In academic and research settings, computer-aided nodule detection software has been shown to increase accuracy, efficiency, and throughput. However, radiologists need to be familiar with the spectrum of errors that can occur when these algorithms are employed in routine clinical settings. We review the spectrum of errors that may result from computer-aided nodule detection. In our clinical practice, we have seen errors in nodule detection, nodule localization, and nodule characterization. Each of these categories are demonstrated with illustrative cases. Through these illustrative cases, readers can be more familiar with nuances and pitfalls generated by computer-aided detection software. Although computer-aided nodule detection software is rapidly advancing, radiologists still need to thoroughly review images with mindfulness of some of the errors that can be generated by AI platforms for nodule detection.

Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist-Fleischner adherence was the agreement between the radiologist's recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/ patient-Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient- radiologist adherence was agreement between the radiologist's recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist-Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient-Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient-radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient-Fleischner concordance: 52.0% concordance among radiologist-Fleischner adherent versus 11.6% concordance among radiologist-Fleischner nonadherent. Conclusions: In this multi-health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.

Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers.Are the HAL and HOMER models valid across multiple centers?This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2|3) disease, and HAL was used to predict the probability of N2|3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test.Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1|2|3) and 0.876 (95%CI, 0.855-0.897) for predicting N2|3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2|3 disease was +0.012; for HOMER, the difference for N1|2|3 was -0.018 and for N2|3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error.HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.

BACKGROUND: Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers. RESEARCH QUESTION: Are the HAL and HOMER models valid across multiple centers? STUDY DESIGN AND METHODS: This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2 vertical bar 3) disease, and HAL was used to predict the probability of N2 vertical bar 3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test. RESULTS: Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1 vertical bar 2 vertical bar 3) and 0.876 (95%CI, 0.855-0.897) for predicting N2 vertical bar 3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2 vertical bar 3 disease was +0.012; for HOMER, the difference for N1 vertical bar 2 vertical bar 3 was -0.018 and for N2 vertical bar 3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error. INTERPRETATION: HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.

Rationale: Because of improvements in screening, there is an increasing number of patients with early-stage non-small-cell lung cancer (NSCLC) who are making treatment decisions. Objectives: Among patients with suspected stage I NSCLC, we evaluated longitudinal patient-centered outcomes (PCOs) and the association of changes in PCOs with treatment modality, stereotactic body radiotherapy (SBRT) compared with surgical resection. Methods: We conducted a multisite, prospective, observational cohort study at seven medical institutions. We evaluated minimum clinically important differences of PCOs at four time points (during treatment, 4-6 wk after treatment, 6 mo after treatment, and 12 mo after treatment) compared with pretreatment values using validated instruments. We used adjusted linear mixed models to examine whether the association between treatment and European Organization for Research and Treatment of Cancer global and physical quality-of-life (QOL) scales differed over time. Results: We included 127 individuals with stage I NSCLC (53 surgery, 74 SBRT). At 12 months, approximately 30% of patients remaining in each group demonstrated a clinical deterioration on global QOL from baseline. There was a significant difference in slopes between treatment groups on global QOL (-12.86; 95% confidence interval [CI], -13.34 to -12.37) and physical QOL (-28.71; 95% CI, -29.13 to -28.29) between baseline and during treatment, with the steeper decline observed among those who underwent surgery. Differences in slopes between treatment groups were not significant at all other time points. Conclusions: Approximately 30% of patients with stage I NSCLC have a clinically significant decrease in QOL 1 year after SBRT or surgical resection. Surgical resection was associated with steeper declines in QOL immediately after treatment compared with SBRT; however, these declines were not lasting and resolved within a year for most patients. Our results may facilitate treatment option discussions for patients receiving treatment for early-stage NSCLC.

Limited data exist about patient-centered communication (PCC) and patient-centered outcomes among patients who undergo surgery or stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC). We aimed to examine the relationship between PCC and decision-making processes among NSCLC patients, using baseline data from a prospective, multicenter study.

