Challenges of Implementing Lung Cancer Screening in a Developing Country: Results of the Second Brazilian Early Lung Cancer Screening Trial (BRELT2)

PURPOSE

This paper aims to present the results of a series of several Brazilian institutions that have been carrying out lung cancer screening (LCS).

MATERIALS AND METHODS

This is a retrospective, cohort study, with follow-up of individuals of both sexes, with a heavy smoking history, who participated in LCS programs between December 2013 and January 2021 in six Brazilian institutions located in the states of São Paulo, Rio Grande do Sul, and Bahia.

RESULTS

Three thousand four hundred seventy individuals were included, of which 59.8% were male (n = 2,074) and 50.6% were current smokers (n = 1,758), with 60.7 years (standard deviation 8.8 years). Lung-RADS 4 was observed in 233 (6.7%) patients. Biopsy was indicated by minimally invasive methods in 122 patients (3.5%). Two patients who demonstrated false-negative biopsies and lung cancer were diagnosed in follow-up. Diagnosis of lung cancer was observed in 74 patients (prevalence rate of 2.1%), with 52 (70.3%) in stage I or II. Granulomatous disease was found in 20 patients. There were no statistical differences in the incidence of lung cancer, biopsies, granulomatous disease, and Lung-RADS 4 nodules between public and private patients.

CONCLUSION

There are still many challenges and obstacles in the implementation of LCS in developing countries; however, our multi-institutional data were possible to obtain satisfactory results in these scenarios and to achieve similar results to the main international studies. Granulomatous diseases did not increase the number of lung biopsies. The authors hope that it could stimulate the creation of organized screening programs in regions still endemic for tuberculosis and other granulomatous diseases.

Challenges still remaining for lung cancer screening. Multi institutional BRELT2 reported good results in Brazil

Communication in radiology: evaluation of terminology and TNM descriptor use at a cancer center

Objective

The purpose of our study was to evaluate the transmission of information from radiologists to physicians, focusing on the level of certainty and the use of imaging descriptors from the tumor-node-metastasis (TNM) staging system.

Materials and Methods

Radiologists (n = 56) and referring physicians (n = 50) participated in this questionnaire-based, singlecenter study, conducted between March 20, 2020, and January 21, 2021. Participants were presented with terms commonly used by the radiologists at the institution and were asked to order them hierarchically in terms of the level of certainty they communicate regarding a diagnosis, using a scale ranging from 1 (most contrary to) to 10 (most favoring). They then assessed TNM system descriptors and their interpretation. Student's t-tests and the kappa statistic were used in order to compare the rankings of the terms of certainty. Items related to T and N staging were analyzed by Fisher's exact test. The confidence level was set to 97% (p < 0.03).

Results

Although overall agreement among the radiologists and referring physicians on term ranking was poor (kappa = 0.10- 0.35), the mean and median values for the two groups were similar. Most of the radiologists and referring physicians (67% and 86%, respectively) approved of the proposal to establish a standard lexicon. Such a lexicon, based on the participant responses, was developed and graphically represented. Regarding the TNM system descriptors, there were significant differences between the two groups in the reporting of lymph node numbers, of features indicating capsular rupture, and of vessel wall irregularities, as well as in the preference for clear descriptions of vascular involvement.

Conclusion

Our findings indicate that ineffective communication and differences in report interpretation between radiologists and referring physicians are still prevalent in the fields of radiology and oncology. Efforts to gain a better understanding of those impediments might improve the objectivity of reporting and the quality of care.

Comparison of hormonal receptor expression and HER2 status between circulating tumor cells and breast cancer metastases

OBJECTIVES

Breast cancer (BC) is the most common neoplasm in women. Biopsy of metastatic lesions is recommended to confirm estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status as there are discrepancies in these patterns between primary tumors and metastases in up to 40% of the cases. Circulating tumor cells (CTCs) are related to BC outcomes and could potentially be an alternative to the invasive procedures of metastasis rebiopsy. ISET® technology is not currently employed to detect CTCs in patients with BC. Emerging data support that the characterization of CTC protein expression can refine its prognostic value. Transforming growth factor (TGF)-β plays a role in BC progression and invasiveness. Thus, in this study, we aimed to compare ER, PR, and HER2 expression in primary tumors, CTCs, and metastases and evaluate TGF-β type 1 receptor (TGF-β RI) expression in CTCs as prognostic factor for progression free survival (PFS) and overall survival (OS).

