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Jesper Holst Pedersen
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P3.13 - Radiology/Staging/Screening (ID 729)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.13-011 - Use of Volume Growth and Fluor-Deoxy-Glucose Positron Emission Tomography in Evaluating Indeterminate Lung Nodules in Lung Cancer Screening (ID 8535)
09:30 - 16:00 | Author(s): Jesper Holst Pedersen
- Abstract
Background:
Indeterminate lung nodules detected during lung cancer screening with low dose computed tomography (CT) present a challenge in distinguishing between malignant and benign disease. Our aim for this study is to compare the sensitivity and specificity of flour-deoxy-glucose positron emission tomography (FDG-PET), volume doubling time (VDT) and a combination of both in the diagnostic workup of indeterminate lung nodules in lung cancer screening.
Method:
The Danish Lung Cancer Screening Trial (DLCST) is a randomized controlled trial with heavy smokers between 50-70 years of age. The screening group underwent 5 annual rounds with low dose CT scan of the thorax. When a lung nodule was detected, participants could either be referred to diagnostic workup, 3-month follow-up or continue with the screening program. We included participants who had a 3-month follow-up scan. Before the follow-up scan was conducted, the participants received a FDG-PET scan. Nodules that were resected or stable for at least 2 years were included. FDG-uptake was categorized from most likely benign (uptake less than background uptake in the mediastinum) to most likely malignant (uptake as mediastinum or higher). VDT was calculated from nodule volume measurements from two time points closest to the FDG-PET scan date. We used a commercially available and validated semi-automated nodule evaluation software. Based on VDT the nodules were divided into three groups. Regressing nodules (VDT<0), slow growing nodules (VDT > 365 days - less likely malignant) and fast-growing nodules (VDT < 365 days – most likely malignant). Finally, we divided combined outcome into three groups: 1. Both tests suggest benignancy, 2. One of the tests suggest malignancy and 3. Both tests suggest malignancy. We used receiver operating characteristic (ROC) curves to compare sensitivity and specificity for the ability to predict a malignant or benign nodule.
Result:
A total of 87 lung nodules in 76 individuals were included. 68/87 (78%) were solid nodules. 41.5% were malignant. Nodule size ranged between 5 mm – 20 mm in largest diameter. The sensitivity and specificity of VDT alone were 61% and 90% respectively. For FDG-PET the sensitivity was 62% and specificity was 90%. Combined use of both tests showed an improvement in test sensitivity to 82% and a specificity of 79%.
Conclusion:
Combined use of FDG-PET and VDT is recommended in the diagnostic workup of indeterminate lung nodules in lung cancer screening.
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WS 01 - IASLC Supporting the Implementation of Quality Assured Global CT Screening Workshop (By Invitation Only) (ID 632)
- Event: WCLC 2017
- Type: Workshop
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/14/2017, 08:30 - 21:00, F203 (Annex Hall)
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WS 01.27 - Surgical Integration at the Earliest Stages Planned CT Screening? (ID 10672)
08:30 - 21:00 | Presenting Author(s): Jesper Holst Pedersen
- Abstract
Abstract:
CT screening for lung cancer is a process that involves both potential benefits and harms. In order to minimize harms and maximize benefits thoracic surgeons should play a key role in any CT screening program, as recommended by ESTS (1), ATS and ACCP (2,3), NCCN (4), IASLC (5). Thoracic surgeons should also be involved in the planning of a screening program in order to integrate surgical expertise in the design of the program and the diagnostic protocols, potentially in order to achieve better results than in the National Lung Screening Trial (NLST) (6). Surgical contributions are most important for the following issues. Minimizing false positive diagnoses by optimal management of screen detected nodules. The target population should be defined as selection of a higher risk cohort may influence the false positive rate. The NLST criteria [6] have been widely endorsed by organisations engaged in screening, but also higher risk groups selecting individuals with a 5-year lung cancer risk > 5% or 2% have been suggested (7) . Nodule characteristics and criteria determine follow-up examinations or referral for noninvasive or invasive tests to determine the indication for surgical excision. The lower cut-off size for defining a positive nodule has great impact on the false positive rate, and a change to higher cut-offs has been shown to be possible without a major reduction in sensitivity (8). Reduction of surgery for benign lesions. Prior to resection of screen-detected nodules, a preoperative diagnosis is preferred. In patients with peripheral nodules with high likelihood of malignancy, VATS wedge resection prior to anatomic resection may be justifiable . For larger or more central lesions, obtaining a preoperative diagnosis would be possible also with CT-guided transthoracic needle aspiration, trans-bronchial needle aspiration, navigational bronchoscopy, or endobronchial ultrasound guided aspiration. In any case, a diagnosis should be secured prior to proceeding with lung major resection. In case of suspicious lung lesions less than 2 cm with no preoperative diagnosis, resectable in the volume of an anatomical segmentectomy, it can be acceptable to perform a diagnostic and therapeutic minimally invasive segmental resection using both VATS or Robotics, while diagnostic lobectomy should be avoided or limited to extremely rare cases (1). In all of the published studies of CT screening for lung cancer, surgery has been performed for benign lesions. The reported extent varies from 