OBJECTIVE:While surgical resection is recommended for most patients with early stage lung cancer, stereotactic body radiotherapy (SBRT) is being increasingly utilized. Provider-patient communication regarding risks/benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. Our objective was to determine a framework and recommended strategies on how to best communicate with patients with early stage non-small cell lung cancer (NSCLC) in the post-treatment setting. We qualitatively evaluated the experiences of 11 patients with early clinical stage NSCLC after treatment, with a focus on treatment experience, knowledge obtained, communication, and recommendations. We used conventional content analysis and a patient-centered communication theoretical model to guide our understanding.RESULTS:Five patients received surgery and six received SBRT. Both treatments were generally well-tolerated. Few participants reported communication deficits around receiving follow-up information, although several had remaining questions about their treatment outcome (mainly those who underwent SBRT). They described feeling anxious regarding their first surveillance CT scan and clinician visit. Overall, participants remained satisfied with care because of implicit trust in their clinicians rather than explicit communication. Communication gaps remain but may be addressed by a trusting relationship with the clinician. Patients recommend clinicians give thorough explanations and personalize when possible.

Rationale: Many patients are diagnosed with small pulmonary nodules for which professional societies recommend subsequent imaging surveillance. Adherence to these guidelines involves many steps from both clinicians and patients but has not been well studied.Objectives: In a health care setting with a nodule tracking system, we evaluated the association of communication processes and distress with patient and clinician adherence to recommended follow up and Fleischner Society guidelines, respectively.Methods: We conducted a prospective, longitudinally assessed, cohort study of patients with incidentally detected nodules who received care at one Veterans Affairs Medical Center. We measured patient-centered communication with the Consultation Care Measure and distress with the Impact of Event Scale. We abstracted data regarding participant adherence to clinician recommendations (defined as receiving the follow-up scan within 30 d of the recommended date) and clinician adherence to Fleischner guidelines (defined as planning the follow-up scan within 30 d of the recommended interval) from the electronic medical record. We measured associations of communication and distress with adherence using multivariable-adjusted generalized estimating equations.Measurements and Main Results: Among 138 veterans, 39% were nonadherent at least once during follow up. Clinicians were nonadherent to Fleischner guidelines for 27% of follow-up scans. High-quality communication (adjusted odds ratio, 3.65; P = 0.02) and distress (adjusted odds ratio, 0.38; P = 0.02) were associated with increased and decreased participant adherence, respectively. Neither was associated with clinician adherence.Conclusions: Patients and clinicians often do not adhere to nodule follow-up recommendations. Interventions designed to improve communication quality and decrease distress may also improve patient adherence to nodule follow-up recommendations.

Rationale: While surgical resection is recommended for most patients with early stage lung cancer according to the National Comprehensive Cancer Network guidelines, stereotactic body radiotherapy is increasingly being used. Provider-patient communication regarding the risks and benefits of each approachmay be amodifiable factor leading to improved patient-centered outcomes.Objectives: To qualitatively describe the experiences of patients undergoing either surgery or stereotactic body radiotherapy for early stage non-small cell lung cancer.Methods: We qualitatively evaluated and used content analysis to describe the experiences of 13 patients with early clinical stage nonsmall cell lung cancer before undergoing treatment in three health care systems in the Pacific Northwest, with a focus on knowledge obtained, communication, and feelings of distress.Measurements and Main Results: Although most participants reported rarely having been told about other options for treatment and could not readily recall many details about specific risks of recommended treatment, they were satisfied with their care. The patients paradoxically described clinicians as displaying caring and empathy despite not explicitly addressing their concerns and worries. We found that the communication domains that underlie shared decision making occurred infrequently, but that participants were still pleased with their role in the decision-making process. We did not find substantially different themes based on where the participant received care or the treatment selected.Conclusions: Patients were satisfied with all aspects of their care, despite reporting little knowledge about risks or other treatment options, no direct elicitation of worries from providers, and a lack of shared decision making. While the development of effective communication strategies to address these gaps is warranted, their effect on patient-centered outcomes, such as distress and decisional conflict, is unclear.

