Radiation Oncology/NSCLC/Screening

Screening National Lung Screening Trial (2002-2004) 2011 21714641 Full Text -- "Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening" (NEJM. 2011 Aug 4;365(5):395-409.) Randomized. 53,454 persons, between 55 and 74 year of age, at high risk for lung cancer, randomly assigned to undergo three annual screenings with either low-dose CT or single-view posteroanterior chest radiography. Outcome: Rate of positive screening tests: 24.2% (low-dose CT) vs. 6.9% (radiography); False positive: 96.4% vs. 94.5%; Diagnosis: 645 cases per 100,000 person-years vs. 572 per 100,000 person-years (rate ratio 1.13, 95%CI: 1.03 to 1.23); 20.0% (SS) relative reduction in mortality from lung cancer with low-dose CT screening. Conclusion: Screening with the use of low-dose CT reduces mortality from lung cancer. 2013 - Incidence -- 24004119 -- "Results of the two incidence screenings in the National Lung Screening Trial." (Aberle DR, N Engl J Med. 2013 Sep 5;369(10):920-31.) 2013 - Initial LDCT -- 23697514 -- "Results of initial low-dose computed tomographic screening for lung cancer." (National Lung Screening Trial Research Team, N Engl J Med. 2013 May 23;368(21):1980-91.) Positive screening test: LDCT 27% vs X-ray 9%; lung cancer diagnosis 1.1% vs 0.7%. Sensitivity and specificity LDCT 94% and 73% vs x-ray 73% and 91% Conclusion: Initial screening result suggest reduction in mortality is achievable Multi-Institutional, 2007 17341709 -- "Computed tomography screening and lung cancer outcomes." (Bach PB, JAMA. 2007 Mar 7;297(9):953-61.) Retrospective. 3246 asymptomatic current or former smokers, annual CT screening, began in 1998. 3 institutions (Milan, Mayo, Moffitt) Outcome: Diagnosis: 144 patients vs. 44 expected (RR 3.2, SS); lung resection 109 vs. expected 11 (RR 10.0, SS); advanced cases 42 vs. expected 33 (NS); deaths 38 vs. expected 39 (NS) Conclusion: Screening increases rate of diagnosis and treatment, but may not reduce death from lung cancer NY Times commentary, -- "How Two Studies on Cancer Screening Led to Two Results" (Welch GH, NY Times, March 13, 2007). Interpretation of these two trials. Significant controversy over this point JCO Comment The International Early Lung Cancer Action Program (I-ELCAP) (1993-2005) - 17065637 — "Survival of Patients with Stage I Lung Cancer Detected on CT Screening." Henschke CI et al. NEJM. 2006 Oct 26;355(17):1763-1771. 31,567 pts. Screening annually using low-dose CT. 484 lung cancers detected. 85% had Stage I. Of those Stage I pts, 10-year survival rate was 88% (92% for those who underwent surgical resection). Conclusion: Annual CT screening can detect lung cancer that is curable. Comment: Interpretation of survival data only in those screened positive. Concern about lead-time and length bias, since those patients diagnosed earlier may live longer (longer survival) but have same death rate nonetheless. Not clear who should be screened. Dutch Belgian Randomised Lung Cancer Screening Trial (NELSON) (2002 - Ongoing) Registry Randomised trial comparing spiral CT screening vs. observation in high risk individuals for decreasing disease specific mortality. Results expected 2011 Work-Up of Pulmonary Nodules Mass General Hospital, 2007 17544146 -- "Evaluating pulmonary nodules." (Miller JC, J Am Coll Radiol. 2007 Jun;4(6):422-6.) Review. Algorithm described: Compare current study with old study (CXR or CT). If growth, biopsy If no old study, do CT. If benign calcification or fat, no action If nodule on CT: If immunocompromised or fever, consider short (4-6 week) follow up or biopsy If history of malignancy, consider follow-up CT (3, 6, 12 months) Otherwise, look at size: If <=4mm, repeat CT (timing depends on age). If growth, biopsy If 4-8mm, repeat CT (timing depends on age). If growth, biopsy If >8mm, biopsy or PET Indiana University, 2006 16567482 -- "The solitary pulmonary nodule." (Winer-Muram HT, Radiology. 2006 Apr;239(1):34-49.) Review. Solitary pulmonary nodule defined as round/oval opacity <3cm diameter, surrounded by pulmonary parenchyma, not associated with lymphadenopathy, atelectasis, or pneumonia Most lesions: granulomas, hamartomas, or lung cancer Size: nodules approaching 3cm likely malignant, nodules <1cm likely benign Location: RUL most common location of cancer. 70% of lung CA in upper lobes Calcification: typically benign, unless history of bone malignancy Fat: typically benign, unless history of renal cell or liposarcoma Imaging features: consider attenuation, air bronchograms, margin, and cavitation; however, significant overlap in features Growth rate: If no change over 2 years, can consider benign PET: Best test to determine malignancy in lesions >1cm