Geographic differences in therapy for stage I non-small-cell lung cancer in older adults.

BACKGROUND: Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States. METHODS: Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed. RESULTS: Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05). CONCLUSIONS: Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Preserving NLST mortality benefits and acceptable morbidity for lung cancer surgery in a community hospital.

BACKGROUND AND OBJECTIVES: The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST). METHODS: This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques. RESULTS: There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p < 0.05). Higher clinical stage and larger tumor size were associated with occult Stage III disease (both p < 0.05). CONCLUSIONS: The low morbidity and mortality rates from the NLST were achievable in a community setting for early-stage lung cancer. Characterization of cancers using CT imaging identified factors most commonly associated with postoperative complications and the presence of occult Stage III disease.

Long-Term Radiologic Evaluation of Microaspirations among Patients after Esophagectomy.

OBJECTIVES: Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance. METHODS: The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected. RESULTS: A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging (n = 51 [42.5%] vs. n = 13 [10.8%] respectively, p < 0.05). Most of these were found in the lower lobes (61%). A higher rate of lesions was found among patients in whom the conduit was bulging to the right hemithorax compared with totally mediastinal or completely in the right hemithorax (54.5 vs. 35.2% and 34.6%, respectively, p < 0.05). No correlation was found with conduit diameter or anastomotic site. These lesions were more prevalent among patients who complained of reflux or cough during meals (NS). CONCLUSIONS: A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings.

Computed Tomography Scanning for Early Detection of Lung Cancer.

Parallel and often unrelated developments in health care and technology have all been necessary to bring about early detection of lung cancer and the opportunity to decrease mortality from lung cancer through early detection of the disease by computed tomography. Lung cancer screening programs provide education for patients and clinicians, support smoking cessation as primary prevention for lung cancer, and facilitate health care for tobacco-associated diseases, including cardiovascular and chronic lung diseases. Guidelines for lung cancer screening will need to continue to evolve as additional risk factors and screening tests are developed. Data collection from lung cancer screening programs is vital to the further development of fiscally responsible guidelines to increase detection of lung cancer, which may include small groups with elevated risk for reasons other than tobacco exposure.

Propensity Score Adjusted Comparison of Minimally Invasive versus Open Thymectomy in the Management of Early Stage Thymoma.

BACKGROUND: The benefits of minimally invasive versus open thymectomy for the management of thymoma are debatable. Further, patient factors contributing to the selection of operative technique are not well elucidated. We aim to identify the association between baseline patient characteristics with choice of surgical approach. METHODS: Medical records of early stage thymoma (stages I and II) patients undergoing thymectomy between 2005 and 2015 at a single center were identified. Baseline characteristics and surgical outcomes such as prolonged length of stay (LOS ≥ 4 days), 90-day postoperative morbidity, completeness of resection, and recurrence or mortality free rates were compared by surgical approach. RESULTS: Fifty-three patients underwent thymectomy (34 open [64.15%] vs. 19 minimally invasive [35.85%]). There were no statistical differences between the two surgical approaches in demographic variables, smoking status, lung function, comorbidity, tumor size, or staging. Open thymectomy had significantly prolonged LOS (≥4 days) compared with minimally invasive procedures (odds ratio: 11.65; p < 0.01). There were no significant differences in postoperative composite morbidity (p = 0.56), positive margin (p = 0.40), tumor within 0.1 cm of resection margin (p = 0.38), and survival probability estimates (log rank test; p = 0.48) between the two groups. CONCLUSION: Baseline patient characteristics were not associated with surgical approach selected for thymectomy. Minimally invasive thymectomy patients had shorter LOS but no significant differences in 90-day composite morbidity and recurrence or mortality. Larger multicenter studies are needed to evaluate factors contributing to patient selection for each approach, which may include surgeon preference.

Frequency and Severity of Pulmonary Hemorrhage in Patients Undergoing Percutaneous CT-guided Transthoracic Lung Biopsy: Single-Institution Experience of 1175 Cases.