Purpose/Objective(s)Stereotactic ablative radiation therapy (SABR) is the standard of care for medically inoperable early stage non-small cell lung cancer (NSCLC) patients. However, due to tumor size, location, and dosimetric limitations, not all patients can undergo SABR. At our institution, we have treated these patients with a hypofractionated regimen of 60 Gy in 4 Gy daily fractions. In this study, we aim to determine the clinical outcomes of NSCLC patients treated with this regimen.Materials/MethodsWe performed a retrospective review of 45 consecutive NSCLC patients treated with 60 Gy in 4 Gy fractions (BED a/b 10 = 84) from 2007 to 2014. All patients underwent 4DCT simulation. A 5mm margin was added to the ITV to obtain PTV. Treatment was delivered using a stereotactic immobilization system and daily CBCT image guidance. CT or PET-CT scans were obtained in 3-6 months intervals following treatment. The Kaplan-Meier method and log-rank test were used for survival analysis. Toxicities were scored using CTCAE4.ResultsThe median follow-up was 11 months (range 2 to 55). The median age was 73 yrs (range 57-90). The median tumor diameter and PTV were 3.5 cm (range 1.3 to 7.5) and 83.3 cc (range 15 to 244). Tumor histologies were 27% adenocarcinoma, 56% squamous cell carcinoma, 7% non-small cell lung carcinoma unspecified and 11% clinical diagnosis without tissue confirmation. 73% of tumors were centrally located, 27% were peripheral. Seven (16%) patients received sequential chemotherapy, and 1 received concurrent chemotherapy. Four (9%) patients received treatment for locally recurrent disease after definitive radiation. 17 (38%) patients received subsequent radiation for disease outside of the initial fields. The median survival was 23 months. The 2 yr actuarial local control and survival rates were 87% and 49%. Only 2 patients developed local recurrence (1 central and 1 peripheral). None of the 4 patients receiving treatment for locally recurrent disease failed locally. Chest wall pain was noted in 3 patients. No grade > 2 acute or late toxicity was observed. Patients with central and peripheral tumors had similar overall survival (p = 0.35) and local recurrence free survival (p = 0.82).Conclusion60 Gy in 15 daily fractions was well tolerated with minimal toxicities. Despite having a BED <100, this hypofractionation regimen resulted in favorable local control and overall survival rates in medically inoperable patients who are not candidates for SABR. Longer follow-up is needed to determine the long term efficacy of this approach. Purpose/Objective(s)Stereotactic ablative radiation therapy (SABR) is the standard of care for medically inoperable early stage non-small cell lung cancer (NSCLC) patients. However, due to tumor size, location, and dosimetric limitations, not all patients can undergo SABR. At our institution, we have treated these patients with a hypofractionated regimen of 60 Gy in 4 Gy daily fractions. In this study, we aim to determine the clinical outcomes of NSCLC patients treated with this regimen. Stereotactic ablative radiation therapy (SABR) is the standard of care for medically inoperable early stage non-small cell lung cancer (NSCLC) patients. However, due to tumor size, location, and dosimetric limitations, not all patients can undergo SABR. At our institution, we have treated these patients with a hypofractionated regimen of 60 Gy in 4 Gy daily fractions. In this study, we aim to determine the clinical outcomes of NSCLC patients treated with this regimen. Materials/MethodsWe performed a retrospective review of 45 consecutive NSCLC patients treated with 60 Gy in 4 Gy fractions (BED a/b 10 = 84) from 2007 to 2014. All patients underwent 4DCT simulation. A 5mm margin was added to the ITV to obtain PTV. Treatment was delivered using a stereotactic