Screening for lung cancer revisited and the role of sputum cytology and fluorescence bronchoscopy in a high-risk group

2020 Innovation-Based Optimism for Lung Cancer Outcomes

Lung cancer is the leading cause of cancer death in both males and females in the U.S. and worldwide. Owing to advances in prevention, screening/early detection, and therapy, lung cancer mortality rates are decreasing and survival rates are increasing. These innovations are based on scientific discoveries in imaging, diagnostics, genomics, molecular therapy, and immunotherapy. Outcomes have improved in all histologies and stages. This review provides information on the clinical implications of these innovations that are practical for the practicing physicians, especially oncologists of all specialities who diagnose and treat patients with lung cancer. IMPLICATIONS FOR PRACTICE: Lung cancer survival rates have improved because of new prevention, screening, and therapy methods. This work provides a review of current standards for each of these areas, including targeted and immunotherapies. Treatment recommendations are provided for all stages of lung cancer.

Automatic spectral imaging protocol selection combined with iterative reconstruction can enhance image quality and decrease radiation and contrast dosage in abdominal CT angiography

PURPOSE

To investigate the effect of automatic spectral imaging protocol selection (ASIS) and adaptive statistical iterative reconstruction (ASIR) technology in reducing radiation and contrast dosage.

METHODS

Sixty-four patients were randomly divided into two groups for abdominal computed tomography (CT): the experiment group with ASIS plus 50% ASIR and the control with 120 kVp voltage.

RESULTS

The CT dose-index volume decreased by 23.68 and 23.57% and the dose-length product dropped by 25.59 and 18.45% in the arterial and portal venous phases, respectively, in the experiment than control group. The contrast dose was reduced by 16.86% in the experiment group. In the 55 keV + 50% ASIR group, the arterial contrast-to-noise ratio and scores were significantly (P < 0.05) higher than in the control group in the arterial phase while the portal contrast-to-noise ratio and scores were not significantly different between the two groups (P > 0.05).

CONCLUSION

The ASIS technique plus 50% ASIR can enhance image quality of the abdominal structures while decreasing the radiation and contrast dosage compared with the conventional scan mode.

Potential molecular approaches for the early diagnosis of lung cancer (review)

Lung cancer is the leading cause of mortality from cancer among men and women worldwide. More individuals die each year of lung cancer than of colon, breast and prostate cancer combined. Despite new diagnostic techniques, the overall 5-year survival rate remains at approximately 15% and the majority of patients still present with advanced disease. Therefore, lung cancer is the most lethal cancer at present. Diagnosing and treating cancer at its early stages, ideally during the precancerous stages, could increase the 5-year survival rate by 3-4‑fold, with the possibility of cure. To date, no screening method has been shown to decrease the disease-specific mortality rate. This review describes issues related to early lung cancer screening and their rationale, the management of primary cancers detected by screening and the different approaches that have been tested for cancer screening; these include imaging techniques, bronchoscopies and molecular screening, such as analysis of epigenomics using different noninvasive or invasive sources, such as blood, sputum, bronchoscopic samples and exhaled breath.

Potential of computer-aided diagnosis to improve CT lung cancer screening

The development of low-dose spiral computed tomography (CT) has rekindled hope that effective lung cancer screening might yet be found. Screening is justified when there is evidence that it will extend lives at reasonable cost and acceptable levels of risk. A screening test should detect all extant cancers while avoiding unnecessary workups. Thus optimal screening modalities have both high sensitivity and specificity. Due to the present state of technology, radiologists must opt to increase sensitivity and rely on follow-up diagnostic procedures to rule out the incurred false positives. There is evidence in published reports that computer-aided diagnosis technology may help radiologists alter the benefit-cost calculus of CT sensitivity and specificity in lung cancer screening protocols. This review will provide insight into the current discussion of the effectiveness of lung cancer screening and assesses the potential of state-of-the-art computer-aided design developments.

