Management of Ground-Glass Opacities in the Lung Cancer Spectrum

Clinical application of microwave ablation combined with coaxial needle biopsy using different sequences for treating lung nodules suggestive of malignancy

OBJECTIVE

This study aimed to evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous microwave ablation (MWA) combined with coaxial needle biopsy performed in different sequences for treating lung nodules with signs of malignancy.

METHODS

A retrospective analysis was conducted on 51 patients (56 lesions) with lung nodules treated with MWA and coaxial needle biopsy between January 2020 and March 2024. Patients were divided into Group A (post-MWA biopsy; 26 patients, 29 lesions) and Group B (pre-MWA biopsy; 25 patients, 27 lesions). Ablation parameters, postoperative complications, prognosis, and pathological diagnosis rates were compared between groups. Patients with malignant pathology findings from both groups (Group C) were analyzed for overall survival (OS) and progression-free survival (PFS).

RESULTS

Technical success for needle biopsy and MWA was 100%. Pneumothorax incidence was 24.14% (7/29) in Group A and 33.33% (9/27) in Group B (p = 0.447). Intrapulmonary hemorrhage occurred in 13.79% (4/29) of Group A patients and 37.04% (10/27) of Group B of patients, showing a significantly higher rate in Group B (p = 0.026). The pathological diagnosis rate was 100% in both the groups, with malignancy rates of 72.41% (21/29) in Group A and 81.48% (22/27) in Group B (p = 0.422). For Group C, the 1-3-year OS rates were 100.00%, 93.75%, and 75.00%, respectively, and the corresponding PFS rates were 97.50%, 84.38%, and 60.00%.

CONCLUSIONS

Biopsy post-MWA maintains pathological diagnostic accuracy while significantly reducing the incidence of intrapulmonary hemorrhage compared to pre-MWA biopsy.

CT-based intratumoral and peritumoral radiomics nomogram to predict spread through air spaces in lung adenocarcinoma with diameter ≤ 3 cm: A multicenter study

Purpose

The aim of this study was to explore and develop a preoperative and noninvasive model for predicting spread through air spaces (STAS) status in lung adenocarcinoma (LUAD) with diameter ≤ 3 cm.

Methods

This multicenter retrospective study included 640 LUAD patients. Center I included 525 patients (368 in the training cohort and 157 in the validation cohort); center II included 115 patients (the test cohort). We extracted radiomics features from the intratumor, extended tumor and peritumor regions. Multivariate logistic regression and boruta algorithm were used to select clinical independent risk factors and radiomics features, respectively. We developed a clinical model and four radiomics models (the intratumor model, extended tumor model, peritumor model and fusion model). A nomogram based on prediction probability value of the optimal radiomics model and clinical independent risk factors was developed to predict STAS status.

Results

Maximum diameter and nodule type were clinical independent risk factors. The extended tumor model achieved satisfactory STAS status discrimination performance with the AUC of 0.74, 0.71 and 0.80 in the three cohorts, respectively, performed better than other radiomics models. The integrated discrimination improvement value revealed that the nomogram outperformed compared to the clinical model with the value of 12 %. Patients with high nomogram score (≥ 77.31) will be identified as STAS-positive.

Conclusions

Peritumoral information is significant to predict STAS status. The nomogram based on the extended tumor model and clinical independent risk factors provided good preoperative prediction of STAS status in LUAD with diameter ≤ 3 cm, aiding surgical decision-making.

Predicting High-risk Lung Adenocarcinoma in Solid and Part-solid Nodules on Low-dose CT: A Multicenter Study

RATIONALE AND OBJECTIVES

High-grade patterns, visceral pleural invasion, lymphovascular invasion, spread through air spaces, and lymph node metastasis are high-risk factors and associated with poor prognosis in lung adenocarcinomas (LUADs). This study aimed to construct and validate a radiomic model and a radiographic model derived from low-dose CT (LDCT) for predicting high-risk LUADs in solid and part-solid nodules.

MATERIALS AND METHODS

This study retrospectively enrolled 658 pathologically confirmed LUADs from July 2018 to December 2022 from four centers, which were divided into training set (n=411), internal validation set (n=139), and external validation set (n=108). Radiomic features and radiographic features including maximal diameter, consolidation/tumor ratio (CTR), and semantic features, were obtained to construct a radiomic model and a radiographic model through multivariable logistic regression. Area under receiver operating characteristic curve (AUC) was utilized to assess the diagnostic performance of the models.

RESULTS

Three radiomic features (GLCM_Correlation, GLSZM_SmallAreaEmphasis, and GLDM_LargeDependenceHighGrayLevelEmphasis) and four radiographic features (maximal diameter, CTR, spiculation, and pleural indentation) were selected to build models. The radiomic model yielded AUCs of 0.916 in the internal validation set and 0.938 in the external validation set, which were significantly higher than the AUCs of the radiographic model (0.916 vs. 0.868, P=0.014 and 0.938 vs. 0.880, P=0.002).

CONCLUSION

Our LDCT-based radiomic model enabled non-invasive identification of high-risk LUADs in solid and part-solid nodules with good diagnostic performance and might assist in case-specific decision-making in lung cancer screening.

Proteogenomic characterization reveals tumorigenesis and progression of lung cancer manifested as subsolid nodules

Lung adenocarcinoma (LUAD) radiologically displayed as subsolid nodules (SSNs) is prevalent. Nevertheless, the precise clinical management of SSNs necessitates a profound understanding of their tumorigenesis and progression. Here, we analyze 66 LUAD displayed as SSNs covering 3 histological stages including adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma (IAC) by incorporating genomics, proteomics, phosphoproteomics and glycoproteomics. Intriguingly, cholesterol metabolism is aberrantly regulated in the preneoplastic AIS stage. Importantly, target ablation of proprotein convertase subtilisin/kexin type 9 (PCSK9) promotes the initiation of LUAD. Furthermore, sustained endoplasmic reticulum stress is demonstrated to be a hallmark and a reliable biomarker of AIS progression to IAC. Consistently, target promotion of ER stress profoundly retards LUAD progression. Our study provides comprehensive proteogenomic landscape of SSNs, sheds lights on the tumorigenesis and progression of SSNs and suggests preventive and therapeutic strategies for LUAD.

The evolution of the treatment of non-small cell lung cancer: A shift in surgical paradigm to a more individualized approach

Surgical treatment is an integral part of the comprehensive therapeutic methods for lung cancer, especially for early-stage non-small cell lung cancer (NSCLC). With a deeper understanding of the disease, we found that lung cancer is more commonly detected in young females. For regions of Asia, more lung cancer has been detected in early-stage GGO-dominant non-smokers. Therefore, surgical strategies have also been reformed commensurate with the shift of the disease spectrum. However, the pursuit of lung-sparing individualized approaches has raised worldwide attention. Suitable surgical treatment within the curative time window is recommended to maximize the long-term benefit. This article summarizes the shift in surgical treatment for small NSCLCs and hopes to enlighten further innovations to fill in the gaps between the unmet needs and a more individualized approach.

One-Stage Bilateral Pulmonary Nodule Resection via Unilateral Thoracic Cavity Access: A Single-Center Experience of 12 Cases

BACKGROUND

Surgical intervention remains the primary therapeutic modality for managing multiple pulmonary nodules. However, in cases with bilateral pulmonary nodules, one-stage bilateral resection is discouraged due to tumor aggressiveness and surgical invasiveness. In light of this, we investigated an innovative approach, termed one-stage bilateral pulmonary nodule resection via unilateral thoracic cavity access.

METHODS

From July 2022 to September 2024, a cohort of 12 patients with bilateral pulmonary nodules were enrolled in this study. This technique involves initial unilateral transcostal incision for segmental or lobectomy of a nodule on one side, followed by bilateral mediastinal pleura incision through the anterior mediastinum, facilitating subsequent wedge resection of the contralateral nodule. Clinical and pathological data, along with perioperative imaging findings and follow-up information, were systematically collected and subjected to a comprehensive retrospective analysis.

RESULTS

A total of 25 nodules were resected from 12 patients. Regarding surgical approaches, nine patients underwent right thoracic incision, while three patients underwent left thoracic incision. Intraoperatively, seven patients received bilateral wedge resections, whereas five patients underwent segmentectomy on one side combined with wedge resection on the contralateral side. R0 resection of the contralateral nodules was successfully achieved during the procedures. The average distance between the surgical margin and the contralateral nodules was 12.5 mm, ranging from 5 mm to 25 mm. Of the 12 patients, one (Patient 6) was lost to follow-up, while the remaining 11 patients underwent postoperative chest CT examinations. The median follow-up duration for these 11 patients was 105 days (range: 36-857 days). No evidence of bilateral pleural effusion or tumor recurrence was detected on follow-up chest CT scans.

CONCLUSIONS

This study offers the potential to concurrently address bilateral pulmonary nodules, thereby sparing patients from the need for a subsequent hospitalization for surgical intervention.

Impact of histopathological subtypes on invasive lung adenocarcinoma: from epidemiology to tumour microenvironment to therapeutic strategies

Lung adenocarcinoma is the most prevalent type of lung cancer, with invasive lung adenocarcinoma being the most common subtype. Screening and early treatment of high-risk individuals have improved survival; however, significant differences in prognosis still exist among patients at the same stage, especially in the early stages. Invasive lung adenocarcinoma has different histological morphologies and biological characteristics that can distinguish its prognosis. Notably, several studies have found that the pathological subtypes of invasive lung adenocarcinoma are closely associated with clinical treatment. This review summarised the distribution of various pathological subtypes of invasive lung adenocarcinoma in the population and their relationship with sex, smoking, imaging features, and other histological characteristics. We comprehensively analysed the genetic characteristics and biomarkers of the different pathological subtypes of invasive lung adenocarcinoma. Understanding the interaction between the pathological subtypes of invasive lung adenocarcinoma and the tumour microenvironment helps to reveal new therapeutic targets for lung adenocarcinoma. We also extensively reviewed the prognosis of various pathological subtypes and their effects on selecting surgical methods and adjuvant therapy and explored future treatment strategies.