2–45% (4,9,10), and current recommendations are to keep this rate below 15% (4).The best way to reduce surgery for benign lesions is to have an accurate preoperative/diagnostic biopsy algorithm, as this reduces the number of indeterminate nodules referred for surgery (1,9). Surgeons should be closely involved in diagnostic work-up to locate and mark or biopsy small indeterminate pulmonary nodules. In difficult cases time should be allowed for watchful waiting to verify growth and calculation of tumor volume doubling time and repeated biopsies to substantiate or verify a suspicion of malignancy. In a screening setting a delay in diagnosis under close monitoring is preferable to unnecessary surgery. The extent of surgery for benign lesions during CT screening should be monitored and reported as an indication of surgical quality (1,3,10). Reduction of surgical incision-related trauma. Minimally invasive thoracic surgical procedures should be performed by specialists board certified in thoracic surgery. In anatomic resections of screen detected cancers that are less than 3 cm, the mortality would be less than 1%, major morbidity would be less than 5%, and the length of hospital stay should be approximately 3 days (1,10) . Close collaboration between surgeon and pathologist. Close cooperation of surgeon and on site pathologist using a standardized pathology reporting may enhance effectiveness of diagnostic work-up. The resection of an adenocarcinoma in situ, minimally invasive adenocarcinoma and a lepidic-predominant adenocarcinoma have almost 100% 5-year survival rate, and therefore such patients in the near future may be candidates for sublobar resection (1). Reduction of overdiagnosis. GGO lesions may represent a wide spectrum of disease from benign lesions to invasive carcinoma. Therefore GGO nodules are a diagnostic challenge requiring a MDT approach to ensure correct work-up. Apparently the development and the size of a solid component is more important than the nonsolid/lepidic component for the assessment of prognosis and risk of invasive carcinoma Most GGOs have an indolent clinical course, especially in a screening situation. Careful consideration of the indications for surgery and invasive procedures and longer follow-up, even for more than 4 years, of GGO nodules, to ensure safe management and reduce overdiagnosis and overtreatment (1,10) Qualifications of surgeons involved in a screening program.. Surgeons involved in lung cancer screening should be familiar with minimally invasive thoracic surgery (1,2,3,5,10). Thoracic surgeons have a crucial role in tailoring the procedure to the screen detected lesion and the individual patient prognostic factors including age, comorbidities, performance status and life expectancy. Surgeons must be experienced in the interpretation of lung cancer imaging and tumor variables such as volume doubling time, standardized uptake value at CT/PET, and nodule density. In addition they should be trained in the diagnosis and management of screen detected nodules, and be able to recognize potentially false positive and false negative lesions as well as interval cancers. Surgeons should have propensities to consider follow-up instead of immediate surgery for indeterminate nodules, and in cases with comorbidities, multi-focal disease, or with previous lung lobectomy, to consider non-surgical treatments including stereotactic ablative radiotherapy (1,10). Integration of the smoking cessation policy. The adoption of a tobacco cessation program based on a close cooperation with other specialties managing population diseases (i.e. pulmonologists, cardiologists) will be important (1,2,3). A tobacco cessation program is potentially associated to a reduction in lung cancer specific mortality that exceeds that from lung cancer screening as well as leading to an improvement of the cost-effectiveness of the program. Precise data collection on interventions like enrolment, completion, and ‘quit’ rates are of utmost importance to monitor the outcomes of the screening program (1,2). . References: 1) Pedersen JH, Rzyman W, Veronesi G, D’Amico TA, Van Schil P, Molins L et al. Recommendations from the European Society of Thoracic Surgeons (ESTS) regarding computed tomography screening for lung cancer in Europe. Eur J Cardiothorac Surg 2017; 411–20. 2) Mazzone P , Powell PA, Arenberg D, Bach P , Detterbeck F,; Gould MK , Jaklitsch MT, Jett J , Naidich D, Vachani A , Wiener RS , Silvestri G . Components Necessary for High-Quality Lung Cancer Screening. American College of Chest Physicians and American Thoracic Society Policy Statement. CHEST 2015; 147(2): 295 – 303 3) Mulshine JL, D’amico TA. Issues with implementing a high-quality lung cancer screening program. CA Cancer J Clin. 2014;64: 352–363. 4) Wood DE. National Comprehensive Cancer Network (NCCN) clinical practice guidelines for lung cancer screening. Thorac Surg Clin. 2017;25(2):185–197. 5) Field JK, Smith RA, Aberle DR, et al. International Association for the Study of Lung Cancer Computed Tomography Screening Workshop 2011 Report. J Thorac Oncol. 2012;7:10–19. 6) Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395–409. 7) Field JK, Duffy SW, Baldwin DR, Brain KE, Devaraj A, Eisen T, et al. The UK Lung Cancer Screening Trial:a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer. Health Technol Assess 2016;20(40). 8) Gierada DS, Pinsky P, Nath H, Chiles C, Duan F, Aberle DR. Projected outcomes using different nodule sizes to define a positive CT lung cancer screening examination. J Natl Cancer Inst 2014;106. DOI: 10.1093/jnci/dju284. 9) Flores R, Bauer T, Aye R, Andaz S, Kohman L, Sheppard B et al. I-ELCAP Investigators. Balancing curability and unnecessary surgery in the context of computed tomography screening for lung cancer. J Thorac Cardiovasc Surg 2014;147:1619–26. 10) Grondin SC, Edwards JP, Rocco G. Surgeons and lung cancer screening. Rules of engagement. Thorac Surg Clin 2015, 25, 175-184
