Persisting new nodules in incidence rounds of the NELSON CT lung cancer screening study

Postoperative CT surveillance in the evaluation of local recurrence after sub-lobar resection of neoplastic lesions of the lung

OBJECTIVE

As indications for sub-lobar resections increase, it will become more important to identify risk factors for postsurgical recurrence. We investigated retrospectively the association between local recurrence after sub-lobar resection of neoplastic lung lesions and pre- and post-operative CT imaging and pathologic features.

MATERIALS AND METHODS

We reviewed retrospectively neoplastic lung lesions with postoperative chest CT surveillance of sub-lobar resections in 2006-2016. We defined "suspicious" findings as nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line and/or progression and explored their association with local recurrence. Primary lung cancer stage, tumoral invasion of lymphatics, visceral pleura or large vessels, bronchial and vascular margin distance were also assessed.

RESULTS

Our study group included 45 cases of sub-lobar resection took for either primary (n = 37) or metastatic (n = 8) lung tumors. Local recurrence was observed in 16 of those patients. New nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line on surveillance CT was significantly associated with local recurrence (p = 0.037). Additionally, solid nodule (p = 0.005), age at surgery ≤60 years (p = 0.006), two or more sites of invasion (p < 0.0001) and poor histologic differentiation (p = 0.0001) were also significantly associated with local tumor recurrence. Of 16 patients with surveillance post-surgical PET-CT, 15 had elevated FDG uptake.

CONCLUSION

The postoperative changes along the suture line should follow a predictable time course demonstrating a pattern of stability, thinning or resolution on CT surveillance. New or increasing postoperative nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line requires close diagnostic work-up. Surgical pathology characteristics added prognostic value on postoperative recurrence surveillance.

Advances in proteomics methods for the analysis of exhaled breath condensate

The analysis of exhaled breath condensate (EBC) demonstrates a promising avenue of minimally invasive biopsies for diagnostics. EBC is obtained by cooling exhaled air and collecting the condensation to be utilized for downstream analysis using various analytical methods. The aqueous phase of breath contains a large variety of miscible small compounds including polar electrolytes, amino acids, cytokines, chemokines, peptides, small proteins, metabolites, nucleic acids, and lipids/eicosanoids-however, these analytes are typically present at minuscule levels in EBC, posing a considerable technical challenge. Along with recent improvements in devices for breath collection, the sensitivity and resolution of liquid chromatography coupled to online mass spectrometry-based proteomics has attained subfemtomole sensitivity, vastly enhancing the quality of EBC sample analysis. As a result, proteomics analysis of EBC has been expanding the field of breath biomarker research. We present an au courant overview of the achievements in proteomics of EBC, the advancement of EBC collection devices, and the current and future applications for EBC biomarker analysis.

EarlyCDT Lung blood test for risk classification of solid pulmonary nodules: systematic review and economic evaluation

BACKGROUND

EarlyCDT Lung (Oncimmune Holdings plc, Nottingham, UK) is a blood test to assess malignancy risk in people with solid pulmonary nodules. It measures the presence of seven lung cancer-associated autoantibodies. Elevated levels of these autoantibodies may indicate malignant disease. The results of the test might be used to modify the risk of malignancy estimated by existing risk calculators, including the Brock and Herder models.

OBJECTIVES

The objectives were to determine the diagnostic accuracy, clinical effectiveness and cost-effectiveness of EarlyCDT Lung; and to develop a conceptual model and identify evidence requirements for a robust cost-effectiveness analysis.

DATA SOURCES

MEDLINE (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE), EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, EconLit, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database ( NHS EED ) and the international Health Technology Assessment database were searched on 8 March 2021.

REVIEW METHODS

A systematic review was performed of evidence on EarlyCDT Lung, including diagnostic accuracy, clinical effectiveness and cost-effectiveness. Study quality was assessed with the quality assessment of diagnostic accuracy studies-2 tool. Evidence on other components of the pulmonary nodule diagnostic pathway (computerised tomography surveillance, Brock risk, Herder risk, positron emission tomography-computerised tomography and biopsy) was also reviewed. When feasible, bivariate meta-analyses of diagnostic accuracy were performed. Clinical outcomes were synthesised narratively. A simulation study investigated the clinical impact of using EarlyCDT Lung. Additional reviews of cost-effectiveness studies evaluated (1) other diagnostic strategies for lung cancer and (2) screening approaches for lung cancer. A conceptual model was developed.