Predicting malignant risk of ground-glass nodules using convolutional neural networks based on dual-time-point 18F-FDG PET/CT

BACKGROUND

Accurately predicting the malignant risk of ground-glass nodules (GGOs) is crucial for precise treatment planning. This study aims to utilize convolutional neural networks based on dual-time-point 18F-FDG PET/CT to predict the malignant risk of GGOs.

METHODS

Retrospectively analyzing 311 patients with 397 GGOs, this study identified 118 low-risk GGOs and 279 high-risk GGOs through pathology and follow-up according to the new WHO classification. The dataset was randomly divided into a training set comprising 239 patients (318 lesions) and a testing set comprising 72 patients (79 lesions), we employed a self-configuring 3D nnU-net convolutional neural network with majority voting method to segment GGOs and predict malignant risk of GGOs. Three independent segmentation prediction models were developed based on thin-section lung CT, early-phase 18F-FDG PET/CT, and dual-time-point 18F-FDG PET/CT, respectively. Simultaneously, the results of the dual-time-point 18F-FDG PET/CT model on the testing set were compared with the diagnostic of nuclear medicine physicians.

RESULTS

The dual-time-point 18F-FDG PET/CT model achieving a Dice coefficient of 0.84 ± 0.02 for GGOs segmentation and demonstrating high accuracy (84.81%), specificity (84.62%), sensitivity (84.91%), and AUC (0.85) in predicting malignant risk. The accuracy of the thin-section CT model is 73.42%, and the accuracy of the early-phase 18F-FDG PET/CT model is 78.48%, both of which are lower than the accuracy of the dual-time-point 18F-FDG PET/CT model. The diagnostic accuracy for resident, junior and expert physicians were 67.09%, 74.68%, and 78.48%, respectively. The accuracy (84.81%) of the dual-time-point 18F-FDG PET/CT model was significantly higher than that of nuclear medicine physicians.

CONCLUSIONS

Based on dual-time-point 18F-FDG PET/CT images, the 3D nnU-net with a majority voting method, demonstrates excellent performance in predicting the malignant risk of GGOs. This methodology serves as a valuable adjunct for physicians in the risk prediction and assessment of GGOs.

Reassessment of the Prognostic Implication of Ground-Glass Opacity: An Investigation Into Hypermetabolic Clinical Stage IA Lung Adenocarcinoma

BACKGROUND

Subsolid lung nodules represent a distinct group of lung cancers with less-aggressive biological behavior and favorable survival. We aimed to examine the prognostic impact of the ground-glass opacity (GGO) in clinical stage IA (cIA) lung adenocarcinoma with high metabolic activity.

METHODS

A retrospective study was conducted among patients with resected hypermetabolic and/or pure-solid cIA lung adenocarcinoma from a single institution database. The primary outcome was recurrence-free survival (RFS). The secondary outcomes included overall survival, pathological nodal upstaging, and recurrence rate.

RESULTS

A total of 621 patients were reviewed and classified into three groups: patients with low metabolic, solid nodules (SNs) into group A (N = 128), patients with hypermetabolic ground-glass nodules (GGNs) into group B (N = 105), and patients with hypermetabolic SNs into group C (N = 388). The five-year RFS of group B was significantly better than that of group C in the cT1a + T1b (93.3% vs. 72.5%, p = 0.002) subgroup but not in the cT1c (73.4% vs. 69.0%, p = 0.23) subgroup. Multivariable analysis showed that GGO component was an independent prognostic factor of RFS (hazard ratio [HR] = 0.41, 95% confidence interval [CI]: 0.19-0.89, p = 0.02) and protective factor of nodal upstaging (odds ratio [OR] = 0.44, 95% CI: 0.21-0.94, p = 0.03) among the hypermetabolic subgroup. All except one postoperative recurrence occurred in GGNs with solid component size > 2 cm.

CONCLUSIONS

The presence of GGO component was an independent prognostic factor even in hypermetabolic cIA lung adenocarcinoma. However, the oncologic outcomes of hypermetabolic GGNs were not equally favorable in different T categories.

Peripheral blood immune cell dynamics associate with growth of incidental indeterminate pulmonary nodules

OBJECTIVES

Previous studies suggest peripheral blood immune cells associate with the progression and prognosis of lung cancer. The main purpose of this study was to explore the association of peripheral immune cell and its dynamics with the growth of pulmonary nodules.

MATERIALS AND METHOD

Of 9280 subjects whom had blood cell counts and chest CT scan in health check-up, 1068 participants were enrolled with the incidental pulmonary nodules of above 5 mm in diameter and subsequently followed up for 2 years. The pulmonary nodules were identified as growth based on the increase of at least 2 mm in the diameters within the two years. The relationships of pulmonary nodules growth with peripheral immune cell dynamics and clinical variables were analyzed using univariable inter-group comparison and multivariable logistic regression analyses.

RESULTS

During the two years, 116 (10.9 %) of 1068 participants had the growth pulmonary nodules. Overall, emphysema, nodule diameter and non-solid characteristics associated with the growth of nodules. In the subgroup of pure solid nodules, high baseline eosinophil percentage (OR 1.220; 95 % CI 1.009-1.474; P = 0.040) and the increase of neutrophil count (OR 3.805; 95 % CI 1.027-14.093; P = 0.045) were significant risk factors for the nodule growth. In the subgroup of solid-predominant nodules, the increase of lymphocyte was associated with a lower risk of growth (OR 0.039; 95 % CI 0.002-0.839; P = 0.038).

CONCLUSIONS

High baseline eosinophil and increase of neutrophil were associated with the growth of pure solid pulmonary nodules. The decrease of lymphocyte related to the growth of solid-predominant nodules.

The Association of Chylothorax With Aggressiveness of Lymph Node Management During Pulmonary Resection

BACKGROUND

Chylothorax is a morbid and costly complication that can originate in lymph node resection beds. We hypothesized a close association between the occurrence of chylothorax and the extent and aggressiveness of lymph node dissection.

METHODS

We conducted a nested case-control study of 1728 non-small cell lung cancer patients who underwent resection at our institution between January 2005 and July 2023. Cases were defined as patients who developed chylothorax. Each case was matched with 3 control patients who did not develop chylothorax, based on year of diagnosis, clinical N descriptor, presence of granulomatous lymph nodes, extent of resection, and tumor laterality. Using conditional logistic regression, we estimated risk ratios with 95% CIs to examine the association between the occurrence of chylothorax and several measures of the extent of lymph node resection.

RESULTS

The incidence of chylothorax was 33 of 1728 (1.9%). In the matched groups, patients with chylothorax had higher rates of complete lymphadenectomy (82% vs 65%, P = .059) and systematic lymph node dissection as defined by International Association for the Study of Lung Cancer, European Society of Medical Oncology, and European Society of Thoracic Surgeons (85% vs 52%, P = .002). Station 2 was resected significantly more often in the chylothorax group (48.5% vs 29%, P = .04). The chylothorax group had a longer median in-hospital stay (7 vs 4 days, P = .003) and higher rates of reoperation (18% vs 1.0%, P = .006) and readmission (18% vs 5%, P = .03).

CONCLUSIONS

In matched groups, chylothorax is associated with several measures of more aggressive lymph node management and results in substantial postoperative morbidity. This finding provides additional support for more selective lymph node management approaches when resecting smaller, less solid, and less 18-fluorodeoxyglucose-avid tumors.

One-stage versus two-stage video-assisted thoracic surgery for synchronous bilateral pulmonary nodules: protocol for a single center, non-randomized clinical trial (OTVATS-1)

BACKGROUND

Previous retrospective studies demonstrated both one-stage and two-stage video-assisted thoracic surgery (VATS) for bilateral pulmonary nodules were safe and feasible in selected patients. However, prospective data is still lacking. The purpose of this trial is to prospectively compare the prognostic and perioperative outcomes between one-stage and two-stage VATS for synchronous bilateral pulmonary nodules.

METHODS

We conduct a prospective clinical trial to investigate the surgical outcomes of one-stage and two-stage VATS for patients with synchronous bilateral pulmonary nodules. This trial plan to enroll 198 patients from a single institution during a period of 5 years. The primary outcome is 5-year overall survival. Secondary outcomes include 5-year disease free survival, 3-year overall survival, 3-year disease free survival, overall complications rate, 30-day mortality, pain score after surgery, surgical time, blood loss in the operation, duration of chest tube, length of stay, and quality of life score after surgery.

DISCUSSION

To our knowledge, this study is the first prospective registered clinical trials to compare the clinical outcomes after one-stage or two-stage VATS for synchronous bilateral non-small cell lung cancer.

TRAIL REGISTRATION

This study underwent review by the Ethics Committee of China-Japan Friendship Hospital under No. 2023-KY-061-1. It has been officially registered with the China Clinical Trial Registry, TRN: ChiCTR2300071198 and registration date is May. 8, 2023.

One-stage versus two-stage thoracoscopic surgery for synchronous bilateral pulmonary nodules: a propensity score-matched analysis

BACKGROUND

The aim of this study was to compare the surgical efficacy of one-stage and two-stage video-assisted thoracoscopic surgery (VATS) for bilateral multiple pulmonary nodules (BMPNs).

METHODS

A retrospective analysis was made of 156 patients, 84 who underwent one-stage and 72 who underwent two-stage VATS for BMPNs at our department between January 2019 and December 2022. Perioperative and long-term outcomes were compared between the two groups using propensity score-matched (PSM) analysis.

RESULTS

There were 48 patients in each group after PSM. No significant difference was observed in operation time, blood loss, rates of overall complications, and 3-year overall survival (p>0.05) between one-stage and two-stage groups. The one-stage procedure was associated with shorter length of stay (5 days [IQR 4-5.75 days] vs. 9 days [IQR 7-10 days]; p<0.001), as well as lower total cost (14626.3 ± 4149.4 vs. 18975.9 ± 3720.8 USD, p<0.001) compared to the two-stage procedure. The one-stage group was associated with better 3-year RFS compared with the two-stage group (90.7% vs. 75.3%, p = 0.039).