immobilization system and daily CBCT image guidance. CT or PET-CT scans were obtained in 3-6 months intervals following treatment. The Kaplan-Meier method and log-rank test were used for survival analysis. Toxicities were scored using CTCAE4. We performed a retrospective review of 45 consecutive NSCLC patients treated with 60 Gy in 4 Gy fractions (BED a/b 10 = 84) from 2007 to 2014. All patients underwent 4DCT simulation. A 5mm margin was added to the ITV to obtain PTV. Treatment was delivered using a stereotactic immobilization system and daily CBCT image guidance. CT or PET-CT scans were obtained in 3-6 months intervals following treatment. The Kaplan-Meier method and log-rank test were used for survival analysis. Toxicities were scored using CTCAE4. ResultsThe median follow-up was 11 months (range 2 to 55). The median age was 73 yrs (range 57-90). The median tumor diameter and PTV were 3.5 cm (range 1.3 to 7.5) and 83.3 cc (range 15 to 244). Tumor histologies were 27% adenocarcinoma, 56% squamous cell carcinoma, 7% non-small cell lung carcinoma unspecified and 11% clinical diagnosis without tissue confirmation. 73% of tumors were centrally located, 27% were peripheral. Seven (16%) patients received sequential chemotherapy, and 1 received concurrent chemotherapy. Four (9%) patients received treatment for locally recurrent disease after definitive radiation. 17 (38%) patients received subsequent radiation for disease outside of the initial fields. The median survival was 23 months. The 2 yr actuarial local control and survival rates were 87% and 49%. Only 2 patients developed local recurrence (1 central and 1 peripheral). None of the 4 patients receiving treatment for locally recurrent disease failed locally. Chest wall pain was noted in 3 patients. No grade > 2 acute or late toxicity was observed. Patients with central and peripheral tumors had similar overall survival (p = 0.35) and local recurrence free survival (p = 0.82). The median follow-up was 11 months (range 2 to 55). The median age was 73 yrs (range 57-90). The median tumor diameter and PTV were 3.5 cm (range 1.3 to 7.5) and 83.3 cc (range 15 to 244). Tumor histologies were 27% adenocarcinoma, 56% squamous cell carcinoma, 7% non-small cell lung carcinoma unspecified and 11% clinical diagnosis without tissue confirmation. 73% of tumors were centrally located, 27% were peripheral. Seven (16%) patients received sequential chemotherapy, and 1 received concurrent chemotherapy. Four (9%) patients received treatment for locally recurrent disease after definitive radiation. 17 (38%) patients received subsequent radiation for disease outside of the initial fields. The median survival was 23 months. The 2 yr actuarial local control and survival rates were 87% and 49%. Only 2 patients developed local recurrence (1 central and 1 peripheral). None of the 4 patients receiving treatment for locally recurrent disease failed locally. Chest wall pain was noted in 3 patients. No grade > 2 acute or late toxicity was observed. Patients with central and peripheral tumors had similar overall survival (p = 0.35) and local recurrence free survival (p = 0.82). Conclusion60 Gy in 15 daily fractions was well tolerated with minimal toxicities. Despite having a BED <100, this hypofractionation regimen resulted in favorable local control and overall survival rates in medically inoperable patients who are not candidates for SABR. Longer follow-up is needed to determine the long term efficacy of this approach. 60 Gy in 15 daily fractions was well tolerated with minimal toxicities. Despite having a BED <100, this hypofractionation regimen resulted in favorable local control and overall survival rates in medically inoperable patients who are not candidates for SABR. Longer follow-up is needed to determine the long term efficacy of this approach.

