We aimed to compare outcomes of patients with first primary clinical T1a-bN0M0 NSCLC treated with surgery or stereotactic body radiation therapy (SBRT).
We identified patients with first primary ...clinical T1a-bN0M0 NSCLCs on last pretreatment computed tomography treated by surgery or SBRT in the following two prospective cohorts: International Early Lung Cancer Action Program (I-ELCAP) and Initiative for Early Lung Cancer Research on Treatment (IELCART). Lung cancer-specific survival and all-cause survival after diagnosis were compared using Kaplan-Meier analysis. Propensity score matching was used to balance baseline demographics and comorbidities and analyzed using Cox proportional hazards regression.
Of 1115 patients with NSCLC, 1003 had surgery and 112 had SBRT; 525 in I-ELCAP in 1992 to 2021 and 590 in IELCART in 2016 to 2021. Median follow-up was 57.6 months. Ten-year lung cancer-specific survival was not significantly different: 90% (95% confidence interval: 87%–92%) for surgery versus 88% (95% confidence interval: 77%–99%) for SBRT, p = 0.55. Cox regression revealed no significant difference in lung cancer-specific survival for the combined cohorts (p = 0.48) or separately for I-ELCAP (p = 1.00) and IELCART (p = 1.00). Although 10-year all-cause survival was significantly different (75% versus 45%, p < 0.0001), after propensity score matching, all-cause survival using Cox regression was no longer different for the combined cohorts (p = 0.74) or separately for I-ELCAP (p = 1.00) and IELCART (p = 0.62).
This first prospectively collected cohort analysis of long-term survival of small, early NSCLCs revealed that lung cancer-specific survival was high for both treatments and not significantly different (p = 0.48) and that all-cause survival after propensity matching was not significantly different (p = 0.74). This supports SBRT as an alternative treatment option for small, early NSCLCs which is especially important with their increasing frequency owing to low-dose computed tomography screening. Furthermore, treatment decisions are influenced by many different factors and should be personalized on the basis of the unique circumstances of each patient.
To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter.
...Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11–20 mm, and 21–30 mm) and nodule consistency. Log-rank test statistics were calculated.
The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% p < 0.0001), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% p = 0.0009). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio HR =1.07, 95% confidence interval CI: 1.01–1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25–7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35–75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01–5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01–1.13), whereas PAI was no longer significant (p = 0.19).
Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.
Objectives
Differences in results of baseline and subsequent annual repeat rounds provide important information for optimising the regimen of screening.
Methods
A prospective cohort study of 65,374 ...was reviewed to examine the frequency/percentages of the largest noncalcified nodule (NCN), lung cancer cell types and Kaplan–Meier (K-M) survival rates, separately for baseline and annual rounds.
Results
Of 65,374 baseline screenings, NCNs were identified in 28,279 (43.3%); lung cancer in 737 (1.1%). Of 74,482 annual repeat screenings,
new
NCNs were identified in 4959 (7%); lung cancer in 179 (0.24%). Only adenocarcinoma was diagnosed in subsolid NCNs. Percentages of lung cancers by cell type were significantly different (
p
< 0.0001) in the baseline round compared with annual rounds, reflecting length bias, as were the ratios, reflecting lead times. Long-term K-M survival rate was 100% for typical carcinoids and for adenocarcinomas manifesting as subsolid NCNs; 85% (95% CI 81–89%) for adenocarcinoma, 74% (95% CI 63–85%) for squamous cell, 48% (95% CI 34–62%) for small cell. The rank ordering by lead time was the same as the rank ordering by survival rates.
Conclusions
The significant differences in the frequency of NCNs and frequency and aggressiveness of diagnosed cancers in baseline and annual repeat need to be recognised for an optimal regimen of screening.
Key Points
•
Lung cancer aggressiveness varies considerably by cell type and nodule consistency.
•
Kaplan–Meier survival rates varied by cell type between 100% and 48%.
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The percentages of lung cancers by cell type in screening rounds reflect screening biases.
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Rank ordering by cell type survival is consistent with that by lead times.
•
Empirical evidence provides critical information for the regimen of screening.
Purpose
Clinical management decisions arising from the baseline round for lung cancer screening are the most challenging, as findings have accumulated over a lifetime and may be of no clinical ...concern. To minimize unnecessary harms and costs of workup prior to the first, annual repeat screening, workup should be limited to participants with the highest suspicion of lung cancer while still aiming to identify small, early lung cancers.
Methods
We compared recommendations for immediate, delayed (by 3 or 6 months) workup to assess growth at a malignant rate, and the resulting overall and potential biopsies of three baseline screening protocols: I-ELCAP, the two scenarios of ACR-LungRADS, and the European Consortium. For each protocol, the efficiency ratio (ER) of each recommendation was calculated by dividing the number of participants recommended for that workup by the number of resulting lung cancer diagnoses. The ER for potential biopsies was calculated, assuming that biopsies were performed on all participants recommended for immediate workup as well as those diagnosed with lung cancer after delayed workup.
Results
For I-ELCAP, ACR-LungRADS Scenario 1, ACR-LungRADS Scenario 2, and the European consortium, the overall ER was 13.9, 18.3, 18.3, and 31.9, respectively, and for potential biopsies, it was 2.2, 8.1, 3.2, and 4.4, respectively. ER for immediate workup was 2.9, 8.6, 3.9, and 5.6, respectively, and for delayed workup was 36.1, 160.3, 57.8, and 111.9, respectively.