CONCLUSION

One-stage and two-stage VATS for BMPNs are both safe and feasible in selected patients. One-stage procedure possess potential advantages in reducing hospital stay and cost, as well as preventing tumor progression.

A novel interplay between bacteria and metabolites in different early-stage lung cancer: an integrated microbiome and metabolome analysis

Background

The carcinogenesis mechanism of early-stage lung cancer (ESLC) remains unclear. Microbial dysbiosis is closely related to tumor development. This study aimed to analyze the relationship between microbiota dysbiosis in ESLC.

Methods

We investigated a total of 108 surgical specimens of lung nodules, including ground glass nodules (GGN) diagnosed as lung adenocarcinoma (n = 25), solid nodules (SN) diagnosed as lung adenocarcinoma (n = 27), lung squamous carcinoma (LUSC) presenting as solid nodules (n = 26), and benign pulmonary nodules (BPD) (n = 30) that were collected. 16S rDNA amplicon sequencing and non-targeted metabolomics analysis were performed in all of the specimens.

Results

We found a significantly lower microbiota richness in SN than in the GGN and LUSC. Ralstonia may be an important flora promoting the development of early lung adenocarcinoma, while Feacalibacterium and Blautia play a protective role in the progression of GGN to SN. Akkermansia, Escherichia-shigella, and Klebsiella exhibited high abundance in early lung squamous carcinoma. Compared with BPD, the differential metabolites of both early adenocarcinomas (SN and GGN) are mainly involved in energy metabolic pathways, while early LUSC is mainly involved in glutathione metabolism, producing and maintaining high levels of intracellular redox homeostasis. A correlation analysis revealed that different microbiota in GGN may function in energy metabolism via N-acetyl-1-aspartylglutamic acid (NAAG) when compared to BPD, while creatine and N-acetylmethionine were the main relevant molecules for the function of differential microbiota in LUSC.

Conclusion

Our study identified that early-stage lung adenocarcinoma and squamous carcinoma differ in microbial composition and metabolic status. Ralstonia may be an important flora promoting the development of early lung adenocarcinoma, while Feacalibacterium and Blautia play a protective role in the progression of GGN to SN. Conversely, Akkermansia, Escherichia-shigella, and Klebsiella exhibited high abundance in early lung squamous carcinoma. The metabolites of both early adenocarcinomas (SN and GGN) are mainly involved in energy metabolic pathways, while early LUSC is mainly involved in glutathione metabolism. Our study provides new insights into the carcinogenesis of ESLC.

Clinical, Imaging, and Pathological-Molecular Characteristics Associated with Stage IA Invasive Lung Adenocarcinoma Recurrence After Sub-lobar Resection

RATIONALE AND OBJECTIVES

This study aimed to investigate the association of clinical, imaging, and pathological-molecular characteristics with the prediction of patient prognosis with stage IA invasive lung adenocarcinoma (ILADC) after sub-lobar resection.

MATERIALS AND METHODS

This study assessed 360 patients, including 91 and 269 with and without recurrence 3 years postoperatively, respectively, with stage IA ILADC undergoing preoperative chest computed tomography (CT) scans and subsequent sub-lobar resection at our institution. Their clinical and CT features and histological subtypes and gene mutation status were compared. Binary logistic regression analysis was conducted to identify the independent risk factors for recurrence. An external validation cohort included 113 patients, used to test the model's efficiency.

RESULTS

For clinical features, old age, male gender, smokers, and high age-adjusted Charlson comorbidity index (ACCI) were frequently observed in patients with recurrence than those without (all p < 0.05). For CT features, large tumor size, solid-predominant density, spiculation, peripheral fibrosis, type II pleural tag, and pleural adhesion were more common in recurrent patients than non-recurrent ones (all p < 0.05). The regression model revealed old age, large tumor size, solid-predominant density, spiculation, type II pleural tag, and pleural adhesion as independent risk factors for recurrence, with an area under the curve (AUC) of 0.942. The external validation cohort obtained an AUC of 0.958. For phological-molecular features, micropapillary/solid-predominant growth pattern, KRAS, ALK, and NRAS mutation or fusion were more common in the recurrent group, whereas EGFR mutation was more frequent in the non-recurrent group (all p < 0.05).

CONCLUSION

Clinical and CT features help predict the prognosis of patients with stage IA ILADC after sub-lobar resection and decide for individualized treatment. Moreover, patients with different prognosis demonstrated different pathological-molecular features.

EGFR Mutation Rates Correlate with Age at Diagnosis and Tumor Characteristics in Patients with Pulmonary Ground-Glass Opacities

BACKGROUND

To clearly reveal the correlations between tumor characteristics, age at diagnosis, and epidermal growth factor receptor (EGFR) mutation rates in patients with pulmonary ground-glass opacities (GGOs).

METHODS

We retrospectively reviewed 1473 patients with GGOs between January 2015 and May 2020 from two cancer centers. The tumor characteristics and EGFR mutation rates were compared between different age groups. Multivariate logistic regression was fitted to analyze the relationship between age, tumor characteristics, and EGFR mutation rates.

RESULTS

The older patients had more large tumors, mixed GGOs with a consolidation-to-tumor ratio (CTR) of >0.5, and invasive adenocarcinoma (IAC) and pathologic stage IA2-IB. Overall, the rate of EGFR mutations in GGOs was 57.3% and the main subtypes were L858R and 19del mutations. The distribution of EGFR subtypes varied in different age and GGO diameter groups. Age (p = 0.036), GGO types (p = 0.005), tumor diameter (p = 0.039), and pathological types (p < 0.001) were significant predictors for EGFR mutation status. Importantly, significant differences in EGFR mutation rates between age groups were mainly observed in the GGO ≤2 cm diameter (p < 0.001), pure GGOs (p = 0.001), and IAC (p = 0.039) cohorts. Overall, those diagnosed at >50 years of age had a 47.0% increased likelihood of harboring EGFR mutations. Compared with the older group, the increased chance of harboring EGFR mutations for patients with larger tumors, mixed GGOs, and IAC was greater in the younger group.

CONCLUSIONS

The EGFR mutation rates were varied among different tumor characteristics and age at diagnosis. These findings provide new insights into the treatment of GGOs.

Preoperative fractional exhaled nitric oxide is a risk and predictive factor of postoperative cough for early-stage non-small cell lung cancer patients: a longitudinal study

BACKGROUND

To determine whether preoperative fractional exhaled nitric oxide (FENO) level is a risk and predictive factor of postoperative cough by using the Leicester Cough Questionnaire in Mandarin-Chinese (LCQ-MC).

METHODS

292 early-stage non-small cell lung cancer (NSCLC) patients without preoperative cough were enrolled. 138 patients (47.2%) developed postoperative cough, univariate and multivariate logistic regression analysis were performed to identify the independent risk factors of postoperative cough. For an exploratory analysis, patients with cough were divided into low and high- FENO [≥ 31 parts per billion (ppb)] groups. The LCQ-CM was used to evaluate changes and recovery trajectory of postoperative cough over time between the two groups for 12 months after surgery.

RESULTS

The independent factors of postoperative cough included preoperative FENO level [odds ratio (OR) 1.106, 95% confidence interval (CI): 1.076-1.137, p < 0.001] and duration of anesthesia (OR 1.008, 95% CI: 1.002-1.013, p = 0.004). The low-FENO group reported significantly higher LCQ-MC scores at 1 month after surgery and returned to preoperative physical (28 vs. 91 days), psychological (28 vs. 60 days), social (28 vs. 80 days) and total (28 vs. 91 days) scores faster than the high-FENO group (all p < 0.05).

CONCLUSION

Higher preoperative FENO level and longer duration of anesthesia were independent risk factors related to postoperative cough. Additionally, patients with high preoperative FENO level had worse cough-related quality of life and slower recovery from postoperative cough.

TRIAL REGISTRATION

This study was approved by the Chinese Clinical Trial Registry (Clinicaltrials.gov number: ChiCTR1900023419) on 26 May 2019 and the first patient was enrolled after pre-registration.

Study on the value of 3D visualization in differentiating IA and non-IA pulmonary ground-glass nodules

OBJECTIVE

To determine the most effective diagnostic markers and their associated thresholds for Ground-glass nodules (GGN) for identification of invasive adenocarcinoma (IA) and non-IA (including atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), and minimally invasive adenocarcinoma (MIA)), and to explore the application in preoperative surgical evaluation.

METHODS AND METHODS

A total of 126 cases, confirmed by pathology, were retrospectively analyzed. 70 cases were classified as the IA group, while the non-IA group consisted of cases of AAH, AIS, and MIA, with a total of 56 cases. The study compared the differences in demographic, morphological, and three-dimensional (3D) quantitative parameters between the two groups.

RESULTS

There were statistically significant differences in various signs such as air bronchogram, lobulation, pleural indentation, spiculation, shape, and margin between the two groups. Additionally, Statistical significance was observed in all 3D quantitative parameters for both groups. Notably, when 3D volume of lesions exceeded 447 mm3, the sensitivity to predict IA was 81% with specificity at 69%. Utilizing multivariate logistic regression analysis, it was identified that the independent predictive value in discriminating between IA and non-IA lies with both the 3D volume and solid proportion. Combining these two indexes significantly improved the prediction accuracy (AUC = 0.826).

CONCLUSIONS

Reasonable utilization of 3D visualization technology can effectively aid in distinguishing between IA and non-IA. When coupled with clinical data and CT signs, this technique holds vital importance in directing the evaluation of surgical interventions prior to surgery.

Quantitative analysis of imaging characteristics in lung adenocarcinoma in situ using artificial intelligence

BACKGROUND

With the rising incidence of pulmonary nodules (PNs), lung adenocarcinoma in situ (AIS) is a critical early stage of lung cancer, necessitating accurate diagnosis for early intervention. This study applies artificial intelligence (AI) for quantitative imaging analysis to differentiate AIS from atypical adenomatous hyperplasia (AAH) and minimally invasive adenocarcinoma (MIA), aiming to enhance clinical diagnosis and prevent misdiagnosis.

