ObjectiveLung cancer screening (LCS) is complicated by a high prevalence of incidental findings (IFs), defined as abnormalities detected on low-dose computed tomography (LDCT) of the chest that are outside the scope of LCS. Although the detection of some abnormalities might lead to the diagnosis of conditions of clinical relevance, LDCT protocols are not adequate for the characterisation of most IFs and thus, further investigations are usually necessary. Thus, the detection of such findings is perceived as a double-edged sword, and radiologists still widely disagree on which IFs should be reported.Materials and methodsA survey was circulated amongst radiologists involved in LCS programmes across Europe to investigate their opinions regarding the reporting of IFs, based on their personal experiences and perspectives, as well as national regulations. The responses of 147 European radiologists were included in the final analysis.ResultsThe survey revealed a lack of standardised regulations and limited awareness among European radiologists regarding IFs reporting in LCS. LDCT is perceived as unreliable for evaluating solid organs outside the mediastinum, and mandatory reporting is supported only for clinically relevant findings.ConclusionWith radiologists still partly disagreeing on which IFs should be reported, international evidence-based guidelines around IFs reporting and management are highly awaited but challenging.Critical relevance statementThis study critically highlights the lack of standardised regulations and consensus on IFs reporting in European LCS, underscoring the urgent need for harmonised, evidence-based guidelines to advance consistency and quality in clinical radiology practice.Key PointEuropean radiologists report a lack of standardised regulations and awareness regarding IFs in LCS.LDCT is widely perceived as unreliable for assessing solid organs outside the mediastinum, limiting support for mandatory reporting of extra-thoracic findings.International, evidence-based guidelines are urgently needed to harmonise IFs reporting and management in LCS across Europe.

This study aimed to evaluate the frequency of carotid plaques detected by carotid Doppler ultrasound (CDU) and their potential contribution to therapeutic recommendations, among participants in a lung cancer screening (LCS) programme—notably in those with absent or limited coronary artery calcification (CAC). This prospective study included 250 individuals from the “PEOPLHE” LCS-trial who were evaluated by CDU between November 2022 and August 2023. Stenosis was classified as measurable or severe when > 20

To explore the status of low-dose CT lung cancer screening (LCS) training practices, identify existing gaps, and define key competencies to be included in LCS educational curricula. As part of the European SOLACE project, a structured cross-sectional survey consisting of 11 closed- and open-ended items, developed based on relevant literature, international guidelines, and expert input to assess LCS current practices and training needs, was administered to a panel of European LCS experts. Participants were invited to individual Zoom interviews (May–November 2025). Data were analyzed using descriptive statistics. Twenty-five LCS experts were interviewed from 14 European countries, including 10 radiologists (40

Abstract Lung cancer is the leading cause of cancer-related deaths globally. To detect lung cancer at an earlier, treatable stage, low-dose chest CT is a critical tool for risk-based lung cancer screening. With the growing large-scale, multidisciplinary support for the implementation of lung cancer screening, it is important to ensure these programmes are implemented in a sustainable and effective manner. This review focuses on the three fundamental dimensions of sustainability: ecological, social, and economic. It examines strategies for their effective implementation in accordance with current best practices. Ecological sustainability involves reducing energy use and emissions and leveraging technological innovations to positively impact the environment. Economic sustainability highlights the need to evaluate long-term financial capacity and infrastructure and the role of effective risk-stratification. Social sustainability centres on equitable access to lung cancer screening programmes, particularly for currently underserved populations, with a focus on targeted recruitment strategies. We present an overview of current challenges, an analysis of best practices, and examples of real-world implementation, with a particular emphasis on initiatives in the SOLACE project. Clinical relevance statement This review highlights the importance of a multidisciplinary and sustainable approach to implementing lung cancer screening by integrating ecological, economic and social sustainability practices. Key Points Lung cancer screening requires balanced consideration of all three sustainability pillars: ecological, economic, and social. This review examines sustainability practices in lung cancer screening, highlighting use cases from SOLACE and beyond. Lung cancer screening must embed all aspects of sustainability to achieve lasting clinical and social impact. Graphical Abstract