RESULTS

A total of 47 clinical publications on EarlyCDT Lung were identified, but only five cohorts (695 patients) reported diagnostic accuracy data on patients with pulmonary nodules. All cohorts were small or at high risk of bias. EarlyCDT Lung on its own was found to have poor diagnostic accuracy, with a summary sensitivity of 20.2% (95% confidence interval 10.5% to 35.5%) and specificity of 92.2% (95% confidence interval 86.2% to 95.8%). This sensitivity was substantially lower than that estimated by the manufacturer (41.3%). No evidence on the clinical impact of EarlyCDT Lung was identified. The simulation study suggested that EarlyCDT Lung might potentially have some benefit when considering intermediate risk nodules (10-70% risk) after Herder risk analysis. Two cost-effectiveness studies on EarlyCDT Lung for pulmonary nodules were identified; none was considered suitable to inform the current decision problem. The conceptualisation process identified three core components for a future cost-effectiveness assessment of EarlyCDT Lung: (1) the features of the subpopulations and relevant heterogeneity, (2) the way EarlyCDT Lung test results affect subsequent clinical management decisions and (3) how changes in these decisions can affect outcomes. All reviewed studies linked earlier diagnosis to stage progression and stage shift to final outcomes, but evidence on these components was sparse.

LIMITATIONS

The evidence on EarlyCDT Lung among patients with pulmonary nodules was very limited, preventing meta-analyses and economic analyses.

CONCLUSIONS

The evidence on EarlyCDT Lung among patients with pulmonary nodules is insufficient to draw any firm conclusions as to its diagnostic accuracy or clinical or economic value.

FUTURE WORK

Prospective cohort studies, in which EarlyCDT Lung is used among patients with identified pulmonary nodules, are required to support a future assessment of the clinical and economic value of this test. Studies should investigate the diagnostic accuracy and clinical impact of EarlyCDT Lung in combination with Brock and Herder risk assessments. A well-designed cost-effectiveness study is also required, integrating emerging relevant evidence with the recommendations in this report.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42021242248.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 49. See the NIHR Journals Library website for further project information.

Defining growth in small pulmonary nodules using volumetry: results from a "coffee-break" CT study and implications for current nodule management guidelines

Objectives

An increase in lung nodule volume on serial CT may represent true growth or measurement variation. In nodule guidelines, a 25% increase in nodule volume is frequently used to determine that growth has occurred; this is based on previous same-day, test–retest (coffee-break) studies examining metastatic nodules. Whether results from prior studies apply to small non-metastatic nodules is unknown. This study aimed to establish the interscan variability in the volumetric measurements of small-sized non-metastatic nodules.

Methods

Institutional review board approval was obtained for this study. Between March 2019 and January 2021, 45 adults (25 males; mean age 65 years, range 37–84 years) with previously identified pulmonary nodules (30–150 mm³) requiring surveillance, without a known primary tumour, underwent two same-day CT scans. Non-calcified solid nodules were measured using commercial volumetry software, and interscan variability of volume measurements was assessed using a Bland–Altman method and limits of agreement.

Results

One hundred nodules (range 28–170 mm³; mean 81.1 mm³) were analysed. The lower and upper limits of agreement for the absolute volume difference between the two scans were − 14.2 mm³ and 12.0 mm³ respectively (mean difference 1.09 mm³, range − 33–12 mm³). The lower and upper limits of agreement for relative volume difference were − 16.4% and 14.6% respectively (mean difference 0.90%, range − 24.1–32.8%).

Conclusions

The interscan volume variability in this cohort of small non-metastatic nodules was smaller than that in previous studies involving lung metastases of varying sizes. An increase of 15% in nodule volume on sequential CT may represent true growth, and closer surveillance of these nodules may be warranted.

Key Points

• In current pulmonary nodule management guidelines, a threshold of 25% increase in volume is required to determine that true growth of a pulmonary nodule has occurred.

• This test–retest (coffee break) study has demonstrated that a smaller threshold of 15% increase in volume may represent true growth in small non-metastatic nodules.

• Closer surveillance of some small nodules growing 15–25% over a short interval may be appropriate.

Intergroupe francophone de cancérologie thoracique, Société de pneumologie de langue française, and Société d'imagerie thoracique statement paper on lung cancer screening

Following the American National Lung Screening Trial results in 2011 a consortium of French experts met to edit a statement. Recent results of other randomized trials gave the opportunity for our group to meet again in order to edit updated guidelines. After literature review, we provide here a new update on lung cancer screening in France. Notably, in accordance with all international guidelines, the experts renew their recommendation in favor of individual screening for lung cancer in France as per the conditions laid out in this document. In addition, the experts recommend the very rapid organization and funding of prospective studies, which, if conclusive, will enable the deployment of lung cancer screening organized at the national level.