METHODS

The study analyzed 1215 PNs with confirmed AAH, AIS, and MIA from six centers using the Shukun AI diagnostic module. Parameters evaluated included demographic data and various CT imaging metrics to identify indicators for clinical application, focusing on the mean CT value's predictive value.

RESULTS

Significant differences were found in several parameters between AAH and AIS, with nodule mass showing the highest predictive value. When comparing AIS to MIA, total nodule volume was the best predictor, followed by the maximum CT value.

CONCLUSION

The mean CT value has limited discriminative power for AIS diagnosis. Instead, the maximum CT value and maximum 3D diameter are recommended for clinical differentiation. Nodule mass and volume of solid components are strong indicators for differentiating AIS from AAH and MIA, respectively.

Predicting invasiveness of ground-glass nodules in lung adenocarcinoma: based on preoperative 18 F-fluorodeoxyglucose PET/computed tomography and high-resolution computed tomography

OBJECTIVE

This study was conducted to explore the differential diagnostic value of PET/computed tomography (PET/CT) combined with high-resolution computed tomography (HRCT) in predicting the invasiveness of ground-glass nodules (GGNs).

MATERIALS AND METHODS

This retrospective analysis included 67 patients (mean age 62.5 ± 8.4, including 45 females and 22 males) with GGNs who underwent preoperative 18 F-fluorodeoxyglucose ( 18 F-FDG) PET/CT and HRCT examinations between January 2018 and October 2022. Based on the postoperative pathological results of lung adenocarcinoma, the patients were classified into two groups: invasive adenocarcinoma (IAC) and non-IAC. Besides, the clinical and imaging information of these patients was collected. HRCT signs include the existence of air bronchial signals, vascular convergence, pleural indentation, lobulation, and spiculation. Moreover, the diameter of solid components (D Solid ), diameter of ground-glass nodules (D GGN ), and computed tomography values of ground-glass nodules (CT GGN ) were measured concurrently. Furthermore, the mean standardized uptake value, maximal standardized uptake value (SUVmax), metabolic tumor volume, and total lesion glycolysis were assessed during PET/CT. Associations between invasiveness and these factors were evaluated using univariate and multivariate analyses.

RESULTS

The results of logistic regression analysis demonstrated that D GGN , D Solid , consolidation tumor ratio (CTR), CT GGN , and SUVmax were independent predictors in the IAC group. The combined diagnosis based on these five predictors revealed that area under the curve was 0.825.

CONCLUSION

The D GGN , D Solid , CTR, CT GGN , and SUVmax in GGNs were independent predictors of IAC, and combining 18 F-FDG PET/CT metabolic parameters with HRCT may improve the predictive value of pathological classification in lung adenocarcinoma.

Simultaneous thoracoscopic surgery in patients with atrial fibrillation and early-stage lung cancer

OBJECTIVES

Atrial fibrillation (AF) and early-stage lung cancer can both be treated under thoracoscopy. This study aims to evaluate the feasibility and safety of simultaneous thoracoscopic surgery for atrial fibrillation and early-stage lung cancer.

METHODS

This was a single-center, retrospective study of 865 patients with paroxysmal or non-paroxysmal AF who underwent surgical ablation between October 2014 and December 2021. Patients were divided into two groups according to whether they have undergone simultaneous thoracoscopic early-stage lung cancer surgery and resulting in 24 pairs of patients.

RESULTS

In total, 48 patients (24 matched pairs) were analyzed. The age was 63.71 ± 8.43 years. Procedure time and postoperative mechanical ventilation time were significantly lower in the group AF than group AFLC (Atrial fibrillation and lung cancer) (140.38 ± 27.53 vs. 230.79 ± 59.06 min, P<0.001; 5 vs 6.5 h, P = 0.002). There was no significant difference between the groups in terms of operative bleeding volume (90.00 ± 29.78 vs 85.83 ± 53.56 ml, P = 0.741), total postoperative drainage volume (1020.83 ± 516.5 vs 1406.25 ± 840.33 ml, P = 0.067), ICU (intensive care unit) length of stay (LOS) (43.5 vs 44 h, P = 0.33), hospitalization LOS (9.29 ± 1.92 vs 8.58 ± 1.98 days, P = 0.214) and incidence of freedom from AF or complications.

CONCLUSIONS

Simultaneous thoracoscopic surgical AF ablation and early-stage lung cancer is safe and feasible. It can be used as an alternative method for coexisting atrial fibrillation and lung cancer with acceptable operative risks.

Lung cancer masquerading as COVID-19 in a young non-smoking woman: case report

Introduction and importance

The clinical and radiological similarities between COVID-19 and lung cancer pose diagnostic challenges, particularly in young, non-smoking individuals. Ground glass opacities (GGO) on imaging, often associated with COVID-19, can also indicate lung cancer. Distinguishing between these conditions is crucial but complex, requiring a systematic approach.

Case presentation

The authors present a case of a 31-year-old non-smoking woman initially suspected of COVID-19 due to cough, dyspnea, and GGO on chest CT. Despite negative RT-PCR and inconclusive bronchial aspiration, symptoms persisted, prompting further investigation. A PET scan revealed hypermetabolic consolidation, leading to a biopsy confirming adenocarcinoma.

Clinical discussion

Lung cancer can mimic COVID-19 symptoms, complicating diagnosis, especially in young, non-smoking patients. While smoking remains the primary risk factor, lung cancer in non-smokers, particularly young individuals, is increasingly recognized. GGO, commonly associated with COVID-19, should prompt consideration of malignancy, emphasizing the importance of a comprehensive differential diagnosis.

Conclusion

Early detection of lung cancer in young, non-smoking individuals is vital yet challenging. Clinicians should maintain a high index of suspicion, promptly investigating persistent or worsening symptoms, even in the absence of traditional risk factors. Timely biopsy and intervention are critical for improving outcomes in this population.

Lepidic-Type Lung Adenocarcinomas: Is It Safe to Observe for Growth Before Treating?

BACKGROUND

Lepidic-type adenocarcinomas (LPAs) can be multifocal, and treatment is often deferred until growth is observed. This study investigated the potential downside of that strategy by evaluating the relationship of nodal involvement with tumor size and survival.

METHODS

The impact of tumor size on lymph node involvement and survival was evaluated for National Cancer Database patients who underwent surgery without induction therapy as primary treatment for cT1-3 N0 M0 histologically confirmed LPA from 2006 to 2019 by using logistic regression, Kaplan-Meier, and Cox analyses.

RESULTS

Positive nodes occurred in 442 of 8286 patients (5.3%). The incidence of having positive nodes approximately doubled with each 1-cm increment increase in size. Patients with positive nodes were more likely to have larger tumors (27 mm vs 20 mm, P < .001) and clinical ≥T2 disease (40.7% vs 26.8%, P < .001) compared with node-negative patients. However, tumor size was the only significant independent predictor of having positive nodal disease in logistic regression analysis, and this association grew stronger with each incremental centimeter increase in size. Patients with positive nodes were more likely to undergo adjuvant radiotherapy (23.5% vs 1.1%, P < .001) and chemotherapy (72.9% vs 7.9%, P < .001), and expectedly, had worse survival compared with the node-negative group in univariate (5-year overall survival, 50.9% vs 81.1%, P < .001) and multivariable (hazard ratio, 2.56; 95% CI, 2.14-3.05; P < .001) analyses.

CONCLUSIONS

Nodal involvement is relatively uncommon in early-stage LPAs but steadily increases with tumor size and is associated with dramatically worse survival. These data can be used to inform treatment decisions when evaluating LPA patients.

Feasibility and potential clinical benefit of dose de-escalation in stereotactic ablative radiotherapy for lung cancer lesions with ground glass opacities

Introduction

Treatment of neoplasic lung nodules with ground glass opacities (GGO) faces two primary challenges. First, the standard practice of treating GGOs as solid nodules, which effectively controls the tumor locally, but might increase associated toxicities. The second is the potential for dose calculation errors related to increased heterogeneity. This study addresses the optimization of a dose de-escalation regime for stereotactic ablative radiotherapy (SABR) for GGO lesions.

Materials and Methods

We used the CT scans of 35 patients (40 lesions) with some degree of GGO component treated at our institution between 2017 and 2021. We first assessed the dose calculation accuracy as a function of the GGO component of the lesion. We then analysed the advantages of a dose de-escalation regime in terms of lung dose reduction (Dmean, V20Gy and V300GyBED3) and plan robustness.

Results

We found a positive correlation between the presence of GGO and the dose calculation errors in a phantom scenario. These differences are reduced for patient data and in the presence of breathing motion. When using a de-escalation regime, significant reductions were achieved in mean lung dose, V20Gy and V300GyBED3. This study also revealed that lower doses in GGO areas lead to more stable fluence patterns, increasing treatment robustness.

Conclusions

The study lays the foundation for an eventual use of dose de-escalation in SABR for treating lung lesions with GGO, potentially leading to equivalent local control while reducing associated toxicities. These findings lay the groundwork for future clinical trials.

Knowledge mapping analysis of ground glass nodules: a bibliometric analysis from 2013 to 2023

Background

In recent years, the widespread use of computed tomography (CT) in early lung cancer screening has led to an increase in the detection rate of lung ground glass nodules (GGNs). The persistence of GGNs, which may indicate early lung adenocarcinoma, has been a focus of attention for scholars in the field of lung cancer prevention and treatment in recent years. Despite the rapid development of research into GGNs, there is a lack of intuitive content and trend analyses in this field, as well as a lack of detailed elaboration on possible research hotspots. The objective of this study was to conduct a comprehensive analysis of the knowledge structure and research hotspots of lung ground glass nodules over the past decade, employing bibliometric methods.