Screening for lung cancer in high-risk individuals with annual low-dose computed tomography has been shown to reduce lung cancer mortality by 20% and is recommended by multiple health care organizations. Lung cancer screening is not a specific test; it is a process that involves appropriate selection of high-risk individuals, careful interpretation and follow-up of imaging, and annual testing. Screening should be performed in the context of a multidisciplinary program experienced in the diagnosis and management of lung nodules and early-stage lung cancer.

Purpose Narrow PTV margins and steep dose gradients underscore the importance of evaluating breathing-associated tumor motion for lung SBRT. The specific aim of this study was to determine the impact of anatomic tumor location on inter-fraction tumor motion. Methods and Materials Forty-one patients underwent standard free-breathing 4DCT simulation and daily image-guidance 4DCTs during lung SBRT. Absolute tumor motion amplitude in the mediolateral (ML), anterior-posterior (AP), and superior-inferior (SI) directions was analyzed from 159 total 4DCT scans (simulation and daily pre-treatment). Results Overall, the inter-fraction tumor motion amplitude in the ML, AP, and SI directions was small (mean ≤2.5 mm). Similarly, while both upper lobe (UL) and lower lobe (LL) tumors exhibited limited inter-fraction motion in both the ML and AP directions (mean ≤2.2 mm), tumors in the LL had increased inter-fraction motion in the SI direction compared to UL tumors (mean 4.3±4.0 mm vs. 1.7±1.7 mm, p=0.008). Moreover, 28.6% (n=4) of LL tumors exhibited mean inter-fraction motion along the SI direction >5 mm (all of which resided in the supra-diaphragmatic basal segments of the LL). Conclusions Mean inter-fraction tumor motion amplitude along the SI direction exceeded our PTV margins (an isotropic 5 mm expansion of the ITV) in 28.6% of LL tumors (all of which resided in the basal segments). These results suggest that typical ITV-to-PTV margins may be insufficient for a subset of LL lesions and that increased PTV margins, daily breathing motion re-assessment and/or adaptive re-planning may benefit patients with supra-diaphragmatic tumors in the LL.

Letters4 February 2014Screening for Lung Cancer With Low-Dose Computed TomographyLinda L. Humphrey, MD, MPH, Mark Deffebach, MD, Miranda Pappas, MA, Bernadette Zakher, MBBS, and Christopher G. Slatore, MD, MSLinda L. Humphrey, MD, MPHFrom Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Search for more papers by this author, Mark Deffebach, MDFrom Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Search for more papers by this author, Miranda Pappas, MAFrom Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Search for more papers by this author, Bernadette Zakher, MBBSFrom Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Search for more papers by this author, and Christopher G. Slatore, MD, MSFrom Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L14-5003-3 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:As we noted in our article and the associated systematic review, overdiagnosis is a risk of lung cancer screening of uncertain magnitude. We do not believe that the Mayo Lung Project provides a valid estimate of overdiagnosis for many reasons, most of which we outlined in our report (1) and the prior review (2). More research in this important area is needed.We rated the quality of the DLCST as moderate. Limitations that we identified included a lack of description of allocation concealment, as Drs. Brodersen, Dirksen, and Pedersen note. They state that patients were randomly assigned at ...References1. Humphrey L, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, et al. Screening for Lung Cancer: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Report no. 13-05188-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Google Scholar2. Humphrey LL, Teutsch S, Johnson M; U. S. Preventive Services Task Force. