Faculty Bibliography

Objective: The International Early Lung Cancer Action Program (I-ELCAP) is a collaborative group designed to demonstrate reduction in lung cancer mortality by using low-dose computed tomography (CT) screening to identify early stage disease in high-risk individuals. While the majority of patients with stage I non-small cell lung cancer (NSCLC) were treated with surgical resection, some patients were treated with definitive radiation. This study explores the characteristics and outcomes of this population. Methods: Clinical stage I NSCLC patients in North America treated by radiotherapy or surgery alone were identified in the I-ELCAP database. All had undergone low-dose CT screening according to a common protocol from 1993 to 2009. Patient characteristics and lung cancer-specific Kaplan-Meier survival rates were compared. Results: From 32,521 baseline and 34,394 annual repeat screenings, 455 cases of clinical stage I NSCLC were identified. Only 12 of these patients (2.6 %) underwent definitive radiation with median follow-up of 5.3 years. These 12 patients when compared with the 376 patients treated by surgery alone were older (72 vs. 67 years, p = 0.01), had more pre-existing comorbidities (1.5 vs. 1.0, p = 0.005), but had no significant differences in male gender, pack-years of smoking, emphysema, or tumor size. The median radiation dose was 6,150 cGy. There was no difference in lung cancer-specific survival between surgery and radiation (92 vs. 90 %, p = 0.78). Conclusion: This is the first study to show outcomes of definitive radiation for stage I NSCLC in a screened population. Although only used in a small number of cases, there is no difference in lung cancer-specific survival when comparing definitive radiation to surgical resection. 2014 Springer-Verlag Berlin Heidelberg

In this review, we focus on the radiologic, clinical, and pathologic aspects primarily of solitary subsolid pulmonary nodules. Particular emphasis will be placed on the pathologic classification and correlative computed tomography (CT) features of adenocarcinoma of the lung. The capabilities of fluorodeoxyglucose positron emission tomography-CT and histologic sampling techniques, including CT-guided biopsy, endoscopic-guided biopsy, and surgical resection, are discussed. Finally, recently proposed management guidelines by the Fleischner Society and the American College of Chest Physicians are reviewed.

In this second part of a two-part series, we describe an algorithmic approach to the diagnosis of the solitary pulmonary nodule (SPN). An essential aspect of the evaluation of SPN is determining the pretest probability of malignancy, taking into account the significant medical history and social habits of the individual patient, as well as morphologic characteristics of the nodule. Because pretest probability plays an important role in determining the next step in the evaluation, we describe various methods the physician may use to make this determination. Subsequently, we outline a simple yet comprehensive algorithm for diagnosing a SPN, with distinct pathways for the solid and subsolid SPN.

BACKGROUND: Lung cancer is by far the major cause of cancer deaths largely because in the majority of patients it is at an advanced stage at the time it is discovered, when curative treatment is no longer feasible. This article examines the data regarding the ability of screening to decrease the number of lung cancer deaths. METHODS: A systematic review was conducted of controlled studies that address the effectiveness of methods of screening for lung cancer. RESULTS: Several large randomized controlled trials (RCTs), including a recent one, have demonstrated that screening for lung cancer using a chest radiograph does not reduce the number of deaths from lung cancer. One large RCT involving low-dose CT (LDCT) screening demonstrated a significant reduction in lung cancer deaths, with few harms to individuals at elevated risk when done in the context of a structured program of selection, screening, evaluation, and management of the relatively high number of benign abnormalities. Whether other RCTs involving LDCT screening are consistent is unclear because data are limited or not yet mature. CONCLUSIONS: Screening is a complex interplay of selection (a population with sufficient risk and few serious comorbidities), the value of the screening test, the interval between screening tests, the availability of effective treatment, the risk of complications or harms as a result of screening, and the degree with which the screened individuals comply with screening and treatment recommendations. Screening with LDCT of appropriate individuals in the context of a structured process is associated with a significant reduction in the number of lung cancer deaths in the screened population. Given the complex interplay of factors inherent in screening, many questions remain on how to effectively implement screening on a broader scale.

The solitary pulmonary nodule (SPN) is frequently encountered on chest imaging and poses an important diagnostic challenge to clinicians. The differential diagnosis is broad, ranging from benign granulomata and infectious processes to malignancy. Important concepts in the evaluation of SPNs include the definition, morphologic characteristics via appropriate imaging modalities, and the calculation of pretest probability of malignancy. Morphologic differentiation of SPN into solid or subsolid types is important in the choice of follow-up and further management. In this first part of a two-part series, we describe the morphologic characteristics and various imaging modalities available to further characterize SPN. In Part 2, we will describe the determination of pretest probability of malignancy and an algorithmic approach to the diagnosis of SPN.