Lung cancer screening use before & during the COVID-19 pandemic in the US: Population-based evidence from 2019-2021

Introduction: Lung cancer is the leading cause of cancer-related death in the US with an estimated 236,740 new cases and 130,180 deaths expected in 2022. While early detection with low-dose computed tomography reduces lung cancer mortality by at least 20%, there has been a low uptake of lung cancer screening (LCS) use in the US. The COVID-19 pandemic caused significant disruption in cancer screening. Yet, little is known about how COVID-19 impacted already low use of LCS. This study aims to estimate LCS use before (2019) and during (2020 and 2021) the COVID-19 pandemic among LCS-eligible population in the US. Method(s): We used population-based, nationally representative, cross-section data from the 2019 (n=4,484), 2020 (n=1,239) and 2021 (n=1,673) Behavioral Risk Factor Surveillance System, Lung Cancer Screening module. The outcome was self-reported LCS use among eligible adults in the past 12 months. For 2019 and 2020, the eligibility was defined based on US Preventive Services Task Force (USPSTF) initial criteria-adults aged 55 to 80 years old, who were current and former smokers (had quit within the past 15 years) with at least 30 pack years of smoking history. For 2021, we used the USPSTF updated criteria- adults aged 50 to 80 years, current and former smokers (who had quit within the past 15 years) with at least 20 pack years of smoking history. We applied sampling weights to account for the complex survey design to generate population estimates and conducted weighted descriptive statistics and logistic regression models. Result(s): Overall, there were an estimated 1,559,137 LCS-eligible respondents from 16 US states in 2019 (AZ, ID, KY, ME, MN, MS, MT, NC, ND, PA, RI, SC, UT, VT, WV, WI), 200,301 LCS-eligible respondents from five states in 2020 (DE, ME, NJ, ND, SD), and 668,359 LCS-eligible respondents from four states in 2021 (ME, MI, NJ, RI). Among 2,427,797 LCS-eligible adults, 254,890;38,875;and 122,240 individuals reported receiving LCS in 2019, 2020 and 2021, respectively. Overall, 16.4% (95% CI 14.4-18.5), 19.4% (95% CI 15.3-24.3), and 18.3% (95% CI 15.6-21.3) received LCS during 2019, 2020, and 2021, respectively. In all years, the proportion of LCS use was higher among adults aged 65-74, insured, those with fair and poor health, lung disease and history of cancer (other than lung cancer). In 2020, a higher proportion of adults living in urban areas reported receiving LCS compared to those living in rural areas (20.36% vs. 12.7%, p=0.01). Compared to non-Hispanic White adults, the odds of receiving LCS was lower among Hispanic adults and higher among Non-Hispanic American Indian/Alaskan Native adults in 2020 and 2021, respectively. Conclusion(s): LCS uptake remains low in the US. An estimated 2,011,792 adults at high-risk for developing lung cancer did not receive LCS during 2019, 2020 and 2021. Efforts should be focused to increase LCS awareness and uptake across the US to reduce lung cancer burden.

A narrative review on radiation risk from imaging for COVID-19: Breaking the myths and the mithya

Radiotherapy-induced secondary malignancy is a well-known occurrence. During the COVID-19 pandemic, many people have undergone serial computed tomography (CT) imaging, and concerns have been raised regarding radiation-induced malignancies due to frequent scanning. Accordingly, various low and ultra-low-dose CT (LDCT) thorax protocols have been developed to reduce the dose of radiation. Major governing bodies worldwide have established guidelines regarding the indications for CT scans and chest X-rays during the pandemic. We, therefore, aimed to provide facts about the effects of radiation (both diagnostic and therapeutic). Through this article, we intend to break the myths and 'mithya' (misbeliefs) regarding diagnostic radiation and its association with cancer in this COVID-19 era. For this review, we performed a search in Google using specific keywords pertaining to imaging during COVID-19 and radiation risk. We also included the names of various global governing bodies in the Google search. We included only full text articles and guidelines from authentic websites. From this review, we conclude that if we follow the recommendations of various global governing bodies and use CT scan only in cases of moderate to severe COVID-related symptoms, adhere to the principle of 'as low as reasonably achievable' for radiation protection, and use LDCT scan protocols, we can significantly reduce the mean effective radiation dose delivered and the estimated cancer risk.Copyright © 2023 Cancer Research, Statistics, and Treatment. All rights reserved.

Low-dose computed tomography in COVID-19: systematic review

BACKGROUND: The increased number of computed tomography scans during the COVID-19 pandemic has emphasized the task of decreasing radiation exposure of patients, since it is known to be associated with an elevated risk of cancer development. The ALARA (as low as reasonably achievable) principle, proposed by the International Commission on Radiation Protection, should be adhered to in the operation of radiation diagnostics departments, even during the pandemic. AIM: To systematize data on the appropriateness and effectiveness of low-dose computed tomography in the diagnosis of lung lesions in COVID-19. MATERIALS AND METHODS: Relevant national and foreign literature in scientific libraries PubMed and eLIBRARY, using English and Russian queries "low-dose computed tomography” and "COVID-19,” published between 2020 and 2022 were analyzed. Publications were evaluated after assessing the relevance to the review topic by title and analysis. The references were further analyzed to identify articles omitted during the search that may meet the inclusion criteria. RESULTS: Published studies summarized the current data on the imaging of COVID-19 lung lesions and the use of computed tomography scans and identified possible options for reducing the effective dose. CONCLUSION: We present techniques to reduce radiation exposure during chest computed tomography and preserve high-quality diagnostic images potentially sufficient for reliable detection of COVID-19 signs. Reducing radiation dose is a valid approach to obtain relevant diagnostic information, preserving opportunities for the introduction of advanced computational analysis technologies in clinical practice. © Eco-Vector, 2023.