Method

The Web of Science Core Collection (WoSCC) database was searched for relevant ground-glass lung nodule literature published from 2013-2023. Bibliometric analyses were performed using VOSviewer, CiteSpace, and the R package "bibliometrix".

Results

A total of 2,218 articles from 75 countries and 2,274 institutions were included in this study. The number of publications related to GGNs has been high in recent years. The United States has led in GGNs-related research. Radiology has one of the highest visibilities as a selected journal and co-cited journal. Jin Mo Goo has published the most articles. Travis WD has been cited the most frequently. The main topics of research in this field are Lung Cancer, CT, and Deep Learning, which have been identified as long-term research hotspots. The GGNs-related marker is a major research trend in this field.

Conclusion

This study represents the inaugural bibliometric analysis of applied research on ground-glass lung nodules utilizing three established bibliometric software. The bibliometric analysis of this study elucidates the prevailing research themes and trends in the field of GGNs over the past decade. It also furnishes pertinent recommendations for researchers to provide objective descriptions and comprehensive guidance for future related research.

Immunogenomic features of radiologically distinctive nodules in multiple primary lung cancer

OBJECTIVES

To provide molecular and immunological attributes mechanistic insights for the management of radiologically distinctive multiple primary lung cancer (MPLC).

METHODS

The Bulk RNA-seq data of MPLC were obtained from our center. The Bulk RNA-seq data and CT images of patients with single primary lung cancer (SPLC) were obtained from GSE103584. Immune infiltration algorithms were performed to investigate the disparities in the immunological microenvironment between the two groups. Single-cell gene analysis was used to explore immune cells composition and communication relationships between cells in MPLC.

RESULTS

In MPLC, 11 pure ground-glass opacity nodules (pGGN) and 10 mixed GGN (mGGN) were identified, while in SPLC, the numbers were 18 pGGN and 22 mGGN, respectively. In MPLC, compared to pGGN, mGGN demonstrated a significantly elevated infiltration of CD8+ T cells. Single-cell gene analysis demonstrated that CD8+ T cells play a central role in the signaling among immune cells in MPLC. The transcription factors including MAFG, RUNX3, and TBX21 may play pivotal roles in regulation of CD8+ T cells. Notably, compared to SPLC nodules for both mGGN and pGGN, MPLC nodules demonstrated a significantly elevated degree of tumor-infiltrating immune cells, with this difference being particularly pronounced in mGGN. There was a positive correlation between the proportion of immune cells and consolidation/tumor ratio (CTR).

CONCLUSIONS

Our findings provided a comprehensive description about the difference in the immune microenvironment between pGGN and mGGN in early-stage MPLC, as well as between MPLC and SPLC for both mGGN and pGGN. The findings may provide evidence for the design of immunotherapeutic strategies for MPLC.

Long-term prognostic characteristics of patients with clinical stage IA part-solid lung adenocarcinoma: a conditional survival analysis

OBJECTIVES

Despite excellent 5-year survival, there are limited data on the long-term prognostic characteristics of clinical stage IA part-solid lung adenocarcinoma. The objective was to elucidate the dynamics of prognostic characteristics through conditional survival analysis.

METHODS

Consecutive patients who underwent complete resection for clinical stage IA part-solid lung adenocarcinoma between 2011 and 2015 were retrospectively reviewed. Conditional survival is defined as the probability of surviving further y years, conditional on the patient has already survived x years. The conditional recurrence-free survival (CRFS) and conditional overall survival (COS) were analysed to evaluate prognosis over time, with conditional Cox regression analysis performed to identify time-dependent prognostic factors.

RESULTS

A total of 1539 patients were included with a median follow-up duration of 98.4 months, and 80 (5.2%) patients experienced recurrence. Among them, 20 (1.3%) recurrence cases occurred after 5 years of follow-up with 100% intrathoracic recurrence. The 5-year CRFS increased from 95.8% to 97.4%, while the 5-year COS maintained stable. Multivariable Cox analysis revealed that histologic subtype was always an independent prognostic factor for CRFS even after 5 years of follow-up, while the independent prognostic value of consolidation-to-tumour ratio, visceral pleural invasion and lymph node metastasis was observed only within 5 years. Besides, age, pathologic size and lymph node metastasis maintained independent predictive value for COS during long-term follow-up, while consolidation-to-tumour ratio was predictive for COS only within 5 years of follow-up.

CONCLUSIONS

The independent prognostic factors for clinical stage IA part-solid lung adenocarcinoma changed over time, along with gradually increasing 5-year CRFS and stable 5-year COS.

The 2023 American Association for Thoracic Surgery (AATS) Expert Consensus Document: Management of subsolid lung nodules

OBJECTIVE

Lung cancers that present as radiographic subsolid nodules represent a subtype with distinct biological behavior and outcomes. The objective of this document is to review the existing literature and report consensus among a group of multidisciplinary experts, providing specific recommendations for the clinical management of subsolid nodules.

METHODS

The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an international, multidisciplinary expert panel composed of radiologists, pulmonologists, and thoracic surgeons with established expertise in the management of subsolid nodules. A focused literature review was performed with the assistance of a medical librarian. Expert consensus statements were developed with class of recommendation and level of evidence for each of 4 main topics: (1) definitions of subsolid nodules (radiology and pathology), (2) surveillance and diagnosis, (3) surgical interventions, and (4) management of multiple subsolid nodules. Using a modified Delphi method, the statements were evaluated and refined by the entire panel.

RESULTS

Consensus was reached on 17 recommendations. These consensus statements reflect updated insights on subsolid nodule management based on the latest literature and current clinical experience, focusing on the correlation between radiologic findings and pathological classifications, individualized subsolid nodule surveillance and surgical strategies, and multimodality therapies for multiple subsolid lung nodules.

CONCLUSIONS

Despite the complex nature of the decision-making process in the management of subsolid nodules, consensus on several key recommendations was achieved by this American Association for Thoracic Surgery expert panel. These recommendations, based on evidence and a modified Delphi method, provide guidance for thoracic surgeons and other medical professionals who care for patients with subsolid nodules.

Lung adenocarcinoma manifested as ground-glass nodules in teenagers: characteristics, surgical outcomes and management strategies

OBJECTIVES

Ground-glass nodules-featured lung cancer have been identified in some teenagers in recent years. This study aims to investigate the characteristics and surgical outcomes of these patients and explore proper management strategy.

METHODS

Patients aged ≤20 with incidentally diagnosed lung cancer were retrospectively reviewed from February 2016 to March 2023. Based on lymph node evaluation status, these patients were divided into non-lymph node evaluation and lymph node evaluation groups. The clinical and pathological characteristics were analysed.

RESULTS

A total of 139 teenage patients were included, with an obviously increased cases observed from 2019, corresponding to the COVID-19 pandemic. The median age of the 139 patients was 18 years (range 12-20). Eighty-five patients had pure ground-glass nodules, while others had mixed ground-glass nodules. The mean diameter of nodules was 8.87 ± 2.20 mm. Most of the patients underwent wedge resection (64%) or segmentectomy (31.7%). Fifty-two patients underwent lymph node sampling or dissection. None of these patients had lymph node metastasis. The majority of lesions were adenocarcinoma in situ (63 cases) and minimally invasive adenocarcinoma (72 cases), while four lesions were invasive adenocarcinoma. The median follow-up time was 2.46 years, and none of these patients experienced recurrence or death during follow-up. The lymph node evaluation group had longer hospital stays (P < 0.001), longer surgery time (P < 0.001), and greater blood loss (P = 0.047) than the non-lymph node evaluation group.

CONCLUSIONS

The COVID-19 pandemic significantly increased the number of teenage patients incidentally diagnosed with lung cancer, presenting as ground-glass nodules on CT scans. These patients have favourable surgical outcomes. We propose a management strategy for teenage patients, and suggest that sub-lobar resection without lymph node dissection may be an acceptable surgical procedure for these patients.

Clinical and pathological predictors of engraftment for patient-derived xenografts in lung adenocarcinoma

Patient-derived xenografts (PDXs) are increasingly utilized in preclinical drug efficacy studies due to their ability to retain the molecular, histological, and drug response characteristics of patient tumors. This study aimed to investigate the factors influencing the successful engraftment of PDXs. Lung adenocarcinoma PDXs were established using freshly resected tumor tissues obtained through surgery. Radiological data of pulmonary nodules from this PDX cohort were analyzed, categorizing them into solid tumors and tumors with ground-glass opacity (GGO) based on preoperative CT images. Gene mutation status was obtained from next generation sequencing data and MassARRAY panel. A total of 254 resected primary lung adenocarcinomas were utilized for PDX establishment, with successful initial engraftment in 58 cases (22.8 %); stable engraftment defined as at least three serial passages was observed in 43 cases (16.9 %). The stable engraftment rates of PDXs from solid tumors and tumors with GGO were 22.1 % (42 of 190 cases) and 1.6 % (1 of 64 cases), respectively (P < 0.001). Adenocarcinomas with advanced stage, poor differentiation, solid histologic subtype, and KRAS or TP53 gene mutations were associated with stable PDX engraftment. Avoiding tumors with GGO features could enhance the cost-effectiveness of establishing PDX models from early-stage resected lung adenocarcinomas.

Expert consensus on the multidisciplinary diagnosis and treatment of multiple ground glass nodule-like lung cancer (2024 Edition)

ABSTRACT

This expert consensus reviews current literature and provides clinical practice guidelines for the diagnosis and treatment of multiple ground glass nodule-like lung cancer. The main contents of this review include the following: ① follow-up strategies, ② differential diagnosis, ③ diagnosis and staging, ④ treatment methods, and ⑤ post-treatment follow-up.

Primary lung cancer in children and adolescents

PURPOSE

Primary lung cancer is extremely rare in children and adolescents. The aim of this study is to clarify clinical features and outcomes of primary lung cancer in children and adolescents.

METHODS

Young patients (aged ≤ 20 years) diagnosed as primary lung cancer between 2012 and 2023 were retrospective reviewed. According to radiological appearance of the nodules, they were divided into solid nodule (SN) group and ground glass opacity (GGO) group.