PURPOSE:To retrospectively assess the agreement between human and automated AI-based readings for low-dose computed tomography (LDCT) outcomes according to LungRADS v1.1 in lung cancer screening (LCS); to test the diagnostic performance of both readings. METHODS:We included 4104 baseline LDCTs from the BioMILD trial. Original readings were retrospectively classified into "negative" (LungRADSv1.1 categories 1, 2) and "positive" (categories 3, 4) by a radiologist and analyzed by AI software for category assignment. Diagnosis of lung cancer (LC) at 2 years served as reference standard to assess sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of both human and AI. Agreement between readers was measured by the k-Cohen Index with Fleiss-Cohen weights (Kw) with 95 % CI. RESULTS:Median age of participants was 60 years; 60.8 % were male and 79.2 % current smokers; 68/4104 (1.7 %) were diagnosed with LC; 6/68 (8.8 %) and 7/68 (10.3 %) LDCT were classified as negative by AI and human reading, respectively. The agreement between human and AI readings for negative and positive LDCTs was 83.5 % (Kw 0.47; 95 %CI: 0.43-0.50). Sensitivity and specificity were 91.2 % and 75.7 % for AI, and 89.7 % and 90.0 % for human reading (p-value 0.5637 and < 0.0001). PPV and NPV were 6.0 % and 99.8 % for AI, and 13.1 % and 99.8 % for human reading (p-value < 0.0001 and 0.9351). The expected reduction in LDCT reading workload when using AI as first reader was 74.7 %. CONCLUSION:AI reading showed comparable sensitivity but lower specificity than human reading. High NPV of AI may support its use as a first reader in LCS.

Incidental findings (IFs) are common in lung cancer screening (LCS). While the detection of some of these findings can lead to early diagnosis and treatment of clinically significant conditions, it also carries the risks of overdiagnosis and overtreatment, causing anxiety for patients and increased economic costs for health systems. Effective management of IFs requires a balanced approach guided by clear guidelines, standardized reporting, and participants-centered communication. As the field of LCS evolves, continued research and innovation will be essential in refining the strategies for managing IFs, ensuring that the benefits of screening are maximized while minimizing potential harm. Evidence-based guidelines on reporting and management of IFs, however, are still lacking. This narrative review explores the pros and cons of reporting IFs in LCS, focusing on key controversies.

Introduction: Coronary artery calcification (CAC) is a well- known cardiovascular risk factor. In the past year, the CAC score has been investigated in lung cancer (LC) screening, suggesting promising results in terms of mortality risk assessment. Nevertheless, its role in patients with LC is still to be investigated. This study aimed to evaluate the per- formance of a fully automated CAC scoring alone and combined with a prognostic index on the basis of periop- erative routine blood tests in predicting 5-year survival of patients with stage I LC. Methods: This study included 536 consecutive patients with stage I LC who underwent preoperative chest computed tomography followed by surgical resection. The CAC score was measured by commercially available, fully automated artificial intelligence software. The primary outcome was the 5-year overall survival rate. Results: A total of 110 patients (20.5%) had a CAC score greater than or equal to 400, 149 (27.8%) between 100 and 399, and 277 (51.7%) had less than 100. Male smokers had the highest CAC values: 32% compared with only 17% of nonsmokers. Females had lower CAC values compared with males both in smokers and nonsmokers: CAC greater than or equal to 400 only for 10% of smoking females and 0% in nonsmoking females. The 5-year survival was 80.3% overall, 84.7% in CAC less than 100, 77.5% in CAC 100 to 399, and 73.5% in CAC greater than or equal to 400 (p 1/4 0.0047). Conclusions: We observed that the CAC score predicted the 5-year overall survival in patients with resected stage I LC, both alone and combined with the modified routine blood test score. These results open new prospects for the prevention of noncancer mortality in patients with early-stage LC. (c) 2025 The Authors. Published by Elsevier Inc. on behalf of the International Association for the Study of Lung Cancer. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).both alone and combined with the modified routine blood test score. These results open new prospects for the prevention of noncancer mortality in patients with early-stage LC. (c) 2025 The Authors. Published by Elsevier Inc. on behalf of the International Association for the Study of Lung Cancer. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Low-dose computed tomography (LDCT)-based lung cancer screening (LCS) seems to have very limited impact on small cell lung cancer (SCLC) outcomes. This study aims at describing frequency and outcomes of SCLC in a large LCS population.Patients diagnosed with SCLC among the total population enrolled in three different trials (n = 7473) were selected for the present analysis. Demographic and clinical data were collected at the baseline and follow-up screening rounds, while the vital status and date of death were obtained through a dedicated national platform. Of the 396 diagnosed LCs, 28 (7.1%) were SCLCs; median survival time from the diagnosis was 1.5 years, and overall mortality was 71.4%. Screen-detected SCLCs were 20/28 (71.4%); 5/20 (25%) were prevalent cancers and 15/20 (75%) incident ones. Five-year mortality among the screen-detected and non-screen detected SCLCs was 70% and 62.5%, respectively.The frequency of SCLC was lower as compared to other trials. Although no significant differences in five-year mortality were observed between screen-detected and non-screen-detected SCLCs, the overall five-year mortality was substantially lower than that reported in non-LCS populations, suggesting that LDCT-based LCS has an impact on SCLC outcome, albeit limited.