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:740-53. [PMID: 15126259] LinkGoogle Scholar3. Pedersen JH, Ashraf H, Dirksen A, Bach K, Hansen H, Toennesen P, et al. The Danish randomized lung cancer CT screening trial—overall design and results of the prevalence round. J Thorac Oncol. 2009;4:608-14. [PMID: 19357536] CrossrefMedlineGoogle Scholar4. Saghir Z, Dirksen A, Ashraf H, Bach KS, Brodersen J, Clementsen PF, et al. CT screening for lung cancer brings forward early disease. The randomised Danish Lung Cancer Screening Trial: status after five annual screening rounds with low-dose CT. Thorax. 2012;67:296-301. [PMID: 22286927] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Portland Veterans Affairs Medical Center, Portland, Oregon; Oregon Health & Science University, Portland, Oregon; and Portland Veterans Affairs Medical Center, Portland, Oregon.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1080. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoScreening for Lung Cancer With Low-Dose Computed Tomography: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation Linda L. Humphrey , Mark Deffebach , Miranda Pappas , Christina Baumann , Kathryn Artis , Jennifer Priest Mitchell , Bernadette Zakher , Rongwei Fu , and Christopher G. Slatore Screening for Lung Cancer With Low-Dose Computed Tomography John Brodersen , Jakob Fraes Rasmussen , and Bruno Heleno Screening for Lung Cancer With Low-Dose Computed Tomography John Brodersen , Asger Dirksen , and Jesper Holst Pedersen Metrics Cited ByImplementation of a Lung Cancer Screening Program in Two Federally Qualified Health CentersState-Level Variations in the Utilization of Lung Cancer Screening Among Medicare Fee-for-Service BeneficiariesLINC00261 Is an Epigenetically Regulated Tumor Suppressor Essential for Activation of the DNA Damage ResponseLung Cancer Screening and Its Impact on Surgical VolumeLung Cancer ScreeningCancer screening in the United States, 2015: A review of current American Cancer Society guidelines and current issues in cancer screeningLung-Cancer Screening with Low-Dose Computed Tomography 4 February 2014Volume 160, Issue 3Page: 212KeywordsCancer screeningComputed axial tomographyConflicts of interestDecision makingDisclosureLung and intrathoracic tumorsLung cancer screeningLungsSystematic reviews ePublished: 4 February 2014 Issue Published: 4 February 2014 CopyrightCopyright © 2014 by American College of Physicians. 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BACKGROUND:Embolization coils as fiducial markers for pulmonary stereotactic body radiation therapy (SBRT) are perceived to be the optimal marker type, given their ability to conform and anchor within the small airways. The aim of our study was to assess retention, placement, migration, feasibility, and safety of electromagnetic navigational bronchoscopy (ENB)-guided embolization coil markers throughout courses of SBRT.METHODS:Thirty-one patients with 34 nodules underwent ENB-guided fiducial placement of several 4 mm fibered platinum embolization coils before SBRT. Patient and nodule positioning was confirmed with daily pretreatment cone-beam computed tomography (CBCT). Fiducial positional characteristics were analyzed utilizing radiation treatment-planning software comparing the simulation CT with daily CBCTs.RESULTS:Of 105 fiducials placed, 103 were identifiable on simulation CT (retention rate: 98.1%). Incidence of asymptomatic pneumothoraces was 6%. One patient experienced hemoptysis requiring hospitalization. Eighty-six percent of fiducials were placed within 1 cm of the nodule, with 52% of fiducials placed directly on the nodule surface. Throughout a 5-fraction SBRT course, fiducial displacement was <7, 5, and 2 mm in 98%, 96%, and 67% of pretreatment CBCTs.CONCLUSIONS:ENB placement of embolization coils as fiducials for lung SBRT image guidance is associated with a low rate of iatrogenic pneumothoraces, and resulted in reliable placement of the fiducials in close proximity to the lung nodule. Embolization coils retained their relative position to the nodule throughout the course of SBRT, and provide an excellent alternative to linear gold seeds.

