. The correlations of clinical and CT features with SSN growth were pooled using a random-effects model or fixed-effects model depending on heterogeneity, which was examined by the Q test and I2 test. Pooled odds ratio (OR) or pooled standardized mean differences (SMD) based on univariate analyses were calculated to assess the correlation of clinical and CT features with SSN growth. Pooled ORs based on multivariate analyses were calculated to find out independent risk factors to SSN growth. Subgroup meta-analysis was performed based on nodule consistency (pure ground-glass nodule (pGGN) and part-solid nodule (PSN). Publication bias was examined using funnel plots.

Results

Nineteen original studies were included, consisting of 2444 patients and 3012 SSNs. The median/mean follow-up duration of these studies ranged from 24.2 months to 112 months. Significant correlations were observed between SSN growth and eighteen features. Male sex, history of lung cancer, nodule size &gt; 10 mm, nodule consistency, and age &gt; 65 years were identified as independent risk factors for SSN growth based on multivariate analyses results. Eight features, including male sex, smoking history, nodule size &gt; 10 mm, larger nodule size, air bronchogram, higher mean CT attenuation, well-defined border, and lobulated margin were detected to be significantly correlated with pGGNs growth. Smoking history showed no significant correlation with pGGN growth based on the multivariate analysis results.

Conclusions

Eighteen clinical and CT features were identified to be correlated with SSN growth, among which male sex, history of lung cancer, nodule size &gt; 10 mm, nodule consistency and age &gt; 65 years were independent risk factors while history of lung cancer was not correlated with pGGN growth. These factors should be considered when making risk-based follow-up plans for SSN patients.

Social Disparities in Thoracic Surgery Database Research: Implications and Impact

A complex relationship exists between health care disparities and large databases among the thoracic surgical patient population. Using the example of thoracic malignancies, the ability of investigations leveraging large databases and novel analytical approaches to highlight disparate access to care and discordant outcomes following treatment is illustrated. Large, widely used databases may not be representative of the thoracic surgical patient population as a whole, and caution must be used when interpreting and generalizing results gleaned from such database analyses. Ensuring appropriate representation of all relevant patient subgroups in research databases will improve external generalizability and scientific validity of future investigations.

Intestinal Metaplasia in the Esophageal Remnant Is Rare After Ivor Lewis Esophagectomy

BACKGROUND

Most patients undergoing esophagectomy will experience intermittent reflux of gastric and biliary content into the remnant esophagus postoperatively. The incidence of new or recurrent intestinal metaplasia following chemoradiation and surgery has not been well-described. Furthermore, post-resection guidelines do not exist regarding surveillance for metaplasia in the esophageal remnant.

METHODS

Patients undergoing Ivor Lewis esophagectomy after concurrent chemoradiation for a diagnosis of esophageal adenocarcinoma from 2006 to 2018 were identified. Pathology records were reviewed for the presence of intestinal metaplasia on pretreatment biopsies, surgical specimen, or post-resection biopsies.

RESULTS

In total, 619 patients met inclusion criteria, including 267 (43%) who had intestinal metaplasia noted either prior to or at the time of esophagectomy. The median duration of metaplastic disease prior to resection was 4.4 months. During a median follow-up time of 28 months (interquartile range, 12-60), intestinal metaplasia was noted in the remnant esophagus in 12 (2%) patients, 7 of whom had a prior history of metaplasia. Local recurrence of adenocarcinoma was also uncommon, and occurred in 37/577 (6%) of patients with complete resections, with similar event rates among those with and without a prior history of metaplasia (14/249 [6%] vs. 23/328 [7%], p = 0.614).

CONCLUSIONS

Our findings suggest that despite several factors predisposing to mucosal damage following esophagectomy, occurrence of new intestinal metaplasia after trimodality therapy in our patient population appears to be rare, even among patient with a previous history of this pathologic finding, which may have significant implications for surveillance and cost-savings after resection.

Predicting malignancy: subsolid nodules detected on LDCT in a surgical cohort of East Asian patients

Background

Due to widespread use of low-dose computed tomography (LDCT) screening, increasing number of patients are found to have subsolid nodules (SSNs). The management of SSNs is a clinical challenge and primarily depends on CT imaging. We seek to identify risk factors that may help clinicians determine an optimal course of management.