Purpose Lung cancer screening (LCS) by low-dose computed tomography (LDCT) demonstrated a 20–40% reduction in lung cancer mortality. National stakeholders and international scientific societies are increasingly endorsing LCS programs, but translating their benefits into practice is rather challenging. The “Model for Optimized Implementation of Early Lung Cancer Detection: Prospective Evaluation Of Preventive Lung HEalth” (PEOPLHE) is an Italian multicentric LCS program aiming at testing LCS feasibility and implementation within the national healthcare system. PEOPLHE is intended to assess (i) strategies to optimize LCS workflow, (ii) radiological quality assurance, and (iii) the need for dedicated resources, including smoking cessation facilities. Methods PEOPLHE aims to recruit 1.500 high-risk individuals across three tertiary general hospitals in three different Italian regions that provide comprehensive services to large populations to explore geographic, demographic, and socioeconomic diversities. Screening by LDCT will target current or former (quitting < 10 years) smokers (> 15 cigarettes/day for > 25 years, or > 10 cigarettes/day for > 30 years) aged 50–75 years. Lung nodules will be volumetric measured and classified by a modified PEOPLHE Lung-RADS 1.1 system. Current smokers will be offered smoking cessation support. Conclusion The PEOPLHE program will provide information on strategies for screening enrollment and smoking cessation interventions; administrative, organizational, and radiological needs for performing a state-of-the-art LCS; collateral and incidental findings (both pulmonary and extrapulmonary), contributing to the LCS implementation within national healthcare systems.

Background The management of subsolid nodules (SSNs) in lung cancer screening (LCS) is still a topic of debate, with no current uniform strategy to deal with these lesions at risk of overdiagnosis and overtreatment. The BioMILD LCS trial has implemented a prospective conservative approach for SSNs, managing with annual low-dose computed tomography nonsolid nodules (NSNs) and part-solid nodules (PSNs) with a solid component <5 mm, regardless of the size of the nonsolid component. The present study aims to determine the lung cancer (LC) detection and survival in BioMILD volunteers with SSNs. Materials and methods Eligible participants were 758 out of 4071 (18.6%) BioMILD volunteers without baseline LC and at least one SSN detected at the baseline or further low-dose computed tomography rounds. The outcomes of the study were LC detection and long-term survival. Results A total of 844 NSNs and 241 PSNs were included. LC detection was 3.7% (31 out of 844) in NSNs and 7.1% (17 out of 241) in PSNs, being significantly greater in prevalent than incident nodules (8.4% versus 1.3% in NSNs; 14.1% versus 2.1% in PSNs; p-value for both nodule types p<0.01). Most LCs from SSNs were stage I (42/48, 87.5%), resectable (47/48, 97.9%), and caused no deaths. The 8-year cumulative survival of volunteers with LC derived from SSNs and not derived from SSNs was 93.8% and 74.9%, respectively. Conclusion Conservative management of SSNs in LCS enables timely diagnosis and treatment of LCs arising from SSNs while ensuring the resection of more aggressive LCs detected away from SSNs.