Deep convolutional neural networks for multiplanar lung nodule detection: Improvement in small nodule identification

PURPOSE

Early detection of lung cancer is of importance since it can increase patients' chances of survival. To detect nodules accurately during screening, radiologists would commonly take the axial, coronal, and sagittal planes into account, rather than solely the axial plane in clinical evaluation. Inspired by clinical work, the paper aims to develop an accurate deep learning framework for nodule detection by a combination of multiple planes.

METHODS

The nodule detection system is designed in two stages, multiplanar nodule candidate detection, multiscale false positive (FP) reduction. At the first stage, a deeply supervised encoder-decoder network is trained by axial, coronal, and sagittal slices for the candidate detection task. All possible nodule candidates from the three different planes are merged. To further refine results, a three-dimensional multiscale dense convolutional neural network that extracts multiscale contextual information is applied to remove non-nodules. In the public LIDC-IDRI dataset, 888 computed tomography scans with 1186 nodules accepted by at least three of four radiologists are selected to train and evaluate our proposed system via a tenfold cross-validation scheme. The free-response receiver operating characteristic curve is used for performance assessment.

RESULTS

The proposed system achieves a sensitivity of 94.2% with 1.0 FP/scan and a sensitivity of 96.0% with 2.0 FPs/scan. Although it is difficult to detect small nodules (i.e., <6 mm), our designed CAD system reaches a sensitivity of 93.4% (95.0%) of these small nodules at an overall FP rate of 1.0 (2.0) FPs/scan. At the nodule candidate detection stage, results show that the system with a multiplanar method is capable to detect more nodules compared to using a single plane.

CONCLUSION

Our approach achieves good performance not only for small nodules but also for large lesions on this dataset. This demonstrates the effectiveness of our developed CAD system for lung nodule detection.

Deep learning-based pulmonary nodule detection: Effect of slab thickness in maximum intensity projections at the nodule candidate detection stage

BACKGROUND AND OBJECTIVE

To investigate the effect of the slab thickness in maximum intensity projections (MIPs) on the candidate detection performance of a deep learning-based computer-aided detection (DL-CAD) system for pulmonary nodule detection in CT scans.

METHODS

The public LUNA16 dataset includes 888 CT scans with 1186 nodules annotated by four radiologists. From those scans, MIP images were reconstructed with slab thicknesses of 5 to 50 mm (at 5 mm intervals) and 3 to 13 mm (at 2 mm intervals). The architecture in the nodule candidate detection part of the DL-CAD system was trained separately using MIP images with various slab thicknesses. Based on ten-fold cross-validation, the sensitivity and the F₂ score were determined to evaluate the performance of using each slab thickness at the nodule candidate detection stage. The free-response receiver operating characteristic (FROC) curve was used to assess the performance of the whole DL-CAD system that took the results combined from 16 MIP slab thickness settings.

RESULTS

At the nodule candidate detection stage, the combination of results from 16 MIP slab thickness settings showed a high sensitivity of 98.0% with 46 false positives (FPs) per scan. Regarding a single MIP slab thickness of 10 mm, the highest sensitivity of 90.0% with 8 FPs/scan was reached before false positive reduction. The sensitivity increased (82.8% to 90.0%) for slab thickness of 1 to 10 mm and decreased (88.7% to 76.6%) for slab thickness of 15-50 mm. The number of FPs was decreasing with increasing slab thickness, but was stable at 5 FPs/scan at a slab thickness of 30 mm or more. After false positive reduction, the DL-CAD system, utilizing 16 MIP slab thickness settings, had the sensitivity of 94.4% with 1 FP/scan.

CONCLUSIONS

The utilization of multi-MIP images could improve the performance at the nodule candidate detection stage, even for the whole DL-CAD system. For a single slab thickness of 10 mm, the highest sensitivity for pulmonary nodule detection was reached at the nodule candidate detection stage, similar to the slab thickness usually applied by radiologists.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

Recommendations for Implementing Lung Cancer Screening with Low-Dose Computed Tomography in Europe

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39-61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the "Initiative for European Lung Screening (IELS)"-a large international group of physicians and other experts concerned with lung cancer-agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

The growth feature and its diagnostic value for benign and malignant pulmonary nodules met in routine clinical practice

Background

Growth rate is an independent risk factor for lung cancer in screened pulmonary nodules. This study aimed to clarify growth characteristics of pulmonary nodules in routine clinical practice and examine whether volume doubling time (VDT) can predict the malignancy of these nodules.

Methods

We retrospectively enrolled patients with 5-30-mm-sized pulmonary nodules that had been surgically resected after a follow-up of at least 3 months. Two follow-up computed tomography (CT) images with similar thickness and long interval were obtained. Then, three-dimensional (3D) manual segmentation for all nodules was performed on two follow-up CT scans. Subsequently, VDT was calculated for nodules with a change in volume of at least 25%.