Methods

We retrospectively reviewed the characteristics of 83 SSN lesions, including 48 pure ground-glass nodules and 35 part-solid nodules, collected from 83 patients who underwent surgical resection.

Results

Of the 83 SSNs, 16 (19.28%) were benign and 67 (80.72%) were malignant, including 23 adenocarcinomas in situ (AIS), 16 minimally invasive adenocarcinomas (MIA), and 28 invasive adenocarcinomas (IA). Malignant lesions were found to have significantly larger diameters (P<0.05) with an optimal cut-off point of 9.24 mm. Significant indicators of malignancy include female sex (P<0.05), air bronchograms (P<0.001), spiculation (P<0.05), pleural tail sign (P<0.05), and lobulation (P<0.05). When compared with AIS/MIA combined, IA lesions were found to be larger (P<0.05) with an optimal cut-off of 12 mm, and have a higher percentage of part-solid nodules (P<0.001), pleural tail sign (P<0.001), air bronchograms (P<0.05), and lobulation (P<0.05). Further multivariate analysis found that lesion size and spiculation were independent factors for malignancy while part-solid nodules were associated with IA histology.

Conclusions

East Asian females are at risk of presenting with a malignant lesion even without history of heavy smoking or old age. Nodule features associated with malignancy include larger size, air bronchograms, lobulation, pleural tail sign, spiculation, and solid components. A combination of patient characteristic and LDCT features can be effectively used to guide management of patients with SSNs.

Esophageal adenocarcinoma with any component of signet ring cells portends poor prognosis and response to neoadjuvant therapy

BACKGROUND

Multiple investigations have shown inferior outcomes for esophageal cancer patients with signet ring cell (SRC) histology. Traditionally, SRC adenocarcinoma has been defined by ≥50% of the tumor composed of SRC. We hypothesized that patients with SRC even <50% would show resistance to standard multimodality therapy with poorer long-term outcomes.

METHODS

Patients treated with trimodality therapy for adenocarcinoma from 2006 to 2018 were evaluated for SRC on pretreatment biopsy specimens. Available hematoxylin and eosin slides containing SRC tumors were re-reviewed by an esophageal pathologist to quantify the percent composition of SRC.

RESULTS

SRC histology was identified on at least 1 pathologic specimen in 106 of 819 (13%) patients. Rates of pathologic complete response (pCR) among usual-type and SRC tumors were 25% (177/713) and 10% (11/106), respectively (P = .006). The pretreatment SRC components did not independently affect the rate of pCR (1%-10% SRC: 4% [2/46] pCR; 11%-49% SRC: 25% [7/28] pCR; 50%-100% SRC: 7% [2/30] pCR). Kaplan-Meier analysis demonstrated worse survival among patients with any degree of SRC present on pretreatment biopsy, as compared with usual-type esophageal adenocarcinoma (P < .0001). Cox multivariable analysis failed to identify a relationship between increasing SRC component and poorer survival.

CONCLUSIONS

We present the only known evaluation of the percentage of SRC component in esophageal carcinoma. Our data support the hypothesis that esophageal adenocarcinoma with any component of SRC are more resistant to chemoradiation with poorer survival. Pathologic reporting of esophageal adenocarcinoma should include any component of SRC. Alternative therapies in patients with any SRC component may be indicated.

Importance of resection for locoregional disease control in Masaoka stage IVA thymic neoplasms

BACKGROUND AND OBJECTIVES

It is unclear if a specific strategy for simultaneous treatment of primary thymic neoplasms and pleural metastases confers benefit for Masaoka stage IVA disease. We reviewed our experience with thymic neoplasms with concurrent pleural metastases to identify factors influencing outcomes.

METHODS

Records of patients who presented with stage IVA thymic neoplasms from 2000 to 2018 were assessed. Multivariate Cox proportional hazards analyses were completed to determine predictors of progression-free and overall survival.

RESULTS

Forty-eight patients were identified, including 34 (71%) who underwent surgery. Median overall and progression-free survival were 123 and 21 months, respectively. The extent of resection varied, and was most commonly thymectomy plus partial pleurectomy (22, 65%). Median progression-free survival for patients who underwent surgical resection versus those who had not was 24 versus 12 months (P = .018). Following surgical resection, mediastinal recurrence was uncommon (2, 6%, vs 7, 50% nonoperatively). Five-year survival rates in these groups were suggestive of possible benefit to surgery (87% vs 68%).