PURPOSE:To evaluate the clinical and aesthetic outcome of percutaneous injection of sclerosant agents to treat head and neck cystic malformations (HNCM) and to assess their recurrence rate based on histology and site.METHODS:Fifty-four subjects (mean age 46 years) with HNCM treated by percutaneous injection of sclerosant agents between January and December 2017 were included. Imaging and clinical data before and after the procedure were collected. Quality of Life Index, Pain Visual Analogue Scale, and Aesthetic Scale scores were measured to assess clinical and aesthetic outcomes. A size reduction of ≥ 70% assessed through the visual scale was considered significant.RESULTS:Of the 54 HNCM, there were 26 (48%) lymphatic malformations (LM), 13 (24%) salivary epithelial duct cysts of the parotid gland, 12 (22%) salivary mucoceles, and 3 (5%) branchial cysts. A significant size reduction and a satisfactory clinical-aesthetic outcome were observed in all types of LM. The number of reinterventions was significantly associated with the number of lesions (p < 0.001). The lowest number of interventions was observed in macrocystic lymphatic malformations (average of 1.2 interventions). All salivary epithelial duct cysts showed a significant reduction in size, a satisfactory clinical-aesthetic outcome, and an average of 1.16 interventions per patient. Mucoceles had a worse response, with only 3/14 patients showing a satisfactory and long-lasting clinical outcome (average of 1.16 interventions). Treatment of branchial cysts showed the worst outcome with a limited clinical response (3/3).CONCLUSION:Percutaneous injection of sclerosant agents may be considered as a first-line treatment for LM and salivary epithelial duct cysts.

Airway-related quantitative imaging biomarkers are crucial for examination, diagnosis, and prognosis in pulmonary diseases. However, the manual delineation of airway trees remains prohibitively time-consuming. While significant efforts have been made towards enhancing airway modelling, current public-available datasets concentrate on lung diseases with moderate morphological variations. The intricate honeycombing patterns present in the lung tissues of fibrotic lung disease patients exacerbate the challenges, often leading to various prediction errors. To address this issue, the 'Airway-Informed Quantitative CT Imaging Biomarker for Fibrotic Lung Disease 2023' (AIIB23) competition was organized in conjunction with the official 2023 International Conference on Medical Image Computing and Computer Assisted Intervention (MICCAI). The airway structures were meticulously annotated by three experienced radiologists. Competitors were encouraged to develop automatic airway segmentation models with high robustness and generalization abilities, followed by exploring the most correlated QIB of mortality prediction. A training set of 120 high-resolution computerised tomography (HRCT) scans were publicly released with expert annotations and mortality status. The online validation set incorporated 52 HRCT scans from patients with fibrotic lung disease and the offline test set included 140 cases from fibrosis and COVID-19 patients. The results have shown that the capacity of extracting airway trees from patients with fibrotic lung disease could be enhanced by introducing voxel-wise weighted general union loss and continuity loss. In addition to the competitive image biomarkers for prognosis, a strong airway-derived biomarker (Hazard ratio>1.5, p<0.0001) was revealed for survival prognostication compared with existing clinical measurements, clinician assessment and AI-based biomarkers.

Several trials have shown that low-dose computed tomography-based lung cancer screening (LCS) allows a substantial reduction in lung cancer-related mortality, carrying the potential for other clinical benefits. There are, however, some uncertainties to be clarified and several aspects to be implemented to optimize advantages and minimize the potential harms of LCS. This review summarizes current evidence on LCS, discussing some of the well-established and potential benefits, including lung cancer (LC)-related mortality reduction and opportunity for smoking cessation interventions, as well as the disadvantages of LCS, such as overdiagnosis and overtreatment. Different perspectives are provided on LCS based on the updated literature.