METHODS

This prospective study was conducted at the A.C. Camargo Cancer Center, Brazil. Blood samples were processed in ISET® (Isolation by SizE of Tumors, Rarecells, France) before computed tomography-guided biopsy of suspected metastatic lesions. Protein expression levels in CTCs were compared to those in primary tumors/metastases (medical records).

RESULTS

Of the 39 patients initially included, 27 underwent both biopsies of metastases and blood collection and were considered for analysis. The concordance rates for ER, PR, and HER2 expression between primary tumors and metastases were high. No loss of HER2 expression at any metastasis site and retention of the same pattern of protein expression in all triple-negative (TN) tumors (92.5%, 81.5% and 96.2% respectively) (p<0.0001) was observed. When metastases/CTCs were classified as TN/non-TN, CTCs showed high specificity (93%), accuracy (84.2%), and negative predictive value (88%). The median OS of patients without TGF-β RI expression in CTCs was 42.6 versus 20.8 months for TGF-β RI expression-positive ones (p>0.05).

CONCLUSION

The role of CTCs detected by ISET has not yet been established in BC. Here, we suggest that this methodology may be useful to evaluate metastasis in non-TN cases as well as TGF-β RI expression in CTCs, which may impact patient survival. Due to sample limitations, future studies must focus on specific BC subtypes and an expansion of the cohort.

Computed tomography-guided percutaneous biopsy of head and neck masses: techniques, outcomes, and complications

Objective

To assess the technique, efficacy, and safety of computed tomography (CT)-guided percutaneous biopsies of head and neck masses.

Materials and Methods

This was a retrospective, single-center study of CT-guided percutaneous core-needle biopsies of head and neck masses. For the analysis of diagnostic accuracy, biopsy results were compared with the final diagnosis, which was determined by histological examination and clinical follow-up.

Results

We evaluated 74 biopsies performed in 68 patients. The mean age of the patients was 55.6 years. Most of the lesions (79.7%) were located in the suprahyoid region, and the maximum diameter ranged from 11 mm to 128 mm. The most common approaches were paramaxillary (in 32.4%), retromandibular (in 21.6%), and periorbital (in 14.9%). Five patients (6.8%) developed minor complications. The presence of a complication did not show a statistically significant association with any clinical, radiological, or procedure-related factor. Sufficient material for histological analysis was obtained in all procedures. Thirty-eight biopsies (51.4%) yielded a histological diagnosis of malignancy. There was a false-negative result in three cases (8.3%), and there were no false-positive results. The procedure had a sensitivity of 92.7%, a specificity of 100%, and an accuracy of 96.0%.

Conclusion

Our results demonstrate that CT-guided percutaneous core-needle biopsy of head and neck lesions is a safe, effective procedure for obtaining biological material for histological analysis.

Tomographic score (RAD-Covid Score) to assess the clinical severity of the novel coronavirus infection

OBJECTIVES

The severity of pulmonary Covid-19 infection can be assessed by the pattern and extent of parenchymal involvement observed in computed tomography (CT), and it is important to standardize the analysis through objective, practical, and reproducible systems. We propose a method for stratifying the radiological severity of pulmonary disease, the Radiological Severity Score (RAD-Covid Score), in Covid-19 patients by quantifying infiltrate in chest CT, including assessment of its accuracy in predicting disease severity.

METHODS

This retrospective, single-center study analyzed patients with a confirmed diagnosis of Covid-19 infection by real-time reverse-transcriptase polymerase chain reaction, who underwent chest CT at hospital admission between March 6 and April 6, 2020. CT scans were classified as positive, negative, or equivocal, and a radiological severity score (RAD-Covid Score) was assigned. Clinical severity was also assessed upon hospital admission.

RESULTS

658 patients were included. Agreement beyond chance (kappa statistic) for the RAD-Covid Score was almost perfect among observers (0.833), with an overall agreement of 89.5%. The RAD-Covid Score was positively correlated with clinical severity and death, i.e., the higher the RAD-Covid Score, the greater the clinical severity and mortality. This association proved independent of age and comorbidities. Accuracy of this score was 66.9%.

CONCLUSIONS

The RAD-Covid Score showed good accuracy in predicting clinical severity at hospital admission and mortality in patients with confirmed Covid-19 infection and was an independent predictor of severity.

Factors associated with subcentimeter pulmonary nodule outcomes followed with computed tomography imaging in oncology patients

•

PNs with irregular, lobuled or spiculated margins exhibited faster growth than PNs with regular, smooth margins.

