CT Screening for Lung Cancer: The Value of Short-term CT Follow-up

doi:10.1378/chest.129.4.1039

Chest

Volume 129, Issue 4, April 2006, Pages 1039-1042

https://doi.org/10.1378/chest.129.4.1039 Get rights and content

Background

Although CT screening for lung cancer results in a diagnosis of stage I > 80% of the time, benign noncalcified nodules are also found. We recognized that some nodules appeared to represent infectious bronchopneumonia or other inflammatory processes, as they resolved on follow-up CT, sometimes after antibiotic therapy. To determine the extent to which short-term CT radiographic follow-up might shorten the workup of nodules, we reviewed our experience with baseline and annual repeat CT screenings performed subsequent to the original Early Lung Cancer Action Project series.

Methods

The initial CT of 1,968 consecutive baseline and 2,343 annual repeat screenings performed from 1999 to 2002 was reviewed. We identified all those recommended for antibiotics on the initial CT who had a follow-up CT within 2 months and determined whether the nodule(s) resolved, decreased in size, remained unchanged, or grew. We then determined whether further follow-up resulted in a diagnosis of cancer.

Results

At baseline, among the 41 individuals who had follow-up CT within 2 months of the initial CT, 12 patients (29%) had complete or partial resolution; none of them subsequently received a diagnosis of lung cancer. On annual repeat screening, among the 39 individuals who had follow-up CT within 2 months of the initial CT, 29 patients (74%) had complete or partial resolution; none of them subsequently received a diagnosis of lung cancer. Among the 29 patients with nodules at baseline that were unchanged or grew, a total of 15 cancers were subsequently diagnosed; among the 10 patients on annual repeat scanning, there were 2 cancers.

Conclusions

In asymptomatic individuals undergoing CT screening for lung cancer, short-term follow-up CT within 2 months with or without antibiotics may circumvent the need for further evaluation in some individuals, particularly on annual repeat screening.

Section snippets

Materials and Methods

We reviewed 1,968 consecutive baseline and 2,343 annual repeat screenings conducted from 1999 to 2002 after the completion of our initial experience.¹² Minimum age for enrollment was 40 years (median age, 59 years) with a smoking history of at least 1 pack-year (median, 32 pack-years). The initial CT in all of these screenings and subsequent workup was also performed at Weill Medical College of Cornell University. All patients undergoing screening gave informed consent under institutional

Baseline Screening

Of the 41 patients who returned for follow-up CT within 2 months of the initial CT in baseline screening, 31 had nodules and 10 had patchy consolidation. Five patients (12%) had complete resolution, and seven patients (17%) had partial resolution (Table 2). Among the 10 patients with patchy consolidation, 8 patients (80%) completely or partially resolved after antibiotic therapy as compared to 4 patients (13%) of the 31 patients with nodules. Using either complete or partial resolution as the

Discussion

An important topic of research in CT screening for lung cancer is the development of strategies to either speed up or limit the evaluation of benign nodules. Early on, it was recognized that adult asymptomatic smokers without prior malignancy who had multiple nodules on the initial CT in the baseline cycle of screening probably had inflammatory parenchymal disease. Nodule consistency was also found to help distinguish benign from malignant nodules, since nonsolid and solid nodules were found to