Background:The proper management of suspicious radiologic findings is crucial to optimize the effectiveness of low-dose computed tomography (LDCT) lung cancer screening trials. In the BioMILD study, we evaluated the utility of combining a plasma 24-microRNA signature classifier (MSC) and LDCT to define the individual risk and personalize screening strategies. Here we aim to assess the utility of repeated MSC testing during annual screening rounds in 1024 participants with suspicious LDCT findings. Methods:The primary outcome was two-year lung cancer incidence in relation to MSC test results, reported as relative risk (RR) with 95% confidence interval (CI). Lung cancer incidence and mortality were estimated using extended Cox models for time-dependent covariates, yielding the respective hazard ratios (HR). Clinicaltrials.gov ID: NCT02247453. Findings:With a median follow-up of 8.5 years, the full study set included 1403 indeterminate LDCT (CTind) and 584 positive LDCT (CT+) results. A lung cancer RR increase in MSC+ compared to MSC- participants was observed in both the CTind (RR: 2.5; 95% CI: 1.4-4.32) and CT+ (RR: 2.6; 95% CI: 1.81-3.74) groups and was maintained when considering stage I or resectable tumors only. A 98% negative predictive value in CTind/MSC- and a 30% positive predictive value in CT+/MSC+ lesions were recorded. At seven years' follow-up, MSC+ participants had a cumulative HR of 4.4 (95% CI: 3.0-6.4) for lung cancer incidence and of 8.1 (95% CI: 2.7-24.5) for lung cancer mortality. Interpretation:Our study shows that MSC can be reliably performed during LDCT screening rounds to increase the accuracy of lung cancer risk and mortality prediction and supports its clinical utility in the management of LDCT findings of uncertain malignancy. Funding:Italian Association for Cancer Research; Italian Ministry of Health; Horizon2020; National Cancer Institute (NCI); Gensignia LifeScience.

BackgroundIn patients with idiopathic pulmonary fibrosis (IPF) there is a need to identify biomarkers that 1) are associated with increased risk of adverse outcome and 2) can be used to monitor treatment response or identify disease progression over time.MethodsTwo consecutive cohorts of patients with IPF were accessed from the Open Source Imaging Consortium database. Automated computed tomography (CT) biomarkers of disease severity incorporating fibrotic and pulmonary vascular features (the reticulovascular score and weighted reticulovascular score (WRVS)) were studied. Relationships between imaging biomarkers, lung function and survival were analysed.ResultsIn separate test and validation cohorts, 168 and 176 patients with IPF respectively (median survival 2.6 years) were studied. A threshold of WRVS ≥15% at baseline CT was most strongly associated with transplant-free survival (HR 3.00, 95% CI 1.47–6.10, p=0.002) when adjusted for baseline forced vital capacity (FVC) and age. In patients with 12-month follow-up CT and lung function tests (n=89) an increase in 3% of WRVS (the minimal clinically important difference) was also significantly associated with reduced survival independent of FVC, and outperformed visual evaluation of progressive fibrosis.ConclusionsWRVS is an automated CT biomarker which can identify patients with IPF at increased risk of progression and is able to reliably capture disease progression over time.

To assess the consistency of automated measurements of coronary artery calcification (CAC) burden and emphysema extent on computed tomography (CT) images acquired with different radiation dose protocols in a lung cancer screening (LCS) population. The patient cohort comprised 361 consecutive screenees who underwent a low-dose CT (LDCT) scan and an ultra-low-dose CT (ULDCT) scan at an incident screening round. Exclusion criteria for CAC measurements were software failure and previous history of CVD, including coronary stenting, whereas for emphysema assessment, software failure only. CT images were retrospectively analyzed by a fully automated AI software for CAC scoring, using three predefined Agatston score categories (0–99, 100–399, and ≥ 400), and emphysema quantification, using the percentage of low attenuation areas (