•

Malignancy was significantly associated with male gender, a colorectal cancer diagnosis and advanced stage disease.

•

Oncologic patients should have an individualized CT follow-up strategy, as the rate of malignant pulmonary nodules is higher than in the general population.

Introduction

Technological advancements in computed tomography (CT) have enabled the frequent detection of small pulmonary nodules (PNs), especially in patients with an oncologic history. It is important the malignant versus benign etiology of PNs be determined. The aim of the present study was to evaluate the behavior and clinical/radiological characteristics of subcentimeter PNs detected by CT in oncologic patients.

Methods

An observational, longitudinal, retrospective and single-center study was conducted with a sample of 100 patients with a diagnosis of a primary malignant solid tumor outside of the lungs who developed indeterminate subcentimeter PNs (n = 251) detected on consecutive thoracic CT scans from 2015 to 2017. Follow-up CTs for each patients were examined in each of three periods (0–3 months, 3–6 months, and 6 months to 1 year).

Results

In our study sample, 28 patients (28 %) showed one or more signs suspicious of pulmonary metastasis, including ≥50 % PN growth, nodule growth followed by size reduction in patients undergoing chemotherapy, and the appearance of multiple nodules. The majority (56 %) of the PNs were detected during the 3–6-month follow-up CT scan. PNs with irregular, lobuled, or spiculated margins exhibited faster growth than PNs with regular, smooth margins. Malignancy of PNs was found to be significantly associated with being male, a primary colorectal cancer diagnosis, and advanced stage disease.

Conclusion

Our findings reinforce the necessity of an individualized CT follow-up strategy for patients with an oncologic history, as well as the importance of early nodule screening, with the inter-scan interval being dependent on the primary neoplasm.

Chest CT accuracy in the diagnosis of SARS-CoV-2 infection: initial experience in a cancer center

OBJECTIVE

To evaluate the accuracy of chest computed tomography (CT) in patients with suspected severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) infection at a cancer center.

MATERIALS AND METHODS

This retrospective single-center study selected 91 patients who had chest CT and real-time polymerase chain reaction (RT-PCR) test collected at the same day. CT results were classified in negative, typical, indeterminate or atypical findings. Diagnostic accuracy, sensitivity and specificity were calculated for two different scenarios: in the first, only typical findings on CT were considered positive; in the second, both typical and indeterminate findings were considered positive.

RESULTS

Mean patients' age was 58.2 years, most were male (60.4%) and had prior diagnosis of cancer (85.7%). CT showed typical findings in 28.6%, indeterminate findings in 24.2% and atypical findings in 26.4%. RT-PCR results were positive for SARS-CoV-2 in 27.5%. The sensitivity, specificity and accuracy in the first and second scenarios were respectively 64.0%, 84.8% and 79.1%, and 92.0%, 62.1% and 70.3%.

CONCLUSION

CT has a high accuracy for the diagnosis of SARS-CoV-2 infection. Different interpretation criteria can provide either high sensitivity or high specificity. CT should be integrated as a triage test in resource-constrained environments during the pandemic to assist in the optimization of PCR-tests, isolation beds and intensive care units.

Computed tomography-measured body composition: correlation with postoperative morbidity and mortality in patients with gastroesophageal cancer

Objective

To determine whether preoperative anthropometric and computed tomography (CT) measurements of body composition can predict postoperative morbidity and mortality in patients with gastric or esophageal cancer.

Materials and Methods

This was a retrospective study in which we reviewed the medical records and abdominal CT scans of patients with gastric or esophageal cancer who underwent surgery in 2015 at a cancer center. CT scans performed during routine preoperative evaluation were retrospectively assessed to measure the area of lean body mass at the level of the third lumbar vertebra, as well as the area of visceral and subcutaneous fat.

Results

Seventy patients were included in the study. The mean age was 59.9 years (range, 33-82 years), and 47 patients (67.1%) were men. The mean postoperative follow-up period was 14.9 months. Neither postoperative morbidity nor postoperative mortality correlated significantly with gender, age, the type of primary tumor, the presence of comorbidities, smoking status, body mass index, nutritional status, or visceral fat area. The survival rate was higher for patients with normal lean body mass than for those with low lean body mass (hazard ratio = 0.116; 95% confidence interval: 0.015-0.906; p = 0.040).

Conclusion

Our data suggest that lean body mass can be a relevant prognostic factor in patients with gastric or esophageal cancer, and that CT measurements should be included in the routine preoperative evaluation, because it may provide information that aids nutritional and clinical care for these patients.