Low-dose computed tomography in COVID-19: systematic review

BACKGROUND: The increased number of computed tomography scans during the COVID-19 pandemic has emphasized the task of decreasing radiation exposure of patients, since it is known to be associated with an elevated risk of cancer development. The ALARA (as low as reasonably achievable) principle, proposed by the International Commission on Radiation Protection, should be adhered to in the operation of radiation diagnostics departments, even during the pandemic. AIM: To systematize data on the appropriateness and effectiveness of low-dose computed tomography in the diagnosis of lung lesions in COVID-19. MATERIALS AND METHODS: Relevant national and foreign literature in scientific libraries PubMed and eLIBRARY, using English and Russian queries "low-dose computed tomography” and "COVID-19,” published between 2020 and 2022 were analyzed. Publications were evaluated after assessing the relevance to the review topic by title and analysis. The references were further analyzed to identify articles omitted during the search that may meet the inclusion criteria. RESULTS: Published studies summarized the current data on the imaging of COVID-19 lung lesions and the use of computed tomography scans and identified possible options for reducing the effective dose. CONCLUSION: We present techniques to reduce radiation exposure during chest computed tomography and preserve high-quality diagnostic images potentially sufficient for reliable detection of COVID-19 signs. Reducing radiation dose is a valid approach to obtain relevant diagnostic information, preserving opportunities for the introduction of advanced computational analysis technologies in clinical practice. © Eco-Vector, 2023.

Incidental findings arising from targeted lung health checks: a GP practice perspective

Introduction: Newcastle Gateshead is a phase one Targeted Lung Health Checks site. Walker Medical Group GP practice serves a deprived population and is a designated Deep End practice. We report on the experience of Targeted Lung Health Checks at this practice. Method(s): Invitations were sent to eligible participants registered at the practice. Lung health checks were carried out by telephone according to Standard Protocol in the context of the COVID 19 pandemic. Those meeting criteria for Low Dose CT were invited to a mobile scanner located in the community near to the practice. Scans were reported according to the Standard Protocol. Result(s): Of 1481 eligible patients, 736 (50.44%) attended a telephone lung health check. 458 (63.6%) met criteria for a CT scan, of whom 33 declined a scan and 2 were unable to lie flat. 11 lung cancers (2.6%) and one other cancer were diagnosed. 71 (16.8%) had nodules requiring follow-up. These cases were managed by the TLHC programme and lung cancer MDT. Incidental findings had the greatest impact on general practice. 72.3% of scans showed coronary artery calcification. Of these, over 1 in 4 was not currently prescribed a Statin. New diagnoses of bronchiectasis (8 patients = 2%) and interstitial lung disease (7 patients = 1.6%) required GP action. 5 new cases of undiagnosed thoracic aortic aneurysm were identified, requiring referral for further action (1%). Conclusion(s): Incidental findings of Targeted Lung Health Checks CT scans require substantial input from a GP team. Coronary artery calcification is numerically most significant. Participants and practices should be supported by information and resources. Thoracic aortic aneurysm cases are also found in significant numbers and TLHC projects are advised to work with cardiology and cardiac surgery units when setting up. We plan to explore the reasons for participant refusal of CT scanning. Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.

Application of chest low-dose CT screening of Corona Virus Disease 2019 with a third-generation dual-source scanner.

Objective: To investigate the application value of third-generation dual-source CT(3-G DSCT) low-dose scan mode combined with iterative reconstruction technology in the screening of COVID-19 and to evaluate the radiation dose. Method(s): One hundred and twenty patients suspected of COVID-19 from December 2019 to February 2020 were retrospectively analysed and randomly divided into two groups (test group and conventional group, 60 patients in each). The parameters for test group included 3-G DSCT, Turbo Flash scan mode, CARE kV, with reference 90 kV, pitch 2.0, and ADMIRE algorithm, while those parameters for conventional group included the 128-slice CT, conventional spiral scan mode, 120 kV, pitch 1.2, and FBP algorithm. The CT values of aorta, spinal posterior muscle, and subcutaneous fat, the aortic noise, signal-to-noise ratio (SNR), and contrast noise ratio (CNR) were compared to evaluate the image quality between two groups. Two experienced doctors scored the image quality using a double-blind method, and compared the CT dose index volume (CTDIvol), dose-length product (DLP), and effective dose (E) of the two groups. Result(s): The CT value of the aorta and spinal posterior muscle and the aortic SNR in the test group were (45.38+/-4.77), (53.41+/-8.44) HU, and 2.82+/-0.59, and significantly higher than those in the conventional group [(39.68+/-6.26), (42.66+/-6.32) HU, 2.58+/-0.61, t=5.608, 7.897, 2.162, P<0.05]. The aortic noise, CNR and subjective scores between the two groups had no significant difference( P>0.05). The CTDIvol, DLP, and E in the test group were (3.09+/-1.02) mGy, (107.57+/-32.81) mGy*cm, (1.51+/-0.46) mSv, significantly lower than those in the conventional group [(7.00+/-1.80) mGy, (261.65+/-73.93) mGy*cm, (3.66+/-1.03) mSv;t=-14.680, -14.756, -14.756, P<0.05]. Conclusion(s): In the screening of COVID-19, using low-dose scanning mode of 3-G DSCT combined with iterative reconstruction technology would provide diagnostic quality images and meanwhile effectively reduce the radiation dose and improve the SNR of the image.Copyright © 2020 by the Chinese Medical Association.

The application value of low-dose CT scan in pregnant women with COVID-19.

Objective: To explore the value of low-dose CT in pregnancy with COVID-19. Method(s): A retrospective analysis was performed on the clinical characteristics, laboratory tests, and chest CT findings of 12 pregnant women with COVID-19 diagnosed by nucleic acid testing in the Renmin Hospital of Wuhan University from January 20, 2020 to February 16, 2020. Two radiologists blinded to the reconstruction algorithm independently scored subjective image quality on a 5-point Likert scale. Image quality score >= 3 was acceptable in clinics. The CT radiation doses were recorded, including CT volume dose index (CTDIvol), dose length product (DLP), and effective radiation dose (E). Two radiologists observed the distribution, shape, density, and other characteristics of lung lesions, and they also decided whether hilar, mediastinal lymphadenopathy, and pleural changed. Result(s): A total of 12 pregnant women with COVID-19, 8 had cough, 4 had fever, 2 had chest tightness, and 1 had dyspnea and diarrhea each. The CT image quality score of all patients was 3-4, with an average of 3.46, which fully met the clinical diagnosis requirements. The CTDIvol value was 1.13-4.31 mGy, with an average of 3.02 mGy. The DLP value was 34.48-75.29 mGy*cm, with an average of 55.48 mGy*cm. The Evalue was 0.48-1.05 mSv, with an average of 0.78 mSv. In all cases, chest CT examination showed abnormal manifestations after clinical symptoms, including unilateral lung lesions in 5 cases and bilateral lung lesions in 7 cases, 1 case of ground-glass opacity, 1 case of solidification, 7 cases of ground-glass and consolidation, 1 case of strip opacity, ground-glass, and consolidation and strip cable shadow coexisted in 2 cases. Conclusion(s): The application of low-dose CT scan in pregnant women with COVID-19 is completely feasible. CT mainly manifested as bilateral lung patchy and flaky ground-glass opacity with consolidation. Active and effective treatment can help recover and improve prognosis.Copyright © 2020 by the Chinese Medical Association.

Evaluation of low-dose CT protocol of novel coronavirus pneumonia based on infection prevention and control.

Objective: To explore a low dose CT scanning method on novel coronavirus (COVID-19) pneumonia based on infection prevention and control. Method(s): A total of 140 patients with confirmed novel coronavirus pneumonia in Xiehe hospital from January 20, 2020 to February 28, 2020 were undertaken CT scan and divided into low dose group and conventional dose group. The patients in low dose group(120 kV, 31 mAs) consisted of mild type(51), severe type(15) and critically ill type(4);and those in conventional dose group(120 kv, adaptive milliampere second) consisted of mild type(48), severe type(17) and critically ill type(5). The effective radiation dose, SNR and CNR of CT scan were compared between two groups. A senior and a middle radiologist made the image subjective quality scores, respectively. Result(s): The effective dose in low dose group was lower than that of conventional dose group(t=-48.343, P<0.05). There was no significant difference in SNR and CNR between two groups(P>0.05). For severe and critically ill patients, the score in low dose group was significantly lower than that in conventional dose group(t=-2.781, P<0.05). There was no significant difference in scores between two groups for mild patients(P>0.05). Conclusion(s): Low-dose CT scanning could meet the image quality needs for patients with COVID-19 and meanwhile significantly reduce the radiation dose.Copyright © 2020 by the Chinese Medical Association.

Lung Cancer Screening Program via Primary Care Clinics

Lung Cancer Screening (LCS) reduces lung cancer mortality by 20 to 24% however in the US only 5.7% of eligiblepatients participate. Increasing screening of individuals at risk for lung cancer is an unmet need. We started a LCSprogram using primary care physicians (PCP) visits where the intake nurse asked age appropriate patients abouttheir smoking status. If patients met criteria, the physician was alerted to perform shared decision making, offersmoking cessation and order a low dose screening CT scan (LDCT). The results were managed by a physician'sassistant dedicated to the LCS program. This quality improvement study analyzed all patients enrolled from June2019 to July 2021. The LCS program rolled out slowly beginning with 6 PCPs in June to November 2019, 26 PCPsfrom November 2019 to February 2020 and all 56 PCPs from February 2020 to July 2021. COVID-19 stopped LDCTsfrom March 2020 to August 2020. Use of a LCS program run through PCP clinics screened 1,247 (21.3%) eligibleveterans, a 3.7 fold increase over the national average. Of the 2,069 (35.3%) eligible patients initially identified by thecomputer based reminder, 1,824 (88.2%) accepted LCS, 1,383 (66.8%) completed the initial LDCT and 136 (9.8%)were ultimately found to be ineligible after completion of the LDCT. The 136 ineligible patients received 173 LDCTs ofwhich 91% were Lung-RADS 1 or 2 and 0.6% were Lung-RADS 4A. Within the appropriately screened patients, 12(1%) lung cancers and 1 papillary thyroid cancer were found and 26.5% of scans showed evidence of Chronic Obstructive Pulmonary Disease and 11.9% showed coronary artery disease. Use of PCP clinics increased enrollment 3.7 fold over national averages.

Automated analysis of lung lesions in COVID-19: comparison of standard and low-dose CT

Introduction. Chest computed tomography (CT) plays a prominent role in determining the extent of pulmonary parenchymal lesions in COVID-19. At the same time, subjectivity of lung lesion volume assessment using 0-4 CT scale in COVID-19 and gradual introduction of low-dose CT (LDCT) requires an investigation of semi-automated lung segmentation accuracy in LDCT compared to CT. Study Objective. To compare the accuracy of affected lung tissue volume calculation between CT and LDCT in COVID-19 using a semi-automatic segmentation program. Material and Methods. The retrospective study was performed on data from the earlier prospective multicenter study registered at ClinicalTrials.gov, NCT04379531. CT and LDCT data were processed in 3D Slicer software with Lung CT Segmenter and Lung CT Analyzer extensions, and the volume of affected lung tissue and lung volume were determined by thresholding. Results. The sample size was 84 patients with signs of COVID-19-associated pneumonia. Mean age was 50.6 ± 13.3 years, and the median body mass index (BMI) was 28.15 [24.85;31.31] kg/m2. The effective doses were 10.1 ± 3.26 mSv for the standard CT protocol and 2.64 mSv [1.99;3.67] for the developed LDCT protocol. The analysis of absolute lung lesion volume in cubic centimeters with Wilcoxon Signed Ranks Test revealed a statistically significant difference between CT and LDCT (p-value < 0.001). No statistically significant differences were found in the relative values of lung tissue lesion volume (lesion volume/lung volume) between CT and LDCT using Wilcoxon Signed Ranks Test (p-value = 0.95). Conclusion. The reliability of developed LDCT protocol in COVID-19 for the semi-automated calculation of affected tissue percentage was comparable to the standard chest CT protocol when using 3D Slicer with Lung CT Segmenter and Lung CT Analyzer extensions. © 2022 Tomsk State University. All rights reserved.

Application value of post-discharge chest low-dose CT for patients with COVID-19.

Objective: To explore the value of chest low-dose CT (LDCT) in post-discharge follow-up assessments of patients with coronavirus disease 2019 (COVID-19). Method(s): The chest CT findings of 58 patients with COVID-19 from March 17 to March 25, 2020 at Remin Hospital of Wuhan University were retrospectively analyzed. Two radiologists independently scored the subjective image quality on a 5-point Likert scale. The signal-to-noise ratio (SNR) and SDair of images and the CT radiation dose parameters were calculated, including the CT volume dose index (CTDIvol), dose length product (DLP), and effective radiation dose (E). Result(s): The subjective image quality scores on CT images obtained before and after discharge by readers 1 and 2, were 4.45+/-0.22, 3.88+/-0.33 (P>0.05) and 4.37+/-0.18, 3.91+/-0.35 (P>0.05), respectively. The SNR and SDair in LDCT after discharge were 4.39+/-0.95 and 7.19+/-2.41, which were significantly lower than those in routine chest CT before discharge (5.14+/-1.06, Z=-5.551, P<0.001;6.48+/-1.57, Z=-3.217, P<0.001). All of the obtained images were sufficient for diagnosis. The CTDIvol, DLP, and E in LDCT were significantly lower than those in routine CT [(2.41+/-0.09), (10.53+/-1.03)mGy, Z=-6.568, P<0.001;(88.03+/-5.33), (338.74+/-34.64)mGy*cm, Z=-6.624, P<0.001;and (1.23+/-0.17), (4.74+/-0.48)mSv, Z=-5.976, P<0.001]. Conclusion(s): Patients with COVID-19 can be followed up with low-dose chest CT after discharge.Copyright © 2020 by the Chinese Medical Association.

Infection control status of novel coronavirus pneumonia and radiation safety at CT workplace.

CT is an important imaging tool for the diagnosis of novel coronavirus pneumonia (COVID-19), therefore, it's necessary to strictly control the disinfection of CT workplace and equipment and biosafety to avoid the place from becoming a potential infection source and to reduce the risk of infection of patients and radiological staff. It is also necessary to reduce the CT scan dose to minimize the radiation hazards on patients under the premise of ensuring the CT image quality and diagnostic efficiency. Based on the survey that novel coronavirus residues after disinfection at some CT workplace in domestic and overseas and the application of low-dose CT scan in diagnosis of COVID-19, as well as the current situation of radiological protection management in emergency hospital, this paper summarizes and proposes suggestions on infection control and radiological protection for CT workplace to strengthen the defense line of COVID-19 prevention and control.Copyright © 2021 by the Chinese Medical Association.

24th Asia-Pacific League of Associations for Rheumatology Congress, APLAR

The proceedings contain 539 papers. The topics discussed include: advances in the understanding and management of atherosclerosis in inflammatory arthritis;long-term safety and efficacy of voclosporin in Asian patients with lupus nephritis;clinical profile of four children with juvenile dermatomyositis and anti-SAE antibody positivity: a single center experience from north India;the MMP degraded and citrullinated vimentin (VICM) is a diagnostic and treatment response biomarker;incidence and outcome of covid-19 in AIRD patients on concomitant treatment with tofacitinib- results from KRA covid cohort (KRACC) subset;are we treating-to-target in spondyloarthritis (SPA)? a cross-sectional analysis from the Asia Pacific league of associations for rheumatology (APLAR) SPA registry;utilities of low-dose computed tomography (LDCT) on identifying patient with axial psoriatic arthritis (AXPSA) a cross-sectional study;age-related genes USP2 and ARG2 are involved in the reduction of immune cell infiltration in elderly patients with rheumatoid arthritis;and MICRORNA-27a-3p inhibits lung and skin fibrosis of systemic sclerosis by negatively regulating SPP1.

PSMA PET/CT Detected Prostate Cancer Metastasis in a Patient with Negative mpMRI and Prostate Gland Biopsy

Aim/Introduction: This is a case of [68 Ga]Ga-Prostate-specific membrane antigen(PSMA)-11 PET/CT in a 73-years old patient with significantly high iPSA level despite both multiparametric magnetic resonance imaging (mpMRI) and 12-core saturation biopsy negative for prostate cancer (Pca). Material(s) and Method(s): In November 2021 the patient underwent a routinary abdomen ultrasound with the detection of several pelvic and retro-peritoneal adenomegalies, confirmed by diagnostic CT. Initially the suspect of Pca origin was raised, due to high PSA levels (55 ng/dl versus 2.1ng/dl the previous year). A 12-samples saturation biopsy was then performed, with inconclusive result. Nevertheless, due to further increase in PSA level up to 77ng/dl in December (PSA doubling time approximately 4 months), a mpMRI was performed in January showing absence of clinically significant PCa (PIRADS 2) and persistence of enlarged pelvic lymph nodes. The patient was subsequently referred for a [68Ga]Ga-PSMA-PET/CT, which was performed and reported following standard EANM guidelines. A delayed 90 min scan on the pelvis was also acquired. Result(s): In accordance with previous mpMRI, PSMA-PET/CT detected no significant nor focal uptake within the prostate gland even at delayed acquisition (diffuse pattern, SUVmax 3.6). Interestingly, multiple PSMA-avid pelvic and retroperitoneal lymphadenopathies were detected (SUVmax 34) as well as a single, intense focal bone lesion at L3 vertebral body (SUVmax 14, corresponding with initial focal osteoblastic lesion at low-dose CT images-LDCT), and a single focal uptake in a left axillary lymph-node (SUVmax 19). Of note, the latter lymph-node was homolateral to the injection site of recent anti-SARS-Cov2 vaccination and without clearly pathological pattern on LDCT. However, due to its high PSMA expression, it was chosen for ultrasound-guided biopsy and finally diagnosed as Pca metastasis. Conclusion(s): Several malignancies can present with subdiaphragmatic nodal findings, but this is a highly interesting case as, despite the advanced metastatic spread at initial presentation, the primary Pca was detected by none of the diagnostic techniques. The importance of [68Ga]Ga-PSMA-PET/ CT was to rapidly pave the way to reach the final diagnosis by selecting the unusual axillary lesion with elevated PSMA expression as the target biopsy for a mini-invasive approach optimizing patient management;in addition, it was able to detect a single PSMA avid sclerotic lesion typical for initial bone spread of PCa.

Persistent symptoms after COVID-19 infection : place of pulmonary scintigraphy

Aim/Introduction: COVID-19 and the SARS-CoV-2 pandemic has been ongoing for 2 year and thromboembolic events have been described as a major complication at the time of the infection and as a mid-term event, even in patients on prophylactic anticoagulants.In this study we underline the importance of the pulmonary scintigraphy in the detection of early or mid terme thromboembolic events especially in subsegmental pulmonary arteries who could be missed by CT pulmonary angiography. Material(s) and Method(s): In our department we performed 12 pulmonary perfusion scintigraphy for patients presenting persisting respiratory symptoms (such as dyspnea, thoracic pain ) after covid-19 infection. Most of our patients were women (sex ratio 1,3) and the mean age was 55.4 yAfter intravenous injection of 148-222 MBq (4-6mCi) of 99mTc-macroaggregated albumin, SPECT imaging with low-dose CT was performed with the patient supine. Planar imaging was done in multiple projections (anterior and posterior;right anterior and posterior oblique;and left anterior and posterior oblique). The images were reconstructed in the transaxial, coronal, and sagittal views and were reviewed for perfusion defects. Modified PIOPED criteria were used to interpret the exams : The mismatched perfusion defects in this study were based on a mismatch between CT and scintigraphy images since we do not perform ventilation scans in our department. Result(s): On a median interval of 2 months after infection , Lung perfusion defects (of any type) were observed in 11 out of 12 subjects (92%). Patients with severe COVID-19 were not at higher risk of having mismatched perfusion defects than were patients with moderate COVID-19 and the interval between COVID-19-positive reports and scanning did not reduce the risk for mismatched perfusion defects.Mismatched perfusion defects were the commonest and were observed in 9 subjects (75%), suggestive of pulmonary embolism and leading to the instauration of curative anticoagulants. Conclusion(s): With these results, we aim to show that Lung perfusion scintigraphy can play an important role in the screening of such patients who may be at risk for developing pulmonary embolism as post-SARS-CoV-2 infection sequelae.

Importance of hybrid pulmonary scintigraphy in patients with dyspnea after COVID-19 pneumonia - case report

Aim/Introduction: Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases. ILD causes scarring (fibrosis) of the lungs by immunopathological processes at the level of the lung interstitium (interalveolar interstitium, alveoli and peribronchial interstitium), which blocks efficient gas exchange at the alveolocapillary membrane and can lead to respiratory insufficiency. In the last year, we have encountered a number of patients after COVID-19 pneumonia with this condition. Material(s) and Method(s): A 66-year-old female patient was sent to our department to rule out pulmonary embolism. She had been suffering from bilateral COVID-19 pneumonia with supporting oxygen therapy. Due to the increased serum levels of D-dimers and clinical picture, pulmonary embolism was suspected. In addition, the patient had an urinary tract infection. In her medical history, she had type 2 diabetes mellitus, arterial hypertension, pancreatic polycystosis, and stroke. We performed V/Q lung scintigraphy (81mKr and 99mTc-MAA) on a two-detector hybrid gamma camera with LDCT. Result(s): Pulmonary scintigraphy showed a fairly homogeneous distribution of activity on perfusion and ventilation scans, so we could rule out pulmonary embolism. On low-dose CT, we detected significant parenchymal interstitial changes with a mixed density of a honeycomb character and fluidothorax. This demonstrates the interstitial nature of lung damage from viral pneumonia without a significant change in perfusion and ventilation distribution and explains the clinically present dyspnea. Conclusion(s): Hybrid pulmonary scintigraphy in patients after COVID-19 pneumonia can explain the cause of dyspnea even with reliable exclusion of possible pulmonary embolism by evidence of interstitial parenchymal changes and the presence of effusion.

COVID-19 VACCINATION-ASSOCIATED LYMPHADENOPATHY: A DIAGNOSTIC CONUNDRUM IN LUNG CANCER STAGING

SESSION TITLE: Lung Cancer Imaging Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Coronavirus disease 2019 (COVID-19) pandemic affected millions of people globally, prompting the emergent need for an effective vaccine. Lymphadenopathy associated with COVID-19 vaccine is a recognized phenomenon that can present a diagnostic dilemma for staging thoracic malignancies. We present a case of post COVID-19 vaccination axillary lymphadenopathy complicating the staging process for a patient with newly diagnosed lung adenocarcinoma. CASE PRESENTATION: A 64-year-old-male with chronic obstructive pulmonary disease, former smoker with a 20-pack-year smoking history was found to have a 1.7 cm solid nodule in the left upper lobe with irregular margins on low dose computed tomography (CT) scan of the chest for lung cancer screening. Fine needle aspiration of the nodule was done, and histopathology results were consistent with the diagnosis of adenocarcinoma. Patient then underwent fluorodeoxyglucose-positron emission tomography (FDG-PET) scan that showed a 16 mm nodule in the left upper pulmonary lobe with maximum standardized uptake value (SUVmax) of 5.3 and left axillary nodes measuring up to 8 mm with SUVmax of 4.4 concerning for metastatic disease. On further history, patient had received the Pfizer mRNA vaccination booster three days prior to undergoing the FDG-PET scan. Patient was evaluated by oncology and decision was made to treat with a 7-day course of prednisone 20 mg daily and to repeat FDG-PET scan. FDG-PET scan done four weeks later showed resolution of axillary lymphadenopathy. Patient was clinically staged as T1bN0M0 stage 1A and underwent robotic left upper lobe lingular-sparing lobectomy. DISCUSSION: In patients with thoracic malignancies, lymphadenopathy related to COVID-19 vaccination with avid FDG uptake on PET scan was reported in 29% of patients (2). The presentation of FDG avid lymphadenopathy creates a clinical challenge by confounding accurate cancer staging and leading to unnecessary workup (3). More importantly, detection of lymphadenopathy while staging lung cancer has crucial implications in the process of triaging patients to oncologic management in terms of candidacy for surgical resection (3). Currently, no consensus is available to guide management for incidental lymphadenopathy associated with COVID-19 vaccination in lung cancer patients. For this patient, we chose to treat with steroids and to obtain repeat imaging within 4 weeks of the original FDG-PET to not delay treatment planning. Repeat imaging showed resolution of the axillary lymphadenopathy and patient was able to undergo definitive treatment promptly. CONCLUSIONS: This case highlights the diagnostic challenge posed by COVID-19 lymphadenopathy in patients with newly diagnosed lung cancer and delineates our approach to navigating this challenge to avoid malignancy up-staging and treatment delay. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Nishino M, Hatabu H, Ricciuti B, Vaz V, Michael K, Awad MM. Axillary Lymphadenopathy After Coronavirus Disease 2019 Vaccinations in Patients with Thoracic Malignancy: Incidence, Predisposing Factors, and Imaging Characteristics. J Thorac Oncol. 2022;17(1):154-159. doi:10.1016/j.jthoCH.2021.08.761 Reference #3: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi: 10.1016/j.jacr.2021.03.001 DISCLOSURES: No relevant relationships by Hadya Elshakh No relevant relationships by Stephen Karbowitz No relevant relationships by Gina Villani

