Lung Cancer Screening and Management of Lung Nodules

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تاریخ نمایه سازی: 5 آبان 1397

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The U.S. cancer statistics working group reported 205,974 people in the United States werediagnosed with lung cancer and 158,081 died from it in 2009. (1) National Lung Screening Trialenrolled 53,454 eligible participants from 2002 to 2007 to either annual low-dose computedtomography (LDCT) or Chest X-Ray (CXR) for three years. 649 cancers were detected by LDCT(63% stage I; 30% III/IV), while 279 cancers detected by CXR (48% stage I; 43% III/IV). LDCTLung Cancer Screening showed 20% reduction in lung cancer specific mortality, and 7% reductionin all-cause mortality. The down side of LDCT screening was the false positive results. 39% of thepatients had abnormality, 24% positive for nodule, and 96% of abnormalities were false positive.The rate of at least one complication after a diagnostic evaluation procedure for a positive screeningtest was 28.4% in LDCT group and 23.3% in the CXR group. (2) For every 320 screened patient, 1life was saved and there were 119 false positive results. (3) U.S. Preventive Services Task Forcereleased the recommendation in December 2013 as to screen the population of asymptomatic adultsaged 55 to 80 years, with a 30 pack-year smoking history, currently smoking or have quit within thepast 15 years, to be screened annually for lung cancer with LDCT. Counseling should be performedbefore screening with complete description of potential benefits and harms, so the individual candecide whether to undergo LDCT screening. (4) Management of the lung nodules is classified basedon the risk assessment for probability of lung cancer. In low clinical pre-test probability ofmalignancy (<5%), serial chest CT is recommended; In indeterminate clinical pre-test probability ofmalignancy (5-65%), careful consideration of options in conjunction with patient’s preferences isrecommended; In high clinical pre-test probability of malignancy (> 65%) surgical resection isrecommended. Risk factors for malignancy include: appearance, size, rate of growth, advanced age,smoking, location, history of extra-thoracic malignancy. (5) Results of the AQuIRE Registryreviewing the transbronchial biopsies in 15 centers from 2/2009 to 3/2013 showed the yield of53.7% (312 of 581), sensitivity 60-74%, and a significant difference between centers and physicians in case selection, sampling methods and anesthesia. Medical center diagnostic yields ranged from33-73%. (6) A randomized trial using Ultrathin (UT) vs. thin (T) Bronchoscope for peripheralpulmonary lesions on 310 patients, showed the UT bronchoscopy increased the diagnostic yield (P= 0.044, UT: 74%, T: 59%). (7) A meta-analysis using data from previously published studies usingRadial(R)-EBUS technology in September 2016 showed R-EBUS has a high diagnostic yield(70.6%) with a very low complication rate (2.8%). (8) The experience at Montefiore MedicalCenter/Albert Einstein College of Medicine, NY form December 2015 to April 2018 with R-EBUSonly guide for bronchoscopic biopsy or needle aspiration of peripheral lung lesions, showedvisualization rate of 96% (108 out of 112) with overall diagnostic yield 85%, and rate ofpneumothorax <1%. The yield in lesions of =<1 cm was 50%, > 1-1.5 cm was 67%, > 1.5-2 cm 95%.Significant academic and industrial efforts are ongoing to develop more efficient and less invasivediagnostic technology for tissue sampling of small lung lesions. It is also expected that definitivetherapeutic bronchoscopic techniques be developed in near future and delivered locally viaminimally invasive procedures.


Ali Sadoughi

M.D, Assistant Professor ofMedicine Divisions of Pulmonary and Critical Care, Albert Einstein College ofMedicine, New York. U.S.A