Fluorescence-assisted cytological testing (FACT): Ex Vivo viral method for enhancing detection of rare cancer cells in body fluids

Cytological analysis of body fluids is currently used for detecting cancer. The objective of this study was to determine if the herpes virus carrying an enhanced green fluorescent protein (EGFP) could detect rare cancer cells in body fluids against millions of normal cells. Human cancer cells suspended with normal murine cells were infected with NV1066 at a multiplicity of infection (MOI) of 0.5 and 1.0 for 18 h. Fluorescent microscopy and flow cytometry were used for EGFP detection of cancer cells. EGFP-expressing cells were confirmed as cancer cells with specific markers by immunohistochemistry staining. Limits of detection of cancer cells in body fluid were measured by serial dilutions. Applicability of technique was confirmed with samples from patients with malignant pleural effusions. NV1066 expressed EGFP in 111 human cancer cell lines detected by fluorescent microscopy at an MOI of 0.5. NV1066 selectively infected cancer cells and spared normal cells as confirmed by immunohistochemistry. Sensitivity of detecting fluorescent green cells was 92% (confidence interval [CI] 83% to 97%) at a ratio of 1 cancer cell to 1 million normal cells. EGFP-positive cells were detected by fluorescent microscopy in patients' malignant pleural effusion samples. Our data show proof of the concept that NV1066-induced EGFP expression allows detection of a single cancer cell against a background of 1 million normal cells. This method was demonstrated to be a reliable screening tool for human cancer cells in a suspension of normal murine cells as well as clinical specimens of malignant pleural effusions.

[Protocols for lung cancer screening: Limitations, and consequences]

Lung cancer is the leading cause of cancer mortality in the world. Its incidence is still rising, especially in women, and its prognosis is poor with a 5-year survival of 15%. Since 1970, several studies on lung cancer screening have been conducted using different investigations. Screening by chest X-ray and sputum cytology does not lead to improved survival in lung cancer. Screening by CT scan has the same outcome but the detection of lung cancer, especially in its early stages, is better than with chest X-ray and sputum cytology. Fluorescence endoscopy is a valuable examination for the detection of pre-invasive bronchial lesions. Genetic studies and identification of circulating tumour cells are being developed. All these examinations are very stressful for the patients. Only few trials have studied the consequences of lung cancer screening on the quality of life. In this review, we analyze the various screening strategies, their impact on quality of life and health and their adverse effects.

Fluorescence in situ hybridization in diagnostic cytology

Fluorescence in situ hybridization (FISH) is a technique that uses fluorescently labeled DNA probes to detect chromosomal alterations in cells. FISH can detect various types of cytogenetic alterations including aneusomy (ie, abnormalities of chromosome copy number), duplication, amplification, deletion, and translocation. Because tumor cells generally contain chromosomal alterations, FISH is able to detect cells that have chromosomal abnormalities consistent with neoplasia in exfoliative and aspiration cytology specimens. This review will discuss the utility of FISH for the detection of bladder, lung, pancreatobiliary, and esophageal carcinoma in cytologic specimens.

Contrast-enhanced ultrasound (CEUS) for the study of peripheral lung lesions: a preliminary study

The use of contrast-enhanced ultrasound (CEUS) for the study of peripheral lung lesions has never been systematically investigated. We evaluated the CEUS patterns of 98 peripheral lung lesions before performing US-guided fine-needle biopsies (FNB). The examinations were done with an Esaote Technos MPX scanner in the harmonic mode with a mechanical index of 0.04 or less. Contrast enhancement was achieved with a 4.8 mL bolus of SonoVue (Bracco) administered via an antecubital vein. All FNBs performed under CEUS guidance were adequate for pathologic diagnosis. Seventy-eight lesions were malignant: 33 (41.9%) were adenocarcinomas, 29 (36.5%) were squamous-cell carcinomas, 13 (17.6%) were undifferentiated large-cell carcinomas and the remaining three (4.1%) were small-cell carcinomas. All presented intralesional enhancement consistent with tumor neovascularization. In some cases, there were unenhanced areas consistent with zones of necrosis and these areas were avoided during FNB. The other 20 lesions were benign (four lipomas, two fibrous lung tumor, two noncaseous granulomas, six abscesses, one rheumatoid nodule, one histiocytosis X, one chondroid hamartoma, one sclerosing hemangioma, two sarcoid nodules) and none presented intralesional enhancement. This initial and admittedly limited experience suggests that CEUS may provide diagnostically useful information on peripheral lung lesions and increase the diagnostic yield of transthoracic FNB by reducing the risk of inadequate tissue sampling.

A Comparison of Cytology and Fluorescence in Situ Hybridization for the Detection of Lung Cancer in Bronchoscopic Specimens

STUDY OBJECTIVES

To determine the relative sensitivity and specificity of cytology and fluorescence in situ hybridization (FISH) for the detection of lung cancer in bronchoscopically obtained specimens.

DESIGN

Cytology and FISH were performed on brushing and washing specimens obtained from patients undergoing bronchoscopy for suspected lung cancer. FISH utilized the LAVysion probe set (Abbott Molecular; Des Plaines, IL), which contains locus-specific probes to 5p15, 7p12 (EGFR), 8q24 (C-MYC), and a centromeric probe to chromosome 6.