PURPOSE: To evaluate the frequency and severity of pulmonary hemorrhage after transthoracic needle lung biopsy (TTLB) and assess possible factors associated with pulmonary hemorrhage. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Records from 1113 patients who underwent 1175 TTLBs between January 2008 and April 2013 were retrospectively reviewed. Primary outcomes were pulmonary hemorrhage, documented hemoptysis, and bleeding complications necessitating intervention. Pulmonary hemorrhage was graded as follows: 0, none; 1, less than or equal to 2 cm around the needle; 2, more than 2 cm and sublobar; 3, at least lobar; and 4, hemothorax. Patient, technique, and lesion-related variables were evaluated as predictors of pulmonary hemorrhage. Patient-related variables included main pulmonary artery diameter (mPAD) at computed tomography (CT), pulmonary artery pressures at echocardiography and right-sided heart catheterization, medications, chronic lung disease, bleeding diathesis, and immunodeficiency. Technique- and lesion-related variables included needle gauge, number of passes, pleura-needle angle, lesion size and morphologic characteristics, and distance to pleura. Univariate analysis was performed with χ(2), Fisher exact, and Student t tests. RESULTS: Pulmonary hemorrhage occurred in 483 of the 1175 TTLBs (41.1%); hemoptysis was documented in 21 of the 1175 TTLBs (1.8%). Higher-grade hemorrhage (grade 2 or higher) occurred in 201 of the 1175 TTLBs (17.1%); five of the 1175 TTLBs (0.4%) necessitated hemorrhage-related admission. Higher-grade hemorrhage was more likely to occur with female sex (P = .001), older age (P = .003), emphysema (P = .004), coaxial technique (P = .025), nonsubpleural location (P < .001), lesion size of 3 cm or smaller (P < .001), and subsolid lesions (P = .028). Enlarged mPAD at CT (≥2.95 cm) was not significantly associated with higher-grade hemorrhage (P = .430). CONCLUSION: Pulmonary hemorrhage after TTLB is common but rarely requires intervention. An enlarged mPAD at CT may not be a risk factor for higher-grade hemorrhage.

Clinical, physiologic, and radiographic factors contributing to development of hypoxemia in moderate to severe COPD: a cohort study.

BACKGROUND: Hypoxemia is a major complication of COPD and is a strong predictor of mortality. We previously identified independent risk factors for the presence of resting hypoxemia in the COPDGene cohort. However, little is known about characteristics that predict onset of resting hypoxemia in patients who are normoxic at baseline. We hypothesized that a combination of clinical, physiologic, and radiographic characteristics would predict development of resting hypoxemia after 5-years of follow-up in participants with moderate to severe COPD METHODS: We analyzed 678 participants with moderate-to-severe COPD recruited into the COPDGene cohort who completed baseline and 5-year follow-up visits and who were normoxic by pulse oximetry at baseline. Development of resting hypoxemia was defined as an oxygen saturation ≤88% on ambient air at rest during follow-up. Demographic and clinical characteristics, lung function, and radiographic indices were analyzed with logistic regression models to identify predictors of the development of hypoxemia. RESULTS: Forty-six participants (7%) developed resting hypoxemia at follow-up. Enrollment at Denver (OR 8.30, 95%CI 3.05-22.6), lower baseline oxygen saturation (OR 0.70, 95%CI 0.58-0.85), self-reported heart failure (OR 6.92, 95%CI 1.56-30.6), pulmonary artery (PA) enlargement on computed tomography (OR 2.81, 95%CI 1.17-6.74), and prior severe COPD exacerbation (OR 3.31, 95%CI 1.38-7.90) were independently associated with development of resting hypoxemia. Participants who developed hypoxemia had greater decline in 6-min walk distance and greater 5-year decline in quality of life compared to those who remained normoxic at follow-up. CONCLUSIONS: Development of clinically significant hypoxemia over a 5-year span is associated with comorbid heart failure, PA enlargement and severe COPD exacerbation. Further studies are needed to determine if treatments targeting these factors can prevent new onset hypoxemia. TRIAL REGISTRATION: COPDGene is registered at ClinicalTrials.gov: NCT00608764 (Registration Date: January 28, 2008).

Association of conduit dimensions with perioperative outcomes and long-term quality of life after esophagectomy for malignancy.

Objective: The impact of conduit dimensions and location of esophagogastric anastomosis on long-term quality of life after esophagectomy remains unexplored. We investigated the association of these parameters with surgical outcomes and patient-reported quality of life at least 18 months after esophagectomy. Methods: We identified all patients who underwent esophagectomy for cancer from 2018 to 2020 in our institution. We reviewed each patient's initial postoperative computed tomography scan measuring the gastric conduit's greatest width (centimeters), linear staple line length (centimeters), and relative location of esophagogastric anastomosis (vertebra). Quality of life was ascertained using patient-reported outcome measures. Perioperative complications, length of stay, and mortality were collected. Multivariate regressions were performed. Results: Our study revealed that a more proximal anastomosis was linked to an increased risk of pulmonary complications, a lower recurrence rate, and greater long-term insomnia. Increased maximum intrathoracic conduit width was significantly associated with trouble enjoying meals and reflux long term after esophagectomy. A longer conduit stapled line correlated with fewer issues related to insomnia, improved appetite, less dysphagia, and significantly enhanced "social," "role," and "physical'" aspects of the patient's long-term quality of life. Conclusions: The dimensions of the gastric conduit and the height of the anastomosis may be independently associated with outcomes and long-term quality of life after esophagectomy for cancer.

Informatics in radiology: what can you see in a single glance and how might this guide visual search in medical images?

Diagnostic accuracy for radiologists is above that expected by chance when they are exposed to a chest radiograph for only one-fifth of a second, a period too brief for more than a single voluntary eye movement. How do radiologists glean information from a first glance at an image? It is thought that this expert impression of the gestalt of an image is related to the everyday, immediate visual understanding of the gist of a scene. Several high-speed mechanisms guide our search of complex images. Guidance by basic features (such as color) requires no learning, whereas guidance by complex scene properties is learned. It is probable that both hardwired guidance by basic features and learned guidance by scene structure become part of radiologists' expertise. Search in scenes may be best explained by a two-pathway model: Object recognition is performed via a selective pathway in which candidate targets must be individually selected for recognition. A second, nonselective pathway extracts information from global or statistical information without selecting specific objects. An appreciation of the role of nonselective processing may be particularly useful for understanding what separates novice from expert radiologists and could help establish new methods of physician training based on medical image perception.

Scanners and drillers: characterizing expert visual search through volumetric images.

Modern imaging methods like computed tomography (CT) generate 3-D volumes of image data. How do radiologists search through such images? Are certain strategies more efficient? Although there is a large literature devoted to understanding search in 2-D, relatively little is known about search in volumetric space. In recent years, with the ever-increasing popularity of volumetric medical imaging, this question has taken on increased importance as we try to understand, and ultimately reduce, errors in diagnostic radiology. In the current study, we asked 24 radiologists to search chest CTs for lung nodules that could indicate lung cancer. To search, radiologists scrolled up and down through a "stack" of 2-D chest CT "slices." At each moment, we tracked eye movements in the 2-D image plane and coregistered eye position with the current slice. We used these data to create a 3-D representation of the eye movements through the image volume. Radiologists tended to follow one of two dominant search strategies: "drilling" and "scanning." Drillers restrict eye movements to a small region of the lung while quickly scrolling through depth. Scanners move more slowly through depth and search an entire level of the lung before moving on to the next level in depth. Driller performance was superior to the scanners on a variety of metrics, including lung nodule detection rate, percentage of the lung covered, and the percentage of search errors where a nodule was never fixated.

Incidence of Clinically Relevant Solitary Pulmonary Nodules Utilizing a Universal Health Care System.

INTRODUCTION: Solitary pulmonary nodules (SPNs) are common, but the clinical relevance of these nodules is unknown. Utilizing current screening guidelines, we sought to better characterize the national incidence of clinically important SPNs within the largest universal health care system in the nation. MATERIALS AND METHODS: TRICARE data were queried to identify SPNs for ages 18-64 years. SPNs that had been diagnosed within a year with no prior oncologic history were included to ensure true incidence. A proprietary algorithm was applied to determine clinically significant nodules. Further analysis characterized incidence by age grouping, gender, region, military branch, and beneficiary status. RESULTS: A total of 229,552 SPNs were identified with a 60% reduction seen after application of the clinical significance algorithm (N = 88,628). The incidence increased in each decade of life (all P < 0.01). Adjusted incident rate ratios were significantly higher for SPNs detected in the Midwest and Western regions. The incident rate ratio was also higher in females (1.05, confidence interval [CI] 1.018, P = 0.001) as well as non-active duty members (dependents = 1.4 and retired = 1.6, respectively, CIs 1.383-1.492 and 1.591-1.638, P < 0.01). The incidence calculated per 1,000 patients overall was 3.1/1,000. Ages 44-54 years had an incidence of 5.5/1,000 patients, which is higher than the previously reported incidence of < 5.0 nationally for the same age group. CONCLUSIONS: This analysis represents the largest evaluation of SPNs to date combined with clinical relevance adjustment. These data suggest a higher incidence of clinically significant SPNs starting at an age of 44 years in nonmilitary or retired women localized to the Midwest and Western regions of the United States.

Role of sex in lung cancer risk prediction based on single low-dose chest computed tomography.

A validated open-source deep-learning algorithm called Sybil can accurately predict long-term lung cancer risk from a single low-dose chest computed tomography (LDCT). However, Sybil was trained on a majority-male cohort. Use of artificial intelligence algorithms trained on imbalanced cohorts may lead to inequitable outcomes in real-world settings. We aimed to study whether Sybil predicts lung cancer risk equally regardless of sex. We analyzed 10,573 LDCTs from 6127 consecutive lung cancer screening participants across a health system between 2015 and 2021. Sybil achieved AUCs of 0.89 (95% CI: 0.85-0.93) for females and 0.89 (95% CI: 0.85-0.94) for males at 1 year, p = 0.92. At 6 years, the AUC was 0.87 (95% CI: 0.83-0.93) for females and 0.79 (95% CI: 0.72-0.86) for males, p = 0.01. In conclusion, Sybil can accurately predict future lung cancer risk in females and males in a real-world setting and performs better in females than in males for predicting 6-year lung cancer risk.

A combined pulmonary-radiology workshop for visual evaluation of COPD: study design, chest CT findings and concordance with quantitative evaluation.

UNLABELLED: The purposes of this study were: to describe chest CT findings in normal non-smoking controls and cigarette smokers with and without COPD; to compare the prevalence of CT abnormalities with severity of COPD; and to evaluate concordance between visual and quantitative chest CT (QCT) scoring. METHODS: Volumetric inspiratory and expiratory CT scans of 294 subjects, including normal non-smokers, smokers without COPD, and smokers with GOLD Stage I-IV COPD, were scored at a multi-reader workshop using a standardized worksheet. There were 58 observers (33 pulmonologists, 25 radiologists); each scan was scored by 9-11 observers. Interobserver agreement was calculated using kappa statistic. Median score of visual observations was compared with QCT measurements. RESULTS: Interobserver agreement was moderate for the presence or absence of emphysema and for the presence of panlobular emphysema; fair for the presence of centrilobular, paraseptal, and bullous emphysema subtypes and for the presence of bronchial wall thickening; and poor for gas trapping, centrilobular nodularity, mosaic attenuation, and bronchial dilation. Agreement was similar for radiologists and pulmonologists. The prevalence on CT readings of most abnormalities (e.g. emphysema, bronchial wall thickening, mosaic attenuation, expiratory gas trapping) increased significantly with greater COPD severity, while the prevalence of centrilobular nodularity decreased. Concordances between visual scoring and quantitative scoring of emphysema, gas trapping and airway wall thickening were 75%, 87% and 65%, respectively. CONCLUSIONS: Despite substantial inter-observer variation, visual assessment of chest CT scans in cigarette smokers provides information regarding lung disease severity; visual scoring may be complementary to quantitative evaluation.

Identification of FGF7 as a novel susceptibility locus for chronic obstructive pulmonary disease.

RATIONALE: Traditional genome-wide association studies (GWASs) of large cohorts of subjects with chronic obstructive pulmonary disease (COPD) have successfully identified novel candidate genes, but several other plausible loci do not meet strict criteria for genome-wide significance after correction for multiple testing. OBJECTIVES: The authors hypothesise that by applying unbiased weights derived from unique populations we can identify additional COPD susceptibility loci. Methods The authors performed a homozygosity haplotype analysis on a group of subjects with and without COPD to identify regions of conserved homozygosity haplotype (RCHHs). Weights were constructed based on the frequency of these RCHHs in case versus controls, and used to adjust the p values from a large collaborative GWAS of COPD. RESULTS: The authors identified 2318 RCHHs, of which 576 were significantly (p<0.05) over-represented in cases. After applying the weights constructed from these regions to a collaborative GWAS of COPD, the authors identified two single nucleotide polymorphisms (SNPs) in a novel gene (fibroblast growth factor-7 (FGF7)) that gained genome-wide significance by the false discovery rate method. In a follow-up analysis, both SNPs (rs12591300 and rs4480740) were significantly associated with COPD in an independent population (combined p values of 7.9E-7 and 2.8E-6, respectively). In another independent population, increased lung tissue FGF7 expression was associated with worse measures of lung function. CONCLUSION: Weights constructed from a homozygosity haplotype analysis of an isolated population successfully identify novel genetic associations from a GWAS on a separate population. This method can be used to identify promising candidate genes that fail to meet strict correction for multiple testing.

Optimizing analysis, visualization, and navigation of large image data sets: one 5000-section CT scan can ruin your whole day.

UNLABELLED: The technology revolution in image acquisition, instrumentation, and methods has resulted in vast data sets that far outstrip the human observers' ability to view, digest, and interpret modern medical images by using traditional methods. This may require a paradigm shift in the radiologic interpretation process. As human observers, radiologists must search for, detect, and interpret targets. Potential interventions should be based on an understanding of human perceptual and attentional abilities and limitations. New technologies and tools already in use in other fields can be adapted to the health care environment to improve medical image analysis, visualization, and navigation through large data sets. This historical psychophysical and technical review touches on a broad range of disciplines but focuses mainly on the analysis, visualization, and navigation of image data performed during the interpretive process. Advanced postprocessing, including three-dimensional image display, multimodality image fusion, quantitative measures, and incorporation of innovative human-machine interfaces, will likely be the future. Successful new paradigms will integrate image and nonimage data, incorporate workflow considerations, and be informed by evidence-based practices. This overview is meant to heighten the awareness of the complexities and limitations of how radiologists interact with images, particularly the large image sets generated today. Also addressed is how human-machine interface and informatics technologies could combine to transform the interpretation process in the future to achieve safer and better quality care for patients and a more efficient and effective work environment for radiologists. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11091276/-/DC1.