Lung cancer screening.

Randomised controlled trials, including the National Lung Screening Trial (NLST) and the NELSON trial, have shown reduced mortality with lung cancer screening with low-dose CT compared with chest radiography or no screening. Although research has provided clarity on key issues of lung cancer screening, uncertainty remains about aspects that might be critical to optimise clinical effectiveness and cost-effectiveness. This Review brings together current evidence on lung cancer screening, including an overview of clinical trials, considerations regarding the identification of individuals who benefit from lung cancer screening, management of screen-detected findings, smoking cessation interventions, cost-effectiveness, the role of artificial intelligence and biomarkers, and current challenges, solutions, and opportunities surrounding the implementation of lung cancer screening programmes from an international perspective. Further research into risk models for patient selection, personalised screening intervals, novel biomarkers, integrated cardiovascular disease and chronic obstructive pulmonary disease assessments, smoking cessation interventions, and artificial intelligence for lung nodule detection and risk stratification are key opportunities to increase the efficiency of lung cancer screening and ensure equity of access.

Multimodality Management of Thoracic Tumors: Initial Experience With a Multidisciplinary Thoracic Ablation Conference.

BACKGROUND: This study aimed to describe lesion-specific management of thoracic tumors referred for consideration of image-guided thermal ablation (IGTA) at a newly established multidisciplinary ablation conference. METHODS: This retrospective single-center cohort study included consecutive patients with non-small cell lung cancer (NSCLC) or thoracic metastases evaluated from June 2020 to January 2022 in a multidisciplinary conference. Outcomes included the management recommendation, treatments received (IGTA, surgical resection, stereotactic body radiation therapy [SBRT], multimodality management), and number of tumors treated per patient. Pearson's chi-square test was used to assess for a change in management, and Poisson regression was used to compare the number of tumors by treatment received. RESULTS: The study included 172 patients (58 % female; median age, 69 years; 56 % thoracic metastases; 27 % multifocal primary lung cancer; 59 % ECOG 0 [range, 0-3]) assessed in 206 evaluations. For the patients with NSCLC, IGTA was considered the most appropriate local therapy in 12 %, equal to SBRT in 22 %, and equal to lung resection in 3 % of evaluations. For the patients with thoracic metastases, IGTA was considered the most appropriate local therapy in 22 %, equal to SBRT in 12 %, and equal to lung resection in 3 % of evaluations. Although all patients were referred for consideration of IGTA, less than one third of patients with NSCLC or thoracic metastases underwent IGTA (p < 0.001). Multimodality management allowed for treatment of more tumors per patient than single-modality management (p < 0.01). CONCLUSIONS: Multidisciplinary evaluation of patients with thoracic tumors referred for consideration of IGTA significantly changed patient management and facilitated lesion-specific multimodality management.

High-Frequency Jet Ventilation Versus Spontaneous Respiration for Percutaneous Cryoablation of Lung Tumors: Comparison of Adverse Events and Procedural Efficiency.

BACKGROUND. High-frequency jet ventilation (HFJV) facilitates accurate probe placement in percutaneous ablation of lung tumors but may increase risk for adverse events, including systemic air embolism. OBJECTIVE. The purpose of this study was to compare major adverse events and procedural efficiency of percutaneous lung ablation with HFJV under general anesthesia to spontaneous respiration (SR) under moderate sedation. METHODS. This retrospective study included consecutive adults who underwent CT-guided percutaneous cryoablation of one or more lung tumors with HFJV or SR between January 1, 2017, and May 31, 2023. We compared major adverse events (Common Terminology Criteria for Adverse Events grade ≥ 3) within 30 days postprocedure and hospital length of stay (HLOS) of 2 days or more using logistic regression analysis. We compared procedure time, room time, CT guidance acquisition time, CT guidance radiation dose, total radiation dose, and pneumothorax using generalized estimating equations. RESULTS. Overall, 139 patients (85 women, 54 men; median age, 68 years) with 310 lung tumors (82% metastases) underwent 208 cryoablations (HFJV, n = 129; SR, n = 79). HFJV showed greater rates than SR for the treatment of multiple tumors per session (43% vs 19%, respectively; p = .02) and tumors in a nonperipheral location (48% vs 24%, p < .001). Major adverse event rate was 8% for HFJV and 5% for SR (p = .46). No systemic air embolism occurred. HLOS was 2 days or more in 17% of sessions and did not differ significantly between HFJV and SR (p = .64), including after adjusting for probe number per session, chronic obstructive pulmonary disease, and operator experience (p = .53). Ventilation modalities showed no significant difference in procedure time, CT guidance acquisition time, CT guidance radiation dose, or total radiation dose (all p > .05). Room time was longer for HFJV than SR (median, 154 vs 127 minutes, p < .001). For HFJV, the median anesthesia time was 136 minutes. Ventilation modalities did not differ in the frequencies of pneumothorax or pneumothorax requiring chest tube placement (both p > .05). CONCLUSION. HFJV appears to be as safe as SR but had longer room times. HFJV can be used in complex cases without significantly impacting HLOS of 2 days or more, procedure time, or radiation exposure. CLINICAL IMPACT. Selection of the ventilation modality during percutaneous lung ablation should be based on patient characteristics and anticipated procedural requirements as well as operator preference.

Ablation of Stage I-II Non-Small Cell Lung Cancer in Patients With Interