USPSTF2013 versus PLCOm2012 lung cancer screening eligibility criteria (International Lung Screening Trial): interim analysis of a prospective cohort study.

BACKGROUND: Lung cancer is a major health problem. CT lung screening can reduce lung cancer mortality through early diagnosis by at least 20%. Screening high-risk individuals is most effective. Retrospective analyses suggest that identifying individuals for screening by accurate prediction models is more efficient than using categorical age-smoking criteria, such as the US Preventive Services Task Force (USPSTF) criteria. This study prospectively compared the effectiveness of the USPSTF2013 and PLCOm2012 model eligibility criteria. METHODS: In this prospective cohort study, participants from the International Lung Screening Trial (ILST), aged 55-80 years, who were current or former smokers (ie, had ≥30 pack-years smoking history or ≤15 quit-years since last permanently quitting), and who met USPSTF2013 criteria or a PLCOm2012 risk threshold of at least 1·51% within 6 years of screening, were recruited from nine screening sites in Canada, Australia, Hong Kong, and the UK. After enrolment, patients were assessed with the USPSTF2013 criteria and the PLCOm2012 risk model with a threshold of at least 1·70% at 6 years. Data were collected locally and centralised. Main outcomes were the comparison of lung cancer detection rates and cumulative life expectancies in patients with lung cancer between USPSTF2013 criteria and the PLCOm2012 model. In this Article, we present data from an interim analysis. To estimate the incidence of lung cancers in individuals who were USPSTF2013-negative and had PLCOm2012 of less than 1·51% at 6 years, ever-smokers in the Prostate Lung Colorectal and Ovarian Cancer Screening Trial (PLCO) who met these criteria and their lung cancer incidence were applied to the ILST sample size for the mean follow-up occurring in the ILST. This trial is registered at ClinicalTrials.gov, NCT02871856. Study enrolment is almost complete. FINDINGS: Between June 17, 2015, and Dec 29, 2020, 5819 participants from the International Lung Screening Trial (ILST) were enrolled on the basis of meeting USPSTF2013 criteria or the PLCOm2012 risk threshold of at least 1·51% at 6 years. The same number of individuals was selected for the PLCOm2012 model as for the USPSTF2013 criteria (4540 [78%] of 5819). After a mean follow-up of 2·3 years (SD 1·0), 135 lung cancers occurred in 4540 USPSTF2013-positive participants and 162 in 4540 participants included in the PLCOm2012 of at least 1·70% at 6 years group (cancer sensitivity difference 15·8%, 95% CI 10·7-22·1%; absolute odds ratio 4·00, 95% CI 1·89-9·44; p<0·0001). Compared to USPSTF2013-positive individuals, PLCOm2012-selected participants were older (mean age 65·7 years [SD 5·9] vs 63·3 years [5·7]; p<0·0001), had more comorbidities (median 2 [IQR 1-3] vs 1 [1-2]; p<0·0001), and shorter life expectancy (13·9 years [95% CI 12·8-14·9] vs 14·8 [13·6-16·0] years). Model-based difference in cumulative life expectancies for those diagnosed with lung cancer were higher in those who had PLCOm2012 risk of at least 1·70% at 6 years than individuals who were USPSTF2013-positive (2248·6 years [95% CI 2089·6-2425·9] vs 2000·7 years [1841·2-2160·3]; difference 247·9 years, p=0·015). INTERPRETATION: PLCOm2012 appears to be more efficient than the USPSTF2013 criteria for selecting individuals to enrol into lung cancer screening programmes and should be used for identifying high-risk individuals who benefit from the inclusion in these programmes. FUNDING: Terry Fox Research Institute, The UBC-VGH Hospital Foundation and the BC Cancer Foundation, the Alberta Cancer Foundation, the Australian National Health and Medical Research Council, Cancer Research UK and a consortium of funders, and the Roy Castle Lung Cancer Foundation for the UK Lung Screen Uptake Trial.

Feasibility of Applying Real-time Optical Imaging During Bronchoscopic Interventions for Central Airway Obstruction.