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In recent years, there has been a significant increase in the detection rate of Ground Glass Opacity (GGO) nodules through high-resolution computed tomography (HRCT). GGO is an imaging finding that encompasses various pathological types, some of which exhibit indolent growth, while others may represent early lung cancer or remain relatively stable, not significantly impacting the surgical treatment outcome. In clinical practice, patients often experience psychological anxiety when multiple pulmonary GGO nodules are present, and they may request simultaneous resection. However, there is currently no standardized criterion for determining when multiple GGO nodules should be resected. As personalized medicine continues to advance, the treatment approach for multiple pulmonary GGO nodules needs to prioritize accuracy. High-risk factors associated with multiple pulmonary GGO nodules may necessitate surgical intervention along with mediastinal lymph node dissection or sampling. This article provides a review of the characteristics, treatment methods, and clinical experiences related to multiple pulmonary GGO nodules, offering practical insights and guidance for healthcare professionals.
Lung Cancer Screening Considerations During Respiratory Infection Outbreaks, Epidemics or Pandemics: An International Association for the Study of Lung Cancer Early Detection and Screening Committee Report
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After the results of two large, randomized trials, the global implementation of lung cancer screening is of utmost importance. However, coronavirus disease 2019 infections occurring at heightened levels during the current global pandemic and also other respiratory infections can influence scan interpretation and screening safety and uptake. Several respiratory infections can lead to lesions that mimic malignant nodules and other imaging changes suggesting malignancy, leading to an increased level of follow-up procedures or even invasive diagnostic procedures. In periods of increased rates of respiratory infections from severe acute respiratory syndrome coronavirus 2 and others, there is also a risk of transmission of these infections to the health care providers, the screenees, and patients. This became evident with the severe acute respiratory syndrome coronavirus 2 pandemic that led to a temporary global stoppage of lung cancer and other cancer screening programs. Data on the optimal management of these situations are not available. The pandemic is still ongoing and further periods of increased respiratory infections will come, in which practical guidance would be helpful.
The aims of this report were: (1) to summarize the data available for possible false-positive results owing to respiratory infections; (2) to evaluate the safety concerns for screening during times of increased respiratory infections, especially during a regional outbreak or an epidemic or pandemic event; (3) to provide guidance on these situations; and (4) to stimulate research and discussions about these scenarios.
Approach to the Subsolid Nodule
2020, Clinics in Chest Medicine
Differentiating pre- and minimally invasive from invasive adenocarcinoma using CT-features in persistent pulmonary part-solid nodules in Caucasian patients
2015, European Journal of Radiology
Citation Excerpt :
We chose 2 months as a minimal CT interval time instead of the currently recommended 3 months interval for a specific reason. Indeed, most of the studies in our cohort were done prior to the latest recommendations of 2013, and some of them were therefore spaced by only 2 months according to previous evidence [11,12]. On the basis of those criteria, 30 patients were included in the study, with a total of 31 nodules.
To retrospectively investigate the diagnostic value of pre-operative CT-features between pre/minimally invasive and invasive lesions in part-solid persistent pulmonary ground glass nodules in a Caucasian population.
Retrospective review of two pre-operative CTs for 31 nodules in 30 patients. There were 10 adenocarcinomas in situ, 1 minimally invasive adenocarcinoma, 20 invasive adenocarcinomas. We analyzed the correlation between histopathology and the following CT-features: maximal axial diameter, maximal orthogonal axial diameter, height, density, size of solid component, air bronchogram, pleural retraction, nodule mass, disappearance rate and their evolution during follow-up.
In univariate analysis, invasive adenocarcinomas had a higher maximal height, density, solid component size, mass, a lower disappearance rate and presented more often with pleural retraction (p < 0.05). After logistic regression performed with the uncorrelated parameters using a method of selection of variables, only the size of solid component remained significant, with 100% sensitivity for invasive adenocarcinoma when larger than 5 mm.
Preoperative CT-features can help differentiating in situ and minimally invasive adenocarcinomas from invasive adenocarcinomas in Caucasian patients. A solid component larger than 5 mm in diameter had 100% sensitivity for the diagnosis of invasive adenocarcinoma.
The lung reporting and data system (LU-RADS): A proposal for computed tomography screening
2014, Canadian Association of Radiologists Journal
Citation Excerpt :