Retrospective analysis of computed tomography-guided percutaneous nephrostomies in cancer patients

Objective

To establish an overview of computed tomography (CT)-guided percutaneous nephrostomy performed at a referral center for cancer, addressing the characteristics of patients submitted to this intervention, as well as the indications for it, the technical specificities of it, and its main complications.

Materials and Methods

This was a retrospective study involving a review of the electronic medical records and images of patients submitted to CT-guided percutaneous nephrostomy at a referral center for cancer between 2014 and 2016.

Results

A total of 201 procedures were evaluated. In most cases, the obstruction was caused by a malignant neoplasm. Complications occurred in 9.5% of the cases, and an additional intervention was required (typically for catheter repositioning) in 36.6%. Post-procedure complications were not found to be significantly associated with the type of previous cancer treatment, the technique used, the caliber of the drain used in the procedure, or the degree of dilatation of the collection system prior to the procedure.

Conclusion

In cancer patients, CT-guided percutaneous nephrostomy is an effective treatment, with success rates and complication rates similar to those reported in the general population.

CT-guided biopsy of breast lesions: When should it be considered?

Mammography, ultrasound, and magnetic resonance imaging (MRI) are the most commonly used modalities for interventional radiology procedures involving the breast. Computed tomography (CT) is rarely used for breast imaging yet it is able to detect breast lesions and can often provide safe and effective access to breast lesions. The aim of this study was to demonstrate situations in which CT should be considered as an alternative guidance method for the biopsy of breast lesions that are not accessible with conventional imaging modalities.

Early metabolic 18F-FDG PET/CT response of locally advanced squamous-cell carcinoma of head and neck to induction chemotherapy: A prospective pilot study

Objective

The objective of this study was to assess the clinical value of 18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) after the first cycle of induction chemotherapy (IC) in locally advanced squamous cell carcinoma of the head and neck (LASCCHN).

Methods and findings

A prospective, single-arm, single center study was performed, with patients enrolled between February 2010 and July 2013.Patients (n = 49) with stage III/IVA–B LASCCHN who underwent IC with taxanes, cisplatin, and fluorouracil were recruited. Staging procedures included loco-regional and chest imaging, endoscopic examination, and PET/CT scan. On day 14 of the first cycle, a second PET/CT scan was performed. Patients with no early increase in regional lymph node maximum ¹⁸F-FDG standard uptake value (SUV), detected using ¹⁸F-FDG PET/CT after first IC had better progression-free survival (hazard ratio (HR) = 0.18, 95%, confidence interval (CI) 0.056–0.585; p = 0.004) and overall survival (HR = 0.14, 95% CI 0.040–0.498; p = 0.002), and were considered responders. In this subgroup, patients who achieved a reduction of ≥ 45% maximum primary tumor SUV experienced improved progression-free (HR = 0.23, 95% CI 0.062–0.854; p = 0.028) and overall (HR = 0.11, 95% CI 0.013–0.96; p = 0.046) survival.

Conclusions

These results suggest a potential role for early response evaluation with PET/CT examination in patients with LASCCHN undergoing IC. Increased regional lymph node maximum SUV and insufficient decrease in primary tumor uptake predict poorer outcomes.

Computed tomography with a stomach protocol and virtual gastroscopy in the staging of gastric cancer: an initial experience

Objective

To evaluate the accuracy of multidetector computed tomography with a stomach protocol in staging of gastric cancer.

Materials and Methods

We evaluated 14 patients who underwent computed tomography in a 16-channel scanner for preoperative staging of gastric adenocarcinoma between September 2015 and December 2016. All images were analyzed by the same radiologist, who had extensive experience in abdominal cancer imaging. The sensitivity, specificity, and accuracy of the method were calculated by comparing it with the pathology result. All patients underwent partial or total gastrectomy.

Results

The mean age was 61.5 years, and 53.8% of the patients were male. The gastric lesions were classified as T1/T2 in 35.7% of the cases, as T3 in 28.5%, and as T4 in 35.7%. Eleven patients (68.7%) had suspicious (N positive) lymph nodes. The accuracy of the T1/T2, T3, T4, and lymph node staging tests was 85%, 78%, 90%, and 78%, respectively. The respective sensitivity and specificity values were 71% and 100% for T1/T2, 66% and 81% for T3, 100% and 90% for T4, and 88% and 60% for lymph nodes.

Conclusion

Multidetector computed tomography with a stomach protocol, used in conjunction with virtual gastroscopy, shows good accuracy in the tumor and lymph node staging of gastric adenocarcinoma.