BACKGROUND: Interventional bronchoscopists manage central airway obstruction (CAO) through dilation, tumor ablation, and/or stent insertion. Anatomical optical coherence tomography (aOCT), a validated light-based imaging technique, has the unique capacity of providing bronchoscopists with intraprocedural central airway measurements. This study aims to describe the potential role of real-time aOCT in guiding interventions during CAO procedures. METHODS: Prospective case series were recruited from patients referred for bronchoscopic management of symptomatic CAO. Preprocedure chest computed tomography (CT) scans were analyzed for relevant airway dimensions, such as stenosis caliber and length, and aided procedure planning. During bronchoscopy, an aOCT fiberoptic probe was inserted through the working channel of the bronchoscope to image the airway stenosis. From these aOCT images, stenosis dimensions were measured and compared with the preprocedure CT measurements. Preprocedure and postprocedure spirometry, Medical Research Council dyspnea score, and Eastern Cooperative Oncology Group performance status were collected to assess intervention efficacy. RESULTS: Fourteen patients were studied. CT and aOCT-based measurements of airway caliber and length correlated closely (r=0.87, P<0.001). Bland-Altman analysis showed strong agreement between measurements (mean difference 0.4±8.6 mm). The real-time nature of aOCT imaging provided the advantage of more up-to-date measurements where a delay occurred between CT and bronchoscopy or where the quality of the CT image was suboptimal. After bronchoscopy, the predicted forced expiratory flow in 1 second increased from 67±26% to 78±19% (P=0.04). Eastern Cooperative Oncology Group and dyspnea scores improved in 83% and 75% of the patients, respectively. CONCLUSIONS: aOCT provides real-time measurements of obstructing central airway lesions that can assist therapeutic interventions such as selection of endobronchial stents and airway dilatation procedures.

Pulmonary neovascularity: a distinctive radiographic finding in Eisenmenger syndrome.

BACKGROUND: We sought to characterize the distinctive pulmonary vascular abnormalities seen on chest radiographs and computed tomography (CT) scans in Eisenmenger syndrome. METHODS AND RESULTS: Thoracic CT scans, chest radiographs, and clinical data were reviewed for 24 Eisenmenger syndrome patients subdivided into those with interatrial (pretricuspid) versus interventricular or great arterial (posttricuspid) communications and in 14 acyanotic patients with pulmonary arterial hypertension (PAH) and no congenital heart disease. CT scans were scored blindly by 2 thoracic radiologists for the presence and severity of small, tortuous, intrapulmonary vessels, termed "neovascularity," lobular ground-glass opacification, and systemic perihilar and intercostal vessels. Histopathologic lung sections from 5 patients with Eisenmenger syndrome and from 3 patients with acyanotic PAH were reviewed. Associations between clinical and imaging features were tested by ANOVA and chi2 tests. Kendall's rank-order coefficient and the Kruskal-Wallis test were used to test for significant differences in imaging features between Eisenmenger syndrome and acyanotic PAH. Neovascularity on chest radiographs was more common in Eisenmenger syndrome than acyanotic PAH, but differences were not significant. On CT, neovascularity, lobular ground-glass opacification, and hilar and intercostal systemic collaterals were more prevalent in Eisenmenger syndrome, with severity greater in posttricuspid communications. Three previously undescribed vascular lesions were identified histologically in Eisenmenger syndrome: malformed, dilated, muscular arteries within alveolar septa; congested capillaries within alveolar walls; and congested capillaries within the walls of medium-size, muscular pulmonary arteries. These lesions may correspond to the distinctive vascular abnormalities observed on chest radiographs and CT scans. CONCLUSIONS: Distinctive vascular lesions on chest radiographs and CT scans in Eisenmenger syndrome appear to be correlated histologically with collateral vessels that develop more extensively with posttricuspid communications.

Metastatic renal cell carcinoma: CT-guided immunotherapy as a technically feasible and safe approach to delivery of gene therapy for treatment.