CONCLUSIONS

Thymic neoplasms with pleural dissemination represents a treatment challenge. As part of a multidisciplinary approach, surgery appears to be associated with more favorable long-term results, although selection bias may account for some of the survival differences observed.

Immune regulatory markers of lepidic-pattern adenocarcinomas presenting as ground glass opacities

Background

The tumor immune microenvironment of lepidic-pattern adenocarcinoma remains poorly understood. In this study, we characterized tumor infiltrating lymphocytes (TILs) and percent PD-L1 expression among adenocarcinoma presenting as either radiographic ground glass opacities (GGOs) or solid lesions.

Methods

Pathologic specimens of patients with clinical stage I lung adenocarcinoma were analyzed using tissue microarray sectioning. The invasive portion of the tumor was selected for the tissue core. Lepidic growth pattern was confirmed among the GGO lesions using whole section analysis. Progression was defined as pN+ or subsequent recurrence.

Results

A total of 181 patients were identified, among whom 13 (7%) represented GGOs without clinical progression, 113 (62%) represented radiographic solid lesions that never progressed, and 55 (30%) represented radiographic solid lesions that ultimately did progress. CD57+ cell density, a marker for antigen-specific, oligoclonal T cells and NK cells, differed among the three cohorts, with the highest cell density observed within radiographically solid lesions without progression, and lower cell density both in the radiographic solid lesions that progressed and GGOs. Other TIL phenotypes were not statistically different between cohorts. Of substantial clinical interest, median percent PD-L1 positive cells within GGOs was 14, whereas that of radiographic solid lesions without progression was 22, and radiographic solid lesions that subsequently progressed was 27 (P=0.07).

Conclusions

Lepidic pattern adenocarcinoma presenting as GGOs and radiographic solid lesions show differential immune regulation. Further studies to investigate whether GGOs representing adenocarcinoma have varying susceptibility to immune checkpoint inhibitor therapy are warranted.

Advanced Data Analytics for Clinical Research Part II: Application to Cardiothoracic Surgery

In the first part of this series, we introduced the tools of Big Data, including Not Only Standard Query Language data warehouse, natural language processing (NLP), optical character recognition (OCR), and Internet of Things (IoT). There are nuances to the utilization of these analytics tools, which must be well understood by clinicians seeking to take advantage of these innovative research strategies. One must recognize technical challenges to NLP, such as unintended search outcomes and variability in the expression of human written texts. Other caveats include dealing written texts in image formats, which may ultimately be handled with transformation to text format by OCR, though this technology is still under development. IoT is beginning to be used in cardiac monitoring, medication adherence alerts, lifestyle monitoring, and saving traditional labs from equipment failure catastrophes. These technologies will become more prevalent in the future research landscape, and cardiothoracic surgeons should understand the advantages of these technologies to propel our research to the next level. Experience and understanding of technology are needed in building a robust NLP search result, and effective communication with the data management team is a crucial step in successful utilization of these technologies. In this second installment of the series, we provide examples of published investigations utilizing the advanced analytic tools introduced in Part I. We will explain our processes in developing the research question, barriers to achieving the research goals using traditional research methods, tools used to overcome the barriers, and the research findings.

Profiles of Lung Adenocarcinoma With Multiple Ground-Glass Opacities and the Fate of Residual Lesions

BACKGROUND

We aimed to clarify clinical profiles of patients with adenocarcinoma presenting as multifocal ground-glass opacities (MGGOs) to assess their prognosis and the optimal management method for residual satellite lesions.

METHODS

We identified 190 patients with cN0 MGGOs (MGGO cohort) and 1426 patients with solitary lung adenocarcinoma (control cohort) who underwent complete resection between 2004 and 2016. Propensity score matching was performed to adjust for differences in baseline characteristics of both cohorts for survival analyses. MGGOs consist of a main tumor and satellite lesions and were subdivided into 3 groups: the PG group, with multifocal pure GGOs; the GD group, in which the main tumor presented as GGO dominant; and the SD group, where the main tumor presented as solid dominant.