Computed tomography-guided preoperative localization of musculoskeletal lesions using the ROLL technique

Objective

To describe the preoperative localization of musculoskeletal lesions with the radioguided occult lesion localization (ROLL) technique.

Materials and Methods

In all cases, computed tomography-guided injection of technetium-99m sulfur colloid was performed, directly into or near the suspicious lesion, up to 36 hours before the surgical procedure. Lesions were detected intraoperatively with a gamma probe.

Results

We report the cases of six patients submitted to radioguided surgery, including three patients with bone lesions suspicious for metastasis, two patients suspected of recurrent sarcoma, and one patient with no previous diagnosis who had a nodular lesion on the left leg. Patients tolerated the procedure well, and no complications were associated with the puncture. All marked lesions were easily identified intraoperatively and were excised with clear margins.

Conclusion

The ROLL technique was effective in the intraoperative localization of occult musculoskeletal lesions, demonstrating that it is a feasible and promising technique for the surgical exploration of selected cases.

Detection of distant metastases in patients with locally advanced breast cancer: role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography and conventional imaging with computed tomography scans

OBJECTIVE

To evaluate positron emission tomography/computed tomography (PET/CT) and conventional imaging tests for the detection of distant metastases in patients with locally advanced breast cancer.

MATERIALS AND METHODS

We included 81 patients with breast cancer who had undergone ¹⁸F-fluorodeoxyglucose (FDG) PET/CT before treatment. Conventional imaging included the following: bone scintigraphy; chest X-ray (in 14.5%) or CT (in 85.5%); and abdominal ultrasound (in 10.8%), CT (in 87.8%), or magnetic resonance imaging (in 1.4%). Histopathology and clinical/imaging follow-up served as reference.

RESULTS

Distant metastases were observed in nine patients (11.1%). On patient-based analysis, conventional imaging identified distant metastases in all 9 patients. In one patient, the initial ¹⁸F-FDG PET/CT failed to demonstrate bone metastases that was evident on bone scintigraphy. In two patients, the CT scan failed to show extra-axillary lymph node metastases that were identified on ¹⁸F-FDG PET/CT. There was no significant difference between ¹⁸F-FDG PET/CT and conventional imaging in terms of their sensitivity for the detection of distant metastases in patients with locally advanced breast cancer.

CONCLUSION

This study showed that ¹⁸F-FDG PET/CT and conventional imaging with CT scans had similar sensitivity for the diagnosis of distant metastases in patients with locally advanced breast cancer. ¹⁸F-FDG PET/CT can add information about extra-axillary lymph node involvements.

Computed tomography-guided percutaneous gastrostomy: initial experience at a cancer center

Gastrostomy is indicated for patients with conditions that do not allow adequate oral nutrition. To reduce the morbidity and costs associated with the procedure, there is a trend toward the use of percutaneous gastrostomy, guided by endoscopy, fluoroscopy, or, most recently, computed tomography. The purpose of this paper was to review the computed tomography-guided gastrostomy procedure, as well as the indications for its use and the potential complications.

Computed tomography-guided percutaneous biopsy of bone lesions: rate of diagnostic success and complications

OBJECTIVE

To determine the rates of diagnostic success and complications of computed tomography (CT)-guided percutaneous biopsy of bone lesions suspected for malignancy.

MATERIALS AND METHODS

Retrospective study including 186 cases of CT-guided percutaneous biopsies of bone lesions in the period from January, 2010 to December, 2012. All the specimens were obtained with 8-10 gauge needles. The following data were collected: demographics, previous history of malignancy, data related to the lesion, to the procedure, and to histological results.

RESULTS

Most patients were women (57%), and the mean age was 53.0 ± 16.4 years. In 139 cases (74.6%), there was diagnostic suspicion of metastasis and the most common primary tumors were breast (32.1%) and prostate (11.8%). The bones most commonly involved were spine (36.0%), hip (32.8%) and long bones (18.3%). Complications occurred in only three cases (1.6%) including bone fracture, paresthesia with functional impairment, and needle breakage requiring surgical removal. The specimens collected from 183 lesions (98.4%) were considered appropriate for diagnosis. Malignant results were more frequently found in patients who had a suspected secondary lesion and history of known malignancy (p < 0.001), and in patients who underwent PET/CT-guided procedures (p = 0.011).

CONCLUSION

CT-guided percutaneous biopsy is a safe and effective procedure for the diagnosis of suspicious bone lesions.