PURPOSE: To assess the technical feasibility and safety of weekly outpatient percutaneous computed tomographic (CT)-guided intratumoral injections of interleukin-2 (IL-2) plasmid DNA in a wide variety of superficial and deep tumor sites. MATERIALS AND METHODS: Twenty-nine patients with metastatic renal cell carcinoma and a total of 30 lesions measuring 1.0 cm(2) or greater in accessible thoracic (n = 15) or abdominal (n = 15) locations underwent up to three cycles of six weekly intratumoral IL-2 plasmid DNA injections. CT was used to guide needle placement and injection. After injection cycle 1, patients whose tumors demonstrated stable (< or =25% increase and < or =50% decrease in product of lesion diameters) or decreased size (>50% decrease in product of lesion diameters) advanced to injection cycle 2. Patients whose lesions decreased in size by more than 50% over the course of injection cycle 2 were eligible to begin injection cycle 3. An acceptable safety and technical feasibility profile for this technique was deemed to be (a) a safety and feasibility profile similar to that of single-needle biopsy and (b) an absence of serious adverse events (as defined in Title 21 of the Code of Federal Regulations) and/or unacceptable toxicities (as graded according to the National Cancer Institute Common Toxicity Criteria). RESULTS: A total of 284 intratumoral injections were performed, with a mean of 9.8 injections (range, 6-18 injections) received by each patient. Technical success (needle placement and injection of gene therapy agent) was achieved in all cases. Complications were experienced after 42 (14.8%) of the 284 injections. The most common complication was pneumothorax (at 32 [28.6%] of 112 intrathoracic injections), for which only one patient required catheter drainage. Complications occurred randomly throughout injection cycles and did not appear to increase as patients received more injections (P =.532). No patient experienced serious adverse events or unacceptable toxicities. CONCLUSION: Percutaneous CT-guided intratumoral immunotherapy injections are technically feasible and can be safely performed.

Unresectable pulmonary malignancies: CT-guided percutaneous radiofrequency ablation--preliminary results.

PURPOSE: To assess whether percutaneous radiofrequency (RF) ablation of unresectable pulmonary malignancies is safe and technically feasible and to evaluate the usefulness of computed tomographic (CT) nodule densitometry as a tool for following up tumors after ablation. MATERIALS AND METHODS: Twelve patients (seven men and five women; mean age, 60.6 years) with unresectable disease (because of poor lung reserve or multifocality) underwent nodule CT densitometry and CT-guided percutaneous RF ablation of 19 lung tumors (six [32%] tumors were adenocarcinoma, one (5%) was large cell carcinoma, two (10%) were bronchoalveolar carcinoma, four (21%) were colorectal carcinoma, and six (32%) were sarcoma less than 50 cm2 in area (range, 0.25-35.00 cm2). No patients had symptoms of their disease before RF ablation. Follow-up CT densitometry was scheduled for 1, 3, 6, and 12 months after RF ablation. Lesions were evaluated for change in area and contrast enhancement at follow-up CT. RESULTS: RF ablation was well tolerated by all patients. Intraprocedural complications included 12 cases of pneumothoraces (two patients required chest tube placement, while 10 were asymptomatic and required no further treatment), two cases of pleural effusion, and two cases of moderate pain (one case during and one case both during and after the procedure). Mean follow-up was 4(1/2) months (range, 1-12 months). In the eight patients with 3-month follow-up, lesion size increased in two and remained stable in six. Mean contrast enhancement, however, decreased from 46.8 HU (range, 19-107 HU) at baseline to 9.6 HU (range, 0-32 HU) at 1-2-month follow-up. In the one patient with 12-month CT densitometry follow-up, lesion enhancement was less than 50% of that at baseline, and lesion diameter remained stable. CONCLUSION: These preliminary results show that percutaneous RF ablation is a safe and technically feasible management option for unresectable pulmonary malignancies. CT densitometry may have potential for future use as a noninvasive method of following up tumors after RF ablation.

Levitating consolidation in eosinophilic lung disease.

The authors describe a case of histologically proven eosinophilic lung disease in a patient with ulcerative colitis. The patient was not using sulfasalazine or other medications known to be associated with lung disease. Serial chest radiographs revealed an unusual pattern of levitating consolidation.