RESULTS

A total of 74 patients were identified, with a median age at diagnosis of 18 years old (range: 11-20), including 7 patients in SN group and 67 patients in GGO group. In the GGO group, none of the nodules enlarged or changed during an average surveillance period of 10.8 months before surgery, except one. Wedge resection was the most common procedure (82.1%), followed by segmentectomy (16.4%) and lobectomy (1.5%). Histopathological analysis revealed that 64.2% of GGO nodules were adenocarcinoma in situ and minimally invasive adenocarcinomas, while the remaining 35.8% were invasive adenocarcinomas. Mutational analysis was performed in nine patients, with mutations identified in all cases. After a mean follow-up period of 1.73 ± 1.62 years, two patients in the SN group died due to multiple distant metastases, while all patients in the GGO group survived without recurrence. The overall survival (100%) of the GGO group was significantly higher than SN group (66.7%).

CONCLUSIONS

Primary lung cancer in children and adolescents are rare and histopathological heterogeneous. Persistent GGO nodules may indicate early-stage lung adenocarcinoma in children and adolescents.

[Modern individualized diagnostics and treatment of non-small cell lung cancer]

Approximately one half of patients with non-small cell lung cancer (NSCLC) are diagnosed at resectable tumor stages (I-IIIA), which can potentially be curatively treated. In the early tumor stages (tumor diameter ≤2 cm) sublobar resection (segmentectomy or atypical wedge resection) leads to a 5‑year long-term survival comparable to lobectomy. The use of immunotherapy, especially within the framework of neoadjuvant treatment, is anticipated to change the surgical treatment of NSCLC in the future. With the introduction of lung cancer screening for certain risk groups in Germany planned for 2024, lung tumors can be expected to be diagnosed at earlier stages and more frequently curatively treated. This article provides an overview of the potential impact of lung cancer screening, modern minimally invasive surgical techniques and neoadjuvant treatment concepts for the surgical treatment of NSCLC.

Impact of risk perception and disease cognition on the willingness to participate in screening for lung cancer in a high-risk population

OBJECTIVE

Risk perception and disease cognition may influence the efficiency of lung cancer screening by affecting the participation rate. There is still some uncertainty regarding the association between risk perception and disease cognition and how they affect participation in lung cancer screening. Therefore, we explored the influence of risk perception and disease cognition on the willingness to participate in screening among people at high risk of lung cancer.

METHODS

Subjects with high-risk factors for lung cancer were recruited in Lu'an City, Anhui Province, China. Questionnaires were used to determine their demographic characteristics, risk perception, disease cognition, and willingness to engage in screening.

RESULTS

Of the 1955 subjects with high risk factors for lung cancer, 1136 (58.12%) were willing to participate in lung cancer screening. Univariable and multivariable analyses showed that disease cognition ( adj OR = 2.012, 95% CI: 1.528-2.649, P  = 0.000), cognitive risk ( adj OR = 7.661, 95% CI: 6.049-9.704, P  = 0.000), and affective risk ( adj OR = 5.964, 95% CI: 4.552-7.815, P  = 0.000) were significant factors in promoting screening participation. For those with moderate risk perception, improving disease cognition was a key approach to increase screening participation.

CONCLUSION

This study elucidated the relationship between various factors and lung cancer screening participation and proposed a feasible route for the screening implementation, providing a theoretical basis to further improve the participation rate and efficiency of lung cancer screening.

Robotic Versus Thoracoscopic Sub-lobar Resection for Octogenarians with Clinical Stage IA Non-small Cell Lung Cancer: A Propensity Score-Matched Real-World Study

BACKGROUND

Minimally invasive sub-lobectomy is sufficient in treating small early-stage non-small cell lung cancer (NSCLC). However, comparison of the feasibility and oncologic efficacy between robot-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in performing sub-lobectomy for early-stage NSCLC patients age 80 years or older is scarce.

METHODS

Octogenarians with clinical stage IA NSCLC (tumor size, ≤ 2 cm) undergoing minimally invasive wedge resection or segmentectomy at Shanghai Chest Hospital from 2011 to 2020 were retrospectively reviewed from a prospectively maintained database. Propensity score-matching (PSM) with a RATS versus VATS ratio of 1:4 was performed. Perioperative and long-term outcomes were analyzed.

RESULTS

The study identified 594 patients (48 RATS and 546 VATS patients), and PSM resulted in 45 cases in the RATS group and 180 cases in the VATS group. The RATS patients experienced less intraoperative bleeding (60 mL [interquartile range (IQR), 50-100 mL] vs. 80 mL [IQR, 50-100 mL]; P = 0.027) and a shorter postoperative hospital stay (4 days [IQR, 3-5 days] vs. 5 days [IQR, 4-6 days]; P = 0.041) than the VATS patients. The two surgical approaches were comparable concerning other perioperative outcomes and postoperative complications (20.00% vs. 26.11%; P = 0.396). Additionally, during a median follow-up period of 66 months, RATS and VATS achieved comparable 5-year overall survival (90.48% vs. 87.93%; P = 0.891), recurrence-free survival (83.37% vs. 83.18%; P = 0.782), and cumulative incidence of death. Further subgroup comparison also demonstrated comparable long-term outcomes between the two approaches. Finally, multivariate Cox analysis indicated that the surgical approach was not independently correlated with long-term outcomes.

CONCLUSIONS

The RATS approach shortened the postoperative hospital stay, reduced intraoperative bleeding by a statistically notable but clinically insignificant amount, and achieved long-term outcomes comparable with VATS in performing sub-lobectomy for octogenarians with early-stage small NSCLC.

CT imaging features of lung ground-glass nodule patients with upgraded intraoperative frozen pathology

PURPOSE

Intraoperative frozen section pathology (FS) is widely used to guide surgical strategies while the accuracy is relatively low. Underestimating the pathological condition may result in inadequate surgical margins. This study aims to identify CT imaging features related to upgraded FS and develop a predictive model.

METHODS

Collected data from 860 patients who underwent lung surgery from January to December 2019. We analyzed the consistency rate of FS and categorized the patients into three groups: Group 1 (n = 360) had both FS and Formalin-fixed Paraffin-embedded section (FP) as non-invasive adenocarcinoma (IAC); Group 2 (n = 128) had FS as non-IAC but FP as IAC; Group 3 (n = 372) had both FS and FP as IAC. Clinical baseline characteristics were compared and propensity score adjustment was used to mitigate the effects of these characteristics. Univariate analyses identified imaging features with inter-group differences. A multivariate analysis was conducted to screen independent risk factors for FS upgrade, after which a logistic regression prediction model was established and a receiver operating characteristic (ROC) curve was plotted.

RESULTS

The consistency rate of FS with FP was 84.19%. 26.67% of the patients with non-IAC FS diagnosis were upgraded to IAC. The predictive model's Area Under Curve (AUC) is 0.785. Consolidation tumor ratio (CTR) ≤ 0.5 and smaller nodule diameter are associated with the underestimation of IAC in FS.

CONCLUSION

CT imaging has the capacity to effectively detect patients at risk of upstaging during FS.

Prognostic Factors of Non-Predominant-Lepidic Lung Adenocarcinoma Presenting as Ground Glass Opacity: Results of a Multicenter Study

This study aims to define the clinicopathological characteristics and prognosis of non-predominant lepidic invasive adenocarcinoma presenting as Ground Glass Opacity (GGO) nodules. The goal is to assess statistical relationships between histology, tumor size, location, and the incidence of relapse and lymph node dissemination. A retrospective multicenter study was conducted, including patients with GGO observed on CT scans between 2003 and 2021. Anamnestic, radiological, and histological data, as well as SUV values, lymphatic and vascular invasion, pathological stage, resection type, and adjuvant treatment, were analyzed. The primary endpoints were to evaluate prognostic factors for death and recurrence using Cox regression analysis. All 388 patients, including 277 with non-predominant lepidic invasive adenocarcinoma and 161 with lepidic adenocarcinoma, underwent curative anatomical resection. Non-predominant lepidic invasive adenocarcinoma demonstrated a worse prognosis than lepidic adenocarcinoma (p = 0.001). Independent prognostic factors for death and recurrence included lymph node involvement (p = 0.002) and vascular and lymphatic invasion (p < 0.001). In conclusion, non-predominant lepidic invasive adenocarcinoma and lymphatic and vascular invasion are prognostic factors for death and recurrence in GGO patients. Results suggest adjuvant treatment in the case of pN1-N2 disease, emphasizing the necessity of lymphadenectomy (sampling or systematic) for accurate staging and subsequent therapeutic procedures.

The value of CT shape quantification in predicting pathological classification of lung adenocarcinoma

OBJECTIVE

To evaluate whether quantification of lung GGN shape is useful in predicting pathological categorization of lung adenocarcinoma and guiding the clinic.

METHODS

98 patients with primary lung adenocarcinoma were pathologically confirmed and CT was performed preoperatively, and all lesions were pathologically ≤ 30 mm in size. On CT images, we measured the maximum area of the lesion's cross-section (MA). The longest diameter of the tumor (LD) was marked with points A and B, and the perpendicular diameter (PD) was marked with points C and D, which was the longest diameter perpendicular to AB. and D, which was the longest diameter perpendicular to AB. We took angles A and B as big angle A (BiA) and small angle A (SmA). We measured the MA, LD, and PD, and for analysis we derived the LD/PD ratio and the BiA/SmA ratio. The data were analysed using the chi-square test, t-test, ROC analysis, and binary logistic regression analysis.