SUBCLINICAL LYMPHADENOPATHY ON FDG-PET IN LUNG CANCER SCREENING AFTER COVID-19 VACCINE BOOSTER

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaccine-related lymphadenopathy (VRL) is a local reaction like pain and swelling and has been associated with mRNA Pfizer/Moderna COVID-19 vaccines more than other vaccines (1). VRL can lead to false positives on nuclear imaging studies and confound the evaluation of patients during cancer screenings or treatments. The first COVID-19 VRL seen on imaging was reported in January 2021 in two patients undergoing breast mammogram (1). Since then, more cases have been reported in other nuclear imaging studies (1). Here, we report a case of subclinical unilateral VRL by FDG-PET 3 days after the patient received the Moderna COVID-19 booster. CASE PRESENTATION: 73-year-old male smoker returned for a 6 month follow up low dose CT for a 7 mm left upper lobe (LUL) nodule. He received the Moderna COVID-19 booster in the left deltoid the same day. The LUL nodule was found to be slightly larger at 8 mm and ipsilateral axillary nodes were not enlarged (Figure 1). He returned 3 days later for FDG-PET which showed mild uptake in the LUL nodule (SUV 1.8) and hypermetabolic left axillary nodes (Figure 2). COVID booster date/laterality was documented, and the FDG-PET summary included a comment about a possible inflammatory response to the booster. A repeat low dose chest CT in 3 months was recommended. DISCUSSION: After the first reported cases of COVID-19 VRL, recommendations were published to aid providers in evaluating clinical and imaging abnormalities. The Society of Breast Imaging recommended the "wait and watch” approach for unilateral COVID-19 VRL within the preceding 4 weeks only if appropriate in the clinical context;repeat exam in 4-12 weeks and lymph node sampling if VRL persists (1). All other screening exams should be scheduled prior to the first dose of the COVID-19 vaccine or 4-6 weeks after the second dose (1). Radiology experts recommended: 1) imaging screening exam to be scheduled at least 6 weeks after the final vaccination, 2) administer the vaccine in the arm contralateral to any primary or suspected cancer, and 3) record the vaccine date, injection site, and type (1). Months later, they recommended that in patients with a known vaccination history, ipsilateral VRL can be managed conservatively without further imaging (1). CONCLUSIONS: The current recommended COVID-19 Pfizer/Moderna vaccination consists of a two-dose primary series and a booster dose 5 months later. In a recent single-center study in oncologic patients in Israel who had FDG-PET after the Pfizer booster, the duration of unilateral axillary VRL was found to be shorter than the first and second dose (2). Therefore it has been suggested that FDG-PET can be scheduled 2 weeks after the third dose (3). Whether there will be any changes in the guidelines to accommodate this finding remains to be seen. More studies are needed to best inform clinicians because COVID-19 vaccinations will continue for the foreseeable future. Reference #1: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi:10.1016/J.JACR.2021.03.001 Reference #2: Cohen D, Hazut Krauthammer S, Wolf I, Even-Sapir E. A sigh of relief: vaccine-associated hypermetabolic lymphadenopathy following the third COVID-19 vaccine dose is short in duration and uncommonly interferes with the interpretation of [18F]FDG PET-CT studies performed in oncologic patients. Eur J Nucl Med Mol Imaging. 2021. doi:10.1007/S00259-021-05579-7 Reference #3: Thaweerat W. Optimization of FDG PET study after mRNA COVID-19 vaccination to reduce the interference of vaccine-associated hypermetabolic lymphadenopathy. Ann Nucl Med 2021 363. 2022;36(3):327-328. doi:10.1007/S12149-021-01712-6 DISCLOSURES: No relevant relationships by Anh Nguyen No relevant relationships by Perry Nystrom