Conclusions
I-ELCAP recommendations had the lowest ER values for overall, immediate, and delayed workup, and for potential biopsies.
Key Points
• Small differences in protocol thresholds can lead to many unnecessary diagnostic workups.
• I-ELCAP recommendations were the most efficient for immediate and overall workup, and potential biopsies.
•
Definition of a “positive result” and recommendations for further workup in the baseline round needs to be continually reevaluated and updated.
Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, small airways disease, and emphysema. Diagnosis of COPD requires spirometric evidence and may be normal even when small ...airways disease or emphysema is present. Emphysema increases the risk of exacerbations, and is associated with all-cause mortality and increased risk of lung cancer. We evaluated the prevalence of emphysema in participants with and without a prior history of COPD.
We reviewed a prospective cohort of 52,726 subjects who underwent baseline low dose CT screening for lung cancer from 2003 to 2016 in the International Early Lung Cancer Action Program.
Of 52,726 participants, 23.8%(12,542) had CT evidence of emphysema. Of these 12,542 participants with emphysema, 76.5%(9595/12,542) had no prior COPD diagnosis even though 23.6% (2258/9595) had moderate or severe emphysema. Among 12,542 participants, significant predictors of no prior COPD diagnosis were: male (OR = 1.47, p < 0.0001), younger age (ORage10 = 0.72, p < 0.0001), lower pack-years of smoking (OR10pack-years = 0.90, p < 0.0001), completed college or higher (OR = 1.54, p < 0.0001), no family history of lung cancer (OR = 1.12, p = 0.04), no self-reported cardiac disease (OR = 0.76, p = 0.0003) or hypertension (OR = 0.74, p < 0.0001). The severity of emphysema was significantly lower among the 9595 participants with no prior COPD diagnosis, the OR for moderate emphysema was ORmoderate = 0.58(p = 0.0007) and for severe emphysema, it was ORsevere = 0.23(p < 0.0001).
Emphysema was identified in 23.8% participants undergoing LDCT and was unsuspected in 76.5%. LDCT provides an opportunity to identify emphysema, and recommend smoking cessation.
•Emphysema was identified in 23.8% participants and was unsuspected in 76.5%.•23.6% of participants with unsuspected COPD had moderate or severe emphysema on LDCT.•COPD is underdiagnosed in patients undergoing LDCT.•LDCT provides an opportunity to identify emphysema, reduce morbidity and mortality.
It has been hypothesized that women are more susceptible to tobacco carcinogens than men, but after diagnosis of lung cancer, they have better survival rates than men.
To add to the evidence on the ...lung cancer risk of women who smoke and their survival after diagnosis of lung cancer, conditional on other prognostic indicators and compared with men of the same age who smoke.
Nonexperimental, etiologic study with prospective collection of data based on baseline computed tomographic screening for lung cancer and follow-up of diagnosed cases of lung cancer in North America in 1993-2005. A total of 7498 women and 9427 men were screened, all of whom were asymptomatic, aged at least 40 years, and had a history of cigarette smoking.
Comparing women with men, the prevalence odds ratio (OR) for screen-detectable lung cancer (conditional on age and smoking history) and the hazard ratio of fatal outcome of lung cancer (conditional on smoking history, disease stage, tumor cell type, and resection).
Lung cancer was diagnosed in 156 women and 113 men (rates of 2.1% and 1.2%, respectively). The prevalence OR comparing women with men was 1.9 (95% confidence interval CI, 1.5-2.5). The hazard ratio of fatal outcome of lung cancer comparing women with men was 0.48 (95% CI, 0.25-0.89).
Women appear to have increased susceptibility to tobacco carcinogens but have a lower rate of fatal outcome of lung cancer compared with men.
The study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia.
Preoperative and postoperative computed tomography imaging from 373 ...patients from the International Early Lung Cancer Action Program and the Initiative for Early Lung Cancer Research on Treatment were compared at a median of 31.1 months of follow-up after resection of clinical early-stage non–small cell lung cancer. Incidence of new hiatal hernia or changes to preexisting hernias were recorded and evaluated by patient demographics, surgical approach, extent of resection, and resection site.
New hiatal hernias were seen in 9.6% of patients after lung resection (5.6% after wedge or segmentectomy and 12.4% after lobectomy; P = .047). The median size of new hernias was 21 mm, and the most commonly associated resection site was the left lower lobe (24.2%; P = .04). In patients with preexisting hernias, 53.5% demonstrated a small but significant increase in size from 21 to 22 mm (P < .0001). All hernias persisted through the latest postoperative computed tomography scan. When 110 surgical patients without preexisting hernia were matched by sex, age, and smoking to nonoperative controls, the incidence of new hernia at follow-up was significantly higher among those who underwent surgery (17.3% vs 2.7%, P = .0003).
Both open and minimally invasive lung resection for clinical early-stage lung cancer are associated with new or enlarging postoperative hiatal hernia, especially after resections involving the left lower lobe.
HHs occur or grow in a significant number of patients after lung resection, most frequently after resections involving the left lower lobe. Consideration of existing hernias or reflux symptoms may be warranted when planning for elective surgery. Display omitted
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