SETTING

Single-center, academic, tertiary medical center.

PARTICIPANTS

One hundred thirty-seven patients referred for bronchoscopy for suspicion of lung cancer.

INTERVENTIONS

Cytology and FISH were performed on bronchoscopic brushings and washings.

MEASUREMENTS AND RESULTS

One hundred thirty-seven patients undergoing bronchoscopy had pathology, FISH, and cytology results. FISH and cytology were performed on 123 washing and 78 brushing specimens. Sensitivities of FISH and cytology were 71% and 51% (p = 0.007), respectively, for brushing specimens, and 49% and 44% (p = 0.541) for washing specimens. When FISH and cytology results were combined, sensitivities were 75% and 61%, respectively, for brushing and washing specimens, which was significantly better (p < 0.001) than cytology alone. Specificities of FISH and cytology for patients with negative findings at the time of initial bronchoscopy were 83% and 100% (p = 0.125), respectively, for brushing specimens, and 95% and 100% (p = 0.500) for washing specimens.

CONCLUSIONS

These findings show that FISH is significantly more sensitive than conventional cytology for detecting lung cancer in bronchial brushing specimens; when combined with cytology, FISH can improve the diagnostic sensitivity of detecting malignancy in bronchial brushing and washing specimens.

Screening for lung cancer: a review

PURPOSE OF REVIEW

After the disappointing results of lung cancer screening trials conducted in the 1960s to the 1980s, a renewed interest in lung cancer screening emerged in the 1990s with the development of new technologies such as low-dose spiral CT. The literature regarding screening with biomarkers and CT continues to expand rapidly.

RECENT FINDINGS

Although the specificity of CT screening is relatively poor, the sensitivity for the detection of early-stage cancers, particularly adenocarcinoma, is considerably superior to that of chest radiography used in older screening trials. The results of uncontrolled cohort studies of CT screening are promising, but such studies are susceptible to screening biases such as overdiagnosis.

SUMMARY

There is insufficient evidence to support widespread screening in current practice. However, randomized controlled trials are now being conducted to determine whether improved detection by CT will translate into reduced lung cancer mortality. Alternative approaches to secondary prevention such as screening with biomarkers, autofluorescence bronchoscopy, and chemoprevention hold great promise for the future but await further development and evaluation in prospective trials.

Multi-target interphase fluorescence in situ hybridization assay increases sensitivity of sputum cytology as a predictor of lung cancer

Survival rates for lung cancer are low because patients have disseminated disease at diagnosis; therefore tests for early diagnosis are highly desirable. This pilot study investigated occurrence of chromosomal aneusomy in sputum from a 33 case-control cohort matched on age, gender, and date of sample collection. Subjects had chronic obstructive pulmonary disease and > or = 30 pack-years of tobacco use, and aneusomy was tested using a multi-target DNA FISH assay (LAVysion, Abbott/Vysis). In specimens collected within 12 months of lung cancer diagnosis, abnormality was more frequent among the 18 cases (41%) than the 17 controls (6%; P = 0.04). Aneusomy had no significant association with cytologic atypia, which might indicate that molecular and morphological changes could be independent markers of tumorigenesis. Combining both tests, abnormality was found in 83% of the cases and 20% of the controls (P = 0.0004) suggesting that FISH may improve the sensitivity of cytologic atypia as a predictor of lung cancer.

Sputum examination for early detection of lung cancer

Conventional sputum cytology can be used for the detection of lung cancer, but has shown a low yield in prospective screening trials. This review focuses on the technical aspects relevant to the outcome of DNA and image analysis in sputum. Published articles are discussed in the light of the technical background. Recent developments in DNA analysis and nuclear image analysis show a clear potential to improve or refine diagnosis beyond that achieved with conventional sputum cytology examination. The challenge for future studies in DNA and nuclear analysis of sputum is to ensure high levels of quality control and to confirm these initial encouraging results.

[Phonation bronchoscopy]

BACKGROUND

Fluorescence bronchoscopy is one of the methods of the early detection of lung cancer that involves the large airways. The method is based on the detection of the altered autofluorescence of malignantly transformed tissue, and confirmed by biopsy and histopathologic examination.