RESULTS

No significant differences in recurrence-free survival were observed between the 2 cohorts before and after the propensity score matching. For patients with MGGOs, 22 were in the PG group, 47 in the GD group, and 121 in the SD group. Type of MGGOs was a significant factor for recurrence-free survival recurrence-free survival both in the entire population (SD vs PG-GD, P = .008) and in p-stage I cohorts (P = .004) on multivariable analysis. Among 116 patients (61.1%) with residual satellite lesions, 38 patients had progressed lesions and 69 stable lesions. Although the emergence of new lesions during the follow-up period was an independent predictor for satellite lesion progression, neither progressed lesions nor the emergence of new lesions influenced survival.

CONCLUSIONS

Patients with MGGOs and solitary adenocarcinoma had a similar prognosis. The biologic behavior of main tumors dominates clinical outcomes in patients with MGGOs.

Multidisciplinary treatment of thymic neuroendocrine tumors: surgery remains a key component

BACKGROUND

Thymic neuroendocrine tumors (NETs) are rare malignancies often treated in a multidisciplinary fashion. However, evidence for adjunctive therapy is limited, and predictors of survival and recurrence are not well established.

METHODS

Patients treated for thymic NETs at a single center from 1975 to 2018 were reviewed. Variables collected pertained to tumor factors, stage, and treatments, including surgery. Univariate and multivariate regression analyses were used to determine predictors of overall survival (OS) and recurrence.

RESULTS

We identified treated 49 patients, among whom 36 (73%) were male with a median age of 46 years. Surgical resection was pursued in 41 (84%) patients, and chemotherapy and radiation therapy were used in 27 (55%) and 21 (43%) instances as either neoadjuvant, adjuvant, or definitive therapy. Median tumor size was 6.5 centimeters and most tumors were intermediate-grade. During a median follow-up time of 60.8 months following surgical resection, disease recurrence was observed in 29 (71%) patients and median survival time was 83.7 months. In Kaplan-Meier analysis for survival, surgical resection was associated with a longer survival time (P=0.002), while receipt of neoadjuvant therapy was associated with poorer survival. Larger tumor size was associated with recurrence following resection (P=0.047).

CONCLUSIONS

Thymic NETs represent a heterogeneous disease with variable survival. While we are unable to report clear evidence that supports the use of adjunctive therapies, surgery is important to survival. Additionally, it is likely that those receiving induction chemotherapy represent a unique cohort with advanced or aggressive disease. Among surgical candidates, tumor size predicts disease recurrence.

Ground Glass Lesions on Chest Imaging: Evaluation of Reported Incidence in Cancer Patients Using Natural Language Processing

BACKGROUND

Ground glass opacities (GGOs) on computed tomography (CT) have gained significant recent attention, with unclear incidence and epidemiologic patterns. Natural language processing (NLP) is a powerful computing tool that collects variables from unstructured data fields. Our objective was to characterize trends of GGO detection using NLP.

METHODS

Patients were identified at a large quaternary referral center who underwent chest CT from 2000 to 2016 via query of institutional databases. NLP was used to identify imaging reports with GGOs and to obtain additional demographic data. Incidence of reported GGOs was tracked over time. Multivariate regression was used to identify predictors of GGOs identified on chest CT.

RESULTS

A total of 244,391 chest CTs were included, with 35,386 (14.5%) revealing GGOs. There was a significant relationship between advancing year of chest CT and likelihood of reported GGOs (p < 0.001). GGOs were more likely to occur in older subjects (60.5 vs 58.5 years, p < 0.001), males (54.6% vs 51.5%, p < 0.001), and nonwhite races (21.2% Asian, 15.6% Hispanic, 14.4% black, 14.0% white; p < 0.001). Certain occupational histories predicted more frequent GGOs (p < 0.001), including transportation labor (47.4%), metal workers (42.3%), iron workers (33.3%), cabinetry (32.6%), and foremen (29.6%). Multivariate regression revealed age, sex, nonsmokers, increasing year of chest CT, and race as significant independent predictors of identifying GGOs.

CONCLUSIONS

NLP explored a large cohort of patients who underwent chest CT over the study period. Demographic features predicting reported GGOs include age, sex, race, and occupation. GGO recognition continues to increase with time, and further studies investigating etiology and prognostic implications are necessary.