A Programmatic Approach to Improve Efficiency in Lung Cancer Screening

Introduction: Largely as a result of the COVID pandemic, our lung cancer screening (LCS) program was underperforming entering 2021. The program serves a majority minority, socio-economically disadvantaged community. Loss of personnel and reallocated resources, allied to pandemic focus, led to decreased referrals and excessive time from referral to low dose computed tomography (LDCT) appointments. Here we describe our programmatic approach to improve LCS metrics. Methods: LCS transitioned from a Department of Radiology program into a Cancer Center-administered collaborative effort under surgical oncology and radiology leadership. Outreach efforts were reinitiated. To facilitate referrals from our primary care network, the cancer service line created a practical guide, “6 Steps to Lung Cancer Screening”, directly linked to an e-referral mechanism in our EMR. Monthly review and quality assurance meetings were held with a multidisciplinary team, specifically focused on program volume and on addressing delays to LDCT appointments. An additional Nurse Practitioner was brought in to enhance the existing LCS Nurse Navigator and Cancer Center staff were utilized to contact and schedule patients and to perform data compilation and analysis. Results: In 2020, LCS referrals had decreased 13% from 2019. In Q1/2021, the median monthly number of LCS referrals was 132 which increased steadily by quarter to 218 in Q4/2021 (p=0.16, Figure 1A). In January 2021, the average time from LCS referral to LDCT appointment was 101 days. Despite the increasing number of referrals through 2021, we were able to decrease the time to appointment from a median of 86 days in Q1/2021 to a median of 29 days in Q4/2021 (p=0.02, Figure 1B). By December 2021, the average time from LCS referral to LDCT appointment was just 18 days. Our LCS referral population was predominantly non-white (76%). Among them, 7.4% of patients with LDCT scans were found to have Lung RADS 3 or 4 nodules. All of these patients were referred to a newly created high-risk lung nodule clinic for management and follow up. Conclusions: We employed a multidisciplinary team approach to improve inefficiencies in our LCS program. The resources, support, and leadership of the health care system’s Cancer Center were crucial to this multi-pronged initiative. The decreased time from LCS referral to LDCT facilitates our ability to handle the anticipated growth in referral volume. This has been shown to enhance engagement with LCS and to improved annual screening compliance, translating to earlier detection of lung cancer and to improved patient outcomes. [Formula presented] Keywords: Lung cancer screening, Adherence, Disparity

Lung Cancer Screening Patients Experiences and Satisfaction: Quantitative and Qualitative Findings From a Survey Study

Introduction: In 2015, H. Lee Moffitt Cancer Center & Research Institute (MCC) launched a lung cancer screening program for high-risk individuals based on National Comprehensive Cancer Network guidelines. To identify successes and barriers of this program from the patient perspective, we conducted a survey study to measure patient experiences and satisfaction with lung cancer screening. Methods: In August 2020, a survey and cover letter were mailed to 576 patients who completed one or more lung cancer screenings at MCC. In addition to demographics, smoking history, and impact of the COVID-19 pandemic to get screened, the survey included 34 quantitative questions using a 5-point Likert scale and six open-ended questions. The quantitative questions measured patient satisfaction and experiences across 6 domains: appointment process, clinical staff interactions, communication, visit with the provider, screening results, cost, and clinic facility/overall satisfaction. Results were quantified using descriptive statistics. The six open-ended items elicited barriers and facilitators related to returning for screening, experiences with other cancer screenings, positive and negative experiences with the low-dose computed tomography (LDCT) visit, and suggestions for improving the process of LDCT screening visits. Content analysis using the constant comparison method was applied to the text and coded based on the a priori codes of the open-ended questions. Results: Among the 212 patients (37% completion rate) who completed the survey, 97.6% were white, 48.6% were female, and the mean age was 69 years. In the communication domain, 81.1% “strongly agreed/agreed” that the lung cancer screening process was clearly explained, 92.5% “strongly agreed/agreed” that the potential harms and limitations were clearly explained and 76.9% “strongly agreed/agreed” that the process for follow-up screening was clearly explained. For the provider questions, 71.7% “strongly agreed/agreed” that the provider was willing to listen carefully and 68.4% “strongly agreed/agreed” that the instructions were easy to understand. For results and costs, 78.3% “strongly agreed/agreed” the screening results were clearly explained and 70.8% “strongly agreed/agreed” that the cost of the screening was justified. Regarding overall satisfaction, 88.2% “strongly agreed/agreed” they would recommend lung cancer screening at MCC. Patients who had Medicare insurance or paid out-of-pocket had higher agreement about helpfulness of the staff who assisted them with billing or insurance compared to patients who had private insurance coverage (79.4% Medicare coverage, 60.0% private, and 75.0% self-pay: P-value=0.025). In the qualitative findings, respondents provided generally positive comments about their lung cancer screening experience. Negative comments were related to desire for more information about results, long wait times for results, and billing issues. Conclusions: This study provided insights about patient experiences and satisfaction with lung cancer screening which are important, given the low uptake of this life-saving modality. Ongoing patient-centered feedback may improve the lung cancer screening experience and increase follow-up screening rates. Keywords: survey, screening, patient satisfaction