We have entered an era of lung cancer screening, to the extent that low-dose CT scans for lung cancer screening are being offered for free at some institutions (http://www.lahey.org/lungscreening/). Although free may be a very good price, it may come at substantial cost. These costs include a wide range of detected abnormalities, many of which have uncertain clinical significance and can create considerable anxiety in patients and their health care providers. One of these abnormalities is the ground glass nodule (GGN), a focal CT finding where there is increased attenuation through which normal parenchymal and airway structures remain visible. In the current issue of the journal, Kobayyashi et al.1Kobayyashi Y Fukui T Ito S et al.How long should small lung lesions of ground glass opacity be followed?.J Thorac Oncol. 2012; 8: 309-314Google Scholar describe their experience in observing GGNs. Their aim was to describe the natural history of a most unnatural phenomenon, a radiographic finding in asymptomatic individuals. They followed 108 lesions in 61 individuals detected at screening or as incidental findings. Most of the findings remained stable with observation up to 12 years. Twenty-seven percent increased in size, with some showing both growth and increases in a solid component. In their analysis, all lesions demonstrating growth did so within the first 3 years. Primarily on the basis of growth, 21 patients went on to surgical resection with almost half the lesions being atypical adenomatous hyperplasia or adenocarcinoma-in-situ, with most of the remaining lesions being minimally invasive adenocarcinoma. They correctly conclude and suggest that GGNs should be observed for at least 3 years before deciding that they will remain stable. Before incorporating this into practice, there is still much to consider. For example, the context is very important. The population Kobayyashi studied is a uniquely Japanese population. Two-thirds of the subjects were nonsmoking women, and 90% of the adenocarcinomas contained epidermal growth factor receptor mutations. Although indolent growth may be a nearly universal characteristic of GGNs, the “natural” history needs to be defined in other populations as well. This study does not answer some of the most important questions surrounding GGNs. With wide spread CT screening for lung cancer, GGNs will become more frequent, and the goals of management will become more complex. Minimizing procedures, radiation exposure, and expenditures will become increasingly important. An emphasis on outcomes, with less focus on specific histology and when and how to intervene will be needed. Kobayyashi et al. had universally good outcomes, but with significant costs, including 12 pulmonary resections for premalignant lesions (adenomatous hyperplasia and adenocarcinoma-in-situ). Given the very indolent nature of all of these abnormalities, some of the malignant lesions might be candidates for “overdiagnosis” of lung cancer. To this end, several organizations have considered the GGN and developed guidelines and recommendations. This includes the National Comprehensive Cancer Network, the American Association for Thoracic Surgery, and most recently the Fleischner Society.2Naidich DP Bankier AA MacMahon H et al.Recommendations for the management of subsolid pulmonary nodules detected at CT: A statement from the Fleischner Society.Radiology. 2012; Google Scholar Of these, the Fleischner Society recommendations are the most complete and complex. In 2005, the Fleischner Society published their ubiquitous guidelines for small pulmonary nodules incidentally detected on CT scan.3MacMahon H Austin JH Gamsu G Fleischner Society et al.Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society.Radiology. 2005; 237: 395-400Crossref PubMed Scopus (1317) Google Scholar These recommendations are simple, clear, and easily condensed into the small table that is posted next to radiology workstations around the world. However, in 2005, they only dealt with solid nodules. Now the Fleischner Society has moved on to subsolid pulmonary nodules, and things get much more complex. GGNs are more heterogeneous, in their radiographic appearance, behavior, and histology. As expected, the new guidelines are much more complex than those for solid nodules and unlikely to be condensed into a single, simple table. All the recommendations made are well researched and justified by current literature and available data, but still represent the opinions of experts in the field. They have yet to be tested prospectively and have not been applied in the real world. Research has shown that even the simple guidelines for solid nodules can be difficult to follow.4Eisenberg RL Bankier AA Boiselle PM Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists.Radiology. 2010; 255: 218-224Crossref PubMed Scopus (116) Google Scholar This fact may represent one of the issues the Fleischner GGN recommendations will have to face in the real world: Are physicians willing and able to follow a complex nodule follow-up pathway, and are the descriptors (size, density, cystic component, etc.) distinct enough to be applicable in daily practice? The current data are robust for pure GGNs between 5 and 8 mm and justify a more conservative approach for this subtype. It gets more complicated once mixed solid and GGNs are to be assessed. The clear distinction between solid and ground glass as well as the size and proportion of each component determines outcome and follow-up recommendations. Interpretative consistency will be very important in such cases. There are technical issues raised by the Fleischner Society GGN recommendations. The Fleischner society recommends contiguous 1-mm thick slices for assessment of GGNs, something not addressed in other guidelines. There are potential pitfalls with respect to differences in reconstruction algorithms, which may alter the appearance and hence density of a GGNs and the challenges of comparing scans from two different institutions and/or manufacturers should not be overlooked. These recent recommendations from the Fleischner society on the management of GGNs provide a solid foundation and starting point for further investigation. They touch on many areas of uncertainty and acknowledge the limitations of many of our standard procedures, such as positron emission tomography scans and biopsies, and they place an emphasis on minimizing radiation exposure and procedures. Their approach is supported by the new data from Kobayyashi et al. in this issue of the journal. It is hoped that these recommendations will guide practitioners and more importantly serve as the foundation for outcome-oriented investigation in the management of these increasingly ubiquitous radiographic findings.