RESULTS

Precursor glandular lesions (PGL) and microinvasive adenocarcinoma (MIA) were distinguished from invasive adenocarcinoma (IAC) by the BiA/SmA ratio and LD, two independent factors (p = 0.007, p = 0.018). Lung adenocarcinoma pathological categorization was indicated by the BiA/SmA ratio of 1.35 and the LD of 11.56 mm with sensitivity of 81.36% and 71.79%, respectively; specificity of 71.79% and 74.36%, respectively; and AUC of 0.8357 (95% CI: 0.7558-0.9157, p < 0.001), 0.8666 (95% CI: 0.7866-0.9465, p < 0.001), respectively. In predicting the pathological categorization of lung adenocarcinoma, the area under the ROC curve of the BiA/SmA ratio combined with LD was 0.9231 (95% CI: 0.8700-0.9762, p < 0.001), with a sensitivity of 81.36% and a specificity of 89.74%.

CONCLUSIONS

Quantification of lung GGN morphology by the BiA/SmA ratio combined with LD could be helpful in predicting pathological classification of lung adenocarcinoma.

Interpretable CT radiomics model for invasiveness prediction in patients with ground-glass nodules

AIM

To evaluate the performance of an interpretable computed tomography (CT) radiomic model in predicting the invasiveness of ground-glass nodules (GGNs).

MATERIALS AND METHODS

The study was conducted retrospectively from 1 August 2017 to 1 August 2022, at three different centres. Two hundred and thirty patients with GGNs were enrolled at centre I as a training cohort. Centres II (n=157) and III (n=156) formed two external validation cohorts. Radiomics features extracted based on CT were reduced by a coarse-fine feature screening strategy. A radiomic model was developed through the use of the LASSO (least absolute shrinkage and selection operator) and XGBoost algorithms. Then, a radiological model was established through multivariate logistic regression analysis. Finally, the interpretability of the model was explored using SHapley Additive exPlanations (SHAP).

RESULTS

The radiomic XGBoost model outperformed the radiomic logistic model and radiological model in assessing the invasiveness of GGNs. The area under the curve (AUC) values for the radiomic XGBoost model were 0.885 (95% confidence interval [CI] 0.836-0.923), 0.853 (95% CI 0.790-0.906), and 0.838 (95% CI 0.773-0.902) in the training and the two external validation cohorts, respectively. The SHAP method allowed for both a quantitative and visual representation of how decisions were made using a given model for each individual patient. This can provide a deeper understanding of the decision-making mechanisms within the model and the factors that contribute to its prediction effectiveness.

CONCLUSIONS

The present interpretable CT radiomics model has the potential to preoperatively evaluate the invasiveness of GGNs. Furthermore, it can provide personalised, image-based clinical-decision support.

Clinical anatomy of pulmonary connections in young people

OBJECTIVE

Aim: To study the clinical anatomy of the pulmonary ligaments of young people.

PATIENTS AND METHODS

Materials and Methods: The study was carried out when performing 28 autopsies of young people aged 25 to 44 years. Methods of dissection of chest organocomplexes, macro-microscopy, morphometry and planimetry, and statistical processing were used. The shape and topography of the pulmonary ligaments was assessed, their area, the localization of lymph nodes was examined.

RESULTS

Results: The pulmonary ligament is an anatomical formation, which is formed as a result of a combination of leaves of the mediastinal pleura, which, covering the surfaces of the roots of the lungs, descend towards the diaphragm and are located between the mediastinal organs and the lungs. Pulmonary connections on both sides have a few edges: the inner, outer and lower free. The pulmonary ligaments with lower free edges do not pass to the diaphragmatic surface of the pleura, but only with inner ones, which are located on the right along the esophagus, and on the left along the aorta. Pulmonary ligaments on both sides pass into the mediastinal part of the pleura, covering the pericardium.

CONCLUSION

Conclusions: There are individual differences between the shape and size of the right and left pulmonary ligaments in males and females. There is no significant difference between the sizes of the right and left pulmonary ligaments, but such dimensions as: the width, the angle of inclination and the ratio of their lower free edge to the lower edge of the lungs are not found in all cases.

Potential Role of Intrapulmonary Concomitant Lesions in Differentiating Non-Neoplastic and Neoplastic Ground Glass Nodules

Purpose

To determine the value of intrapulmonary concomitant lesions in differentiating non-neoplastic and neoplastic ground-glass nodules (GGNs).

Patients and Methods

From January 2014 to March 2022, 395 and 583 patients with confirmed non-neoplastic and neoplastic GGNs were retrospectively enrolled. Their clinical and chest CT data were evaluated. The CT features of target GGNs and intrapulmonary concomitant lesions in these two groups were analyzed and compared, and the role of intrapulmonary concomitant lesions in improving differentiation was evaluated.

Results

The intrapulmonary concomitant lesions were more common in patients with non-neoplastic GGNs than in those with neoplastic ones (87.88% vs 82.18%, P = 0.015). Specifically, patients with non-neoplastic GGNs had a higher incidence of multiple solid nodules (SNs), patchy ground-glass opacity/consolidation, and fibrosis/calcification in any lung fields (each P < 0.05). Logistic regression analysis indicated that patients < 44 years old, diameter < 7.35 mm, irregular shape, and coarse margin or ill-defined boundary for target GGN, pleural thickening, and concomitant SNs in the same lobe and fibrosis or calcification in any lung field were independent indicators for predicting non-neoplastic GGNs. The AUC of the model for predicting non-neoplastic GGNs increased from 0.894 to 0.926 (sensitivity, 83.10%; specificity, 87.10%) after including the concomitant lesions in the patients' clinical characteristics and CT features of target GGNs (P < 0.0001).

Conclusion

Besides the patients' clinical characteristics and CT features of target GGNs, the concomitant multiple SNs in the same lobe and fibrosis/calcification in any lung field should be considered in further differentiating non-neoplastic and neoplastic GGNs.

Using CT imaging features to predict visceral pleural invasion of non-small-cell lung cancer

AIM

To examine the diagnostic performance of different models based on computed tomography (CT) imaging features in differentiating the invasiveness of non-small-cell lung cancer (NSCLC) with multiple pleural contact types.

MATERIALS AND METHODS

A total of 1,573 patients with NSCLC (tumour size ≤3 cm) were included retrospectively. The clinical and pathological data and preoperative imaging features of these patients were investigated and their relationships with visceral pleural invasion (VPI) were compared statistically. Multivariate logistic regression was used to eliminate confounding factors and establish different predictive models.

RESULTS

By univariate analysis and multivariable adjustment, surgical history, tumour marker (TM), number of pleural tags, length of solid contact and obstructive inflammation were identified as independent risk predictors of pleural invasiveness (p=0.014, 0.003, <0.001, <0.001, and 0.017, respectively). In the training group, comparison of the diagnostic efficacy between the combined model including these five independent predictors and the image feature model involving the latter three imaging predictors were as follows: sensitivity of 88.9% versus 77% and specificity of 73.5% versus 84.1%, with AUC of 0.868 (95% CI: 0.848-0.886) versus 0.862 (95% CI: 0.842-0.880; p=0.377). In the validation group, the sensitivity and specificity of these two models were as follow: the combined model, 93.5% and 74.3%, the imaging feature model, 77.4% and 81.3%, and their areas under the curve (AUCs) were both 0.884 (95% CI: 0.842-0.919). The best cut-off value of length of solid contact was 7.5 mm (sensitivity 68.9%, specificity 75.5%).

CONCLUSIONS

The image feature model showed great potential in predicting pleural invasiveness, and had comparable diagnostic efficacy compared with the combined model containing clinical data.

Quality of life after lung cancer surgery: sublobar resection versus lobectomy

BACKGROUND

This study aimed to compare the postoperative quality of life (PQOL) between non-small-cell lung cancer (NSCLC) patients who underwent video-assisted thoracoscopic sublobar resection (subsegment, segment, or wedge) and lobectomy. Meanwhile, we developed a PQOL scale for patients with NSCLC after optimization.

METHODS

Developing and evaluating the postoperative quality-of-life scale of non-small-cell lung cancer (NSCLC-PQOL) followed by the international principles for developing quality-of-life scale. Therefore, we used the NSCLC-PQOL scale to evaluate the PQOL of patients who underwent different surgeries.

RESULTS

The overall PQOL of patients who underwent video-assisted thoracoscopic lobectomy and sublobar resection gradually worsened from discharge to 3 months postoperatively and progressively improved from three to 6 months postoperatively. And the sublobar resection group showed better PQOL in chest tightness, breath shortness, breathlessness, cough and expectoration than the lobectomy group, and the differences were statistically significant (P < 0.05). The final version of the NSCLC-PQOL contained three dimensions: "signs-symptoms", "psychological and psychiatric", and "social-life" dimensions.

CONCLUSIONS

The sublobar resection group showed better PQOL in "chest tightness", "breath shortness", "breathlessness", "cough", and "expectoration" than the lobectomy group. Twenty-two items formed a well-behaved PQOL scale after being validated satisfactorily. The scale was a suitable rating tool for evaluating the NSCLC-PQOL of patients.

TRIAL REGISTRATION

As this study was a retrospective study and not a clinical trial, we did not register this study in the Chinese Clinical Trial Registry.

Evaluation of pain levels treated by the distal end of the hook-wire positioning needle: A randomized controlled study

BACKGROUND

Severe pain can be expected among adult patients undergoing hook-wire CT-guided localization of pulmonary nodules. We compared varying pain degrees between two different treatment techniques.

METHODS

Data from 100 patients who underwent hook-wire puncture localization under preoperative CT between May 2022 and October 2022 were prospectively reviewed. Using the random number table method, the patients were assigned to an observation and control group in a 1:1 ratio. In the observation group (n = 50), the external part of the hook-wire positioning needle was cut off; in the control group (n = 50), the external portion of the needle was bent. Static pain scores were measured using the visual analog scale (VAS) at 30 min, 1, and 2 h post localization for patients.

RESULTS

No significant differences were present between the two groups in terms of patient age, sex, nodule size, and nodule location. The observation group had lower VAS scores at 30 min (2.57 ± 1.38 vs. 3.51 ± 1.87 p = 0.005), 1 h (2.43 ± 1.14 vs. 3.33 ± 1.76 p = 0.003), and 2 h (2.41 ± 1.12 vs. 3.17 ± 1.74 p = 0.011) after localization. Moreover, the pain level did not gradually worsen in either group. Both groups had a 100% localization success rate. There was no statistically significant difference (p = 0.431) in the localized complication incidences between the two groups.