Results

Overall, 305 pulmonary nodules in 305 patients (men, 36.7%; median age, 57) were included. The mean increased diameter, mass, and volume of benign (n=86) and malignant (n=219) nodules were 0.09 vs. 2.37 mm, 0.10 vs. 0.66 g, and 32.74 vs. 1,871.28 mm3, respectively (P<0.05). In total, 24 of 86 benign nodules (28%, 18 grew and 6 shrank) and 121 of 219 malignant nodules (55%, 114 grew and 7 shrank) changed over time. The median VDTs of growing benign and malignant nodules were 389 and 526 days, respectively, (P=0.18), and the area under the receiver operating characteristic (ROC) curve was 0.67 (0.55-0.78), with a sensitivity and specificity of 69% and 58%, respectively. The median VDT for growing nodules was 339 days for inflammatory pseudotumors, 226 days for granulomas, 640 days for benign tumors, 1,541 days for enlarged lymph nodes, 762 days for adenocarcinoma in situ, 954 days for microinvasive adenocarcinoma, 534 days for invasive adenocarcinoma, and 118 days for squamous cell carcinoma.

Conclusions

In routine clinical practice, many malignant nodules could grow slowly or even remain stable over time. Regarding growing nodules, the diagnostic value of VDT was limited.

Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial

BACKGROUND

There are limited data from randomized trials regarding whether volume-based, low-dose computed tomographic (CT) screening can reduce lung-cancer mortality among male former and current smokers.

METHODS

A total of 13,195 men (primary analysis) and 2594 women (subgroup analyses) between the ages of 50 and 74 were randomly assigned to undergo CT screening at T0 (baseline), year 1, year 3, and year 5.5 or no screening. We obtained data on cancer diagnosis and the date and cause of death through linkages with national registries in the Netherlands and Belgium, and a review committee confirmed lung cancer as the cause of death when possible. A minimum follow-up of 10 years until December 31, 2015, was completed for all participants.

RESULTS

Among men, the average adherence to CT screening was 90.0%. On average, 9.2% of the screened participants underwent at least one additional CT scan (initially indeterminate). The overall referral rate for suspicious nodules was 2.1%. At 10 years of follow-up, the incidence of lung cancer was 5.58 cases per 1000 person-years in the screening group and 4.91 cases per 1000 person-years in the control group; lung-cancer mortality was 2.50 deaths per 1000 person-years and 3.30 deaths per 1000 person-years, respectively. The cumulative rate ratio for death from lung cancer at 10 years was 0.76 (95% confidence interval [CI], 0.61 to 0.94; P = 0.01) in the screening group as compared with the control group, similar to the values at years 8 and 9. Among women, the rate ratio was 0.67 (95% CI, 0.38 to 1.14) at 10 years of follow-up, with values of 0.41 to 0.52 in years 7 through 9.

CONCLUSIONS

In this trial involving high-risk persons, lung-cancer mortality was significantly lower among those who underwent volume CT screening than among those who underwent no screening. There were low rates of follow-up procedures for results suggestive of lung cancer. (Funded by the Netherlands Organization of Health Research and Development and others; NELSON Netherlands Trial Register number, NL580.).

Implementation of lung cancer screening in Europe: challenges and potential solutions: summary of a multidisciplinary roundtable discussion

Recent randomised trials on screening with low-dose CT have shown important reductions in lung cancer (LC) mortality and have triggered international efforts to implement LC screening. Detection rates of stage I LC with volume CT approaching 70% have been demonstrated. In April 2019 ‘ESMO Open – Cancer Horizons’ convened a roundtable discussion on the challenges and potential solutions regarding the implementation of LC screening in Europe. The expert panel reviewed the current evidence for LC screening with low-dose CT and discussed the next steps, which are covered in this article. The panel concluded that national health policy groups in Europe should start to implement CT screening as adequate evidence is available. It was recognised that there are opportunities to improve the screening process through ‘Implementation Research Programmes’.

Implementation of lung cancer screening at the national level: Polish example

In Poland the national demonstration lung cancer screening program is about to be started in 2019. We share our concerns and discussing most important topics to be resolved while preparing such a program. The decisions made are virtually based on available scientific data and the results of two randomized controlled trials but also on the personal experience gained during the lung cancer screening studies performed in Poland. The most important and comprehensive guidelines and statements, both European and American, have been searched to find an optimal solution adjusted to the Polish national circumstances-as we assume that should be done in each country implementing such a program.