METHOD

Fluorescence bronchoscopy was performed in 18 patients, mean age of 51.2 years (male n = 12, female n = 6) due to the suspected lung cancer. Fluorescence bronchoscopy was performed using the Xillix LIFE-Lung System, Vancouver, Canada. After conventional white-light bronchoscopy, the tracheobronchial tree was illuminated by blue light (442 nm) using helium-cadmium laser, and the results of autofluorescence were classified into three classes. Normal mucosa was of green fluorescence (Class I), abnormal mucosa was red or dark brown fluorescence (Class II and II), which was the indication for performing biopsy.

RESULTS

Normal endoscopy findings were established in 15 patients by conventional bronchoscopy. In the same group, by fluorescence bronchoscopy, Class I of fluorescence (normal finding) was found in 9 patients, while Class II changes occurred in 6 patients. Histopathologic analysis of bronchial mucosa with Class II changes was performed detecting planocellular carcinoma in situ in one patient. Tumor-like changes were detected in 3 patients by conventional bronchoscopy, and were determined as Class III changes by fluorescence bronchoscopy. By the biopsy of these chages carcinoma was documented in 2 patients while in one patient metaplasia of epithelium and granulation tissue around aspirated foreign body was detected.

CONCLUSION

Fluorescence bronchoscopy is one of the methods for detecting metaplasia, carcinoma in situ and cancerous changes of bronchial epithelium in the large airways. However, the high rate of falsely positive findings represents a limitation of this method.

Cytokines in patients with lung cancer

Lung cancer is one of the most common malignant diseases and is amongst the leading causes of death. Cell-mediated immune response and cytokines could play an important role in antitumour immunity. The aim of the study was to evaluate the cytokines', tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta) and IL-6, releasing capacity in patients with lung carcinoma and benign lung disease. A group of 41 patients were tested for the production of TNF-alpha, IL-1beta and IL-6 in bronchoalveolar lavage (BAL) and blood. The levels of cytokines in the lung cancer patients were: (1) in BAL - IL-6, 173 +/- 85 pg/ml; TNF-alpha, 170 +/- 116 pg/ml; and IL-1beta, 473 +/- 440 pg/ml; (2) in the blood - IL-6, 197 +/- 53 pg/ml; TNF-alpha, 311 +/- 202 pg/ml; and IL-1beta, 915 +/- 239 pg/ml. Alveolar macrophages of the patients with a lung cancer secreted significantly more cytokines, IL-6 (P = 0.0004) and IL-1beta (P = 0.0047), than alveolar macrophages of the patients with a nonmalignant lung cancer. However, significantly lower levels of cytokine production by the BAL cells were found in patients with small cell lung cancer. This production decreased further in phase IV of nonsmall cell lung cancer.

Characteristics of female smokers attending a lung cancer screening program: a pilot study with implications for program development

Anticipating the development of lung cancer early detection programs, we examined the: (1) feasibility of a lung cancer early detection program; (2) characteristics of enrollees (e.g. motivation to quit smoking); (3) correlates of enrollee motivation to quit smoking; and (4) rates of smoking cessation following screening. Brief surveys were completed before and after screening, which involved sputum cytology, chest X-ray, bronchoscopy, spiral CT, and a meeting with an oncologist to discuss smoking cessation. Of the 168 eligible women who were heavy smokers recruited via newspaper and cancer center advertisements, 55 agreed to undergo screening. Enrollees showed low-to-moderate levels of quit motivation and high levels of nicotine addiction; enrollees were interested in a range of smoking cessation treatments; 20% of enrollees exhibited clinical-levels of emotional distress; 64% of enrollees reported low levels of self-efficacy (i.e. self-confidence) to quit; 24% of enrollees reported low levels of quitting pros and 25% reported high levels of quitting cons; 31% of enrollees showed high levels of fatalistic beliefs about cancer; and all enrollees recognized their elevated lung cancer risk. Greater motivation to quit smoking was related to: greater age, lower nicotine addiction, fewer health symptoms, and higher quitting self-efficacy and quitting pros. Finally, 16% of enrollees quit smoking after screening. Overall, many women eligible for screening refused to undergo comprehensive screening that included bronchoscopy and spiral CT. Screening may represent an opportunity for quitting smoking, although more intensive smoking cessation interventions that target nicotine addiction and self-efficacy may be needed to maximize the health benefits of an early detection program.

Cancer screening in the elderly

A number of disease- and patient-specific factors need to be taken into account when cancer screening is considered in an older patient. They include the impact of aging on the cancer's biology and screening test performance, the patient's remaining years of life and candidacy for further diagnostic testing and available therapies, potential barriers to compliance with screening, and the patient's values and preferences about the screening.