CONCLUSIONS

We found both approaches for handling the hook-wire extending outside the chest to be safe and effective. However, cutting off the hook-wire extending outside the chest is associated with lesser pain. Moreover, pain severity does not worsen with time after localization.

Radiologic Identification of Pathologic Tumor Invasion in Patients With Lung Adenocarcinoma

Importance

It is currently unclear whether high-resolution computed tomography can preoperatively identify pathologic tumor invasion for ground-glass opacity lung adenocarcinoma.

Objectives

To evaluate the diagnostic value of high-resolution computed tomography for identifying pathologic tumor invasion for ground-glass opacity featured lung tumors.

Design, Setting, and Participants

This prospective, multicenter diagnostic study enrolled patients with suspicious malignant ground-glass opacity nodules less than or equal to 30 mm from November 2019 to July 2021. Thoracic high-resolution computed tomography was performed, and pathologic tumor invasion (invasive adenocarcinoma vs adenocarcinoma in situ or minimally invasive adenocarcinoma) was estimated before surgery. Pathologic nonadenocarcinoma, benign diseases, or those without surgery were excluded from analyses; 673 patients were recruited, and 620 patients were included in the analysis. Statistical analysis was performed from October 2021 to January 2022.

Exposure

Patients were grouped according to pathologic tumor invasion.

Main Outcomes and Measures

Primary end point was diagnostic yield for pathologic tumor invasion. Secondary end point was diagnostic value of radiologic parameters.

Results

Among 620 patients (442 [71.3%] female; mean [SD] age, 53.5 [12.0] years) with 622 nodules, 287 (46.1%) pure ground-glass opacity nodules and 335 (53.9%) part-solid nodules were analyzed. The median (range) size of nodules was 12.1 (3.8-30.0) mm; 47 adenocarcinomas in situ, 342 minimally invasive adenocarcinomas, and 233 invasive adenocarcinomas were confirmed. Overall, diagnostic accuracy was 83.0% (516 of 622; 95% CI, 79.8%-85.8%), diagnostic sensitivity was 82.4% (192 of 233; 95% CI, 76.9%-87.1%), and diagnostic specificity was 83.3% (324 of 389; 95% CI, 79.2%-86.9%). For tumors less than or equal to 10 mm, 3.6% (8 of 224) were diagnosed as invasive adenocarcinomas. The diagnostic accuracy was 96.0% (215 of 224; 95% CI, 92.5%-98.1%), diagnostic specificity was 97.2% (210 of 216; 95% CI, 94.1%-99.0%); for tumors greater than 20 mm, 6.9% (6 of 87) were diagnosed as adenocarcinomas in situ or minimally invasive adenocarcinomas. The diagnostic accuracy was 93.1% (81 of 87; 95% CI, 85.6%-97.4%) and diagnostic sensitivity was 97.5% (79 of 81; 95% CI, 91.4%-99.7%). For tumors between 10 to 20 mm, the diagnostic accuracy was 70.7% (220 of 311; 95% CI, 65.3%-75.7%), diagnostic sensitivity was 75.0% (108 of 144; 95% CI, 67.1%-81.8%), and diagnostic specificity was 67.1% (112 of 167; 95% CI, 59.4%-74.1%). Tumor size (odds ratio, 1.28; 95% CI, 1.18-1.39) and solid component size (odds ratio, 1.31; 95% CI, 1.22-1.42) could each independently serve as identifiers of pathologic invasive adenocarcinoma. When the cutoff value of solid component size was 6 mm, the diagnostic sensitivity was 84.6% (95% CI, 78.8%-89.4%) and specificity was 82.9% (95% CI, 75.6%-88.7%).

Conclusions and relevance

In this diagnostic study, radiologic analysis showed good performance in identifying pathologic tumor invasion for ground-glass opacity-featured lung adenocarcinoma, especially for tumors less than or equal to 10 mm and greater than 20 mm; these results suggest that a solid component size of 6 mm could be clinically applied to distinguish pathologic tumor invasion.

Application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection

PURPOSE

To explore the application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection.

METHODS

The clinical data of 90 patients who had small pulmonary nodules and received thoracoscopic sublobar resection during the period from September 2021 to October 2022 in the Department of Thoracic Surgery, Juxian People's Hospital, Shandong Province, were retrospectively analyzed.

RESULTS

The diameters of 95 pulmonary nodules in the 90 patients in the whole group ranged from 0.40 to 1.24 cm, and their distances from the visceral pleura ranged from 0.51 to 2.15 cm. In these patients, percutaneous lung puncture was successfully performed under local anesthesia, through which coils were implanted in the nodules and medical adhesive was injected around the nodules, with a success rate of localization of 100%. Localization complications included 10 cases of asymptomatic pneumothorax, 9 cases of intrapulmonary hemorrhage, 5 cases of severe pain, and 1 case of pleural reaction, all of which required no special treatment. After preoperative localization, the success rate of resection of pulmonary nodules was 100%, and sufficient surgical margins were obtained.

CONCLUSION

CT-guided localization using a coil in combination with medical adhesive is a safe, effective, and simple localization method that can meet the requirements of thoracic surgeons for intraoperative localization; for small pulmonary nodules, especially those small-sized and deep-located ground-glass nodules containing few solid mass, this method has important clinical application value, which is a preoperative localization technique worthy of wide application in clinical practice.

Single-cell RNA sequencing reveals distinct tumor microenvironment of ground glass nodules and solid nodules in lung adenocarcinoma

Introduction: Lung adenocarcinoma (LUAD) is the most prevalent lung cancer. LUAD presents as ground glass nodules (GGN) and solid nodules (SN) in imaging studies. GGN is an early type of LUAD with good prognosis. However, SN exhibits a more malignant behavior than GGN, including worse pathological staging and tumor prognosis. The mechanism leading to the different malignancy levels of GGN and SN remains elusive. Methods: Three patients with GGN and three patients with SN diagnosed with early LUAD were enrolled. The tumor samples were digested to a single-cell suspension and analyzed using 10× Genomic Single-cell ribonucleic acid sequences (scRNA-seq) techniques. Results: A total of 15,902 cells were obtained and classified into nine major types. The tumor microenvironment (TME) was subsequently described in detail. ScRNA-seq revealed that ribosome-related pathways and cell adhesion played similar but distinct roles in the two groups. SN also had more active cell proliferation, enriched cell cycle regulatory pathways, and severe inflammatory responses. Conclusion: We observed changes in the cellular composition and transcriptomic profile of GGN and SN. The study improved the understanding of the underlying mechanisms of lung carcinogenesis and contributed to lung cancer prevention and treatment.

Correlation Between Intranodular Vessels and Tumor Invasiveness of Lung Adenocarcinoma Presenting as Ground-glass Nodules: A Deep Learning 3-Dimensional Reconstruction Algorithm-based Quantitative Analysis on Noncontrast Computed Tomography Images

PURPOSE

To evaluate the role of quantitative features of intranodular vessels based on deep learning in distinguishing pulmonary adenocarcinoma invasiveness.

MATERIALS AND METHODS

This retrospective study included 512 confirmed ground-glass nodules from 474 patients with 241 precursor glandular lesions (PGL), 126 minimally invasive adenocarcinomas (MIA), and 145 invasive adenocarcinomas (IAC). The pulmonary blood vessels were reconstructed on noncontrast computed tomography images using deep learning-based region-segmentation and region-growing techniques. The presence of intranodular vessels was evaluated based on the automatic calculation of vessel prevalence, vascular categories, and vessel volume percentage. Further comparisons were made between different invasive groups by the Mantel-Haenszel χ 2 test, χ 2 test, and analysis of variance.

RESULTS

The detection rate of intranodular vessels in PGL (33.2%) was significantly lower than that of MIA (46.8%, P = 0.011) and IAC (55.2%, P < 0.001), while the vascular categories were similar (all P > 0.05). Vascular changes were more common in IAC and MIA than in PGL, mainly in increased vessel volume percentage (12.4 ± 19.0% vs. 6.3 ± 13.1% vs. 3.9 ± 9.4%, P < 0.001). The average intranodular artery and vein volume percentage of IAC (7.5 ± 14.0% and 5.0 ± 10.1%) was higher than that of PGL (2.1 ± 6.9% and 1.7 ± 5.8%) and MIA (3.2 ± 9.1% and 3.1 ± 8.7%), with statistical significance (all P < 0.05).

CONCLUSIONS

The quantitative analysis of intranodular vessels on noncontrast computed tomography images demonstrated that the ground-glass nodules with increased internal vessel prevalence and volume percentages had higher possibility of tumor invasiveness.

Advances in diagnosis and prediction for aggression of pure solid T1 lung cancer

A growing number of early-stage lung cancers presenting as malignant pulmonary nodules have been diagnosed because of the increased adoption of low-dose spiral computed tomography. But pure solid T1 lung cancer with ≤3 cm in the greatest dimension is not always at an early stage, despite its small size. This type of cancer can be highly aggressive and is associated with pathological involvement, metastasis, postoperative relapse, and even death. However, it is easily misdiagnosed or delay diagnosed in clinics and thus poses a serious threat to human health. The percentage of nodal or extrathoracic metastases has been reported to be >20% in T1 lung cancer. As such, understanding and identifying the aggressive characteristics of pure solid T1 lung cancer is crucial for prevention, diagnosis, and therapeutic strategies, and beneficial to improving the prognosis. With the widespread of lung cancer screening, these highly invasive pure solid T1 lung cancer will become the main advanced lung cancer in future. However, there is limited information regarding precision medicine on how to identify these "early-stage" aggressive lung cancers. To provide clinicians with new insights into early recognition and intervention of the highly invasive pure solid T1 lung cancer, this review summarizes its clinical characteristics, imaging, pathology, gene alterations, immune microenvironment, multi-omics, and current techniques for diagnosis and prediction.