A large (≥10 mm) nodule that suddenly appears between annual screening CTs must have a short volume-doubling time (<30 days) and, therefore, is more likely to be a transient nodule than an equivalent-size nodule seen on a baseline screening CT [37,38]. Data from screening research suggest that short-interval follow-up of new large nodules seen on annual screens can avoid biopsy or other workup [14,38]. This strategy for large nodules has also been evaluated on baseline scans in the Canadian arm of I-ELCAP.
Despite the positive outcome of the recent randomized trial of computed tomography (CT) screening for lung cancer, substantial implementation challenges remain, including the clear reporting of relative risk and suggested workup of screen-detected nodules. Based on current literature, we propose a 6-level Lung-Reporting and Data System (LU-RADS) that classifies screening CTs by the nodule with the highest malignancy risk. As the LU-RADS level increases, the risk of malignancy increases. The LU-RADS level is linked directly to suggested follow-up pathways. Compared with current narrative reporting, this structure should improve communication with patients and clinicians, and provide a data collection framework to facilitate screening program evaluation and radiologist training. In overview, category 1 includes CTs with no nodules and returns the subject to routine screening. Category 2 scans harbor minimal risk, including <5 mm, perifissural, or long-term stable nodules that require no further workup before the next routine screening CT. Category 3 scans contain indeterminate nodules and require CT follow up with the interval dependent on nodule size (small [5-9 mm] or large [≥10 mm] and possibly transient). Category 4 scans are suspicious and are subdivided into 4A, low risk of malignancy; 4B, likely low-grade adenocarcinoma; and 4C, likely malignant. The 4B and 4C nodules have a high likelihood of neoplasm simply based on screening CT features, even if positron emission tomography, needle biopsy, and/or bronchoscopy are negative. Category 5 nodules demonstrate frankly malignant behavior on screening CT, and category 6 scans contain tissue-proven malignancies.
En dépit des résultats positifs d’un récent essai clinique randomisé visant le dépistage du cancer du poumon par tomodensitométrie (TDM), l’instauration ou la diffusion des pratiques de dépistage continue de soulever des défis de taille, en ce qui concerne notamment la classification non équivoque du risque relatif et le bilan proposé pour évaluer les nodules décelés par dépistage. Après avoir analysé la documentation scientifique actuelle, nous avons formulé une proposition de système de données et de déclaration à six niveaux, appelée méthodologie LU-RADS (Lung-Reporting and Data System), qui permet de classifier les résultats des tomodensitométries de dépistage en fonction du nodule présentant le risque le plus élevé de cancer du poumon. Dans le cadre de la méthodologie LU-RADS, plus les résultats correspondent à un niveau élevé, plus le risque de malignité est élevé. Le niveau LU-RADS renvoie également directement à des recommandations concernant le cheminement de suivi. Ainsi, comparativement aux comptes rendus descriptifs actuels, cette méthodologie devrait améliorer la communication avec les patients et les cliniciens, et fournir un cadre de collecte de données qui facilitera l’évaluation du programme de dépistage et la formation des radiologistes. En résumé, dans le cadre de la méthodologie LU-RADS, la catégorie 1 correspond aux examens de tomodensitométrie qui ne révèlent aucun nodule et exigent simplement du patient qu’il poursuive le programme de dépistage périodique. Les résultats de catégorie 2 font état d’un risque minimal, notamment de nodules de moins de 5 mm, de nodules péri-scissuraux ou de nodules stables à long terme qui n’exigent aucune autre mesure avant la tenue de la prochaine tomodensitométrie de dépistage périodique. Les résultats de catégorie 3 révèlent des nodules de nature indéterminée. Une tomodensitométrie de suivi doit alors être réalisée, dans un intervalle qui varie selon la taille du nodule (selon qu’il s’agit d’un petit nodule de 5 à 9 mm ou d’un gros nodule de ≥ 10 mm et possiblement transitoire). Pour leur part, les résultats des examens tomodensitométriques de catégorie 4 présentent des caractéristiques suspectes et se subdivisent en trois catégories: 4A, faible risque de malignité; 4B, probabilité d’adénocarcinome de bas grade; et 4C, probabilité de malignité. Les nodules des catégories 4B et 4C sont associés à une forte probabilité de néoplasie simplement en raison des caractéristiques observées par tomodensitométrie de dépistage, et ce, même si une tomographie par émission de positons (TEP), une ponction-biopsie ou une bronchoscopie révèle des résultats négatifs. Enfin, les nodules de catégorie 5 révèlent une séméiologie maligne nettement observable par TDM de dépistage, alors que ceux de catégorie 6 contiennent des tissus dont la malignité a été prouvée.

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Original ResearchCT Screening for Lung Cancer: The Value of Short-term CT Follow-up

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Baseline Screening

Discussion

Lancet

Clin Imaging

Early Lung Cancer Action Project: initial results of annual repeat screening

Cancer

Original Research
CT Screening for Lung Cancer: The Value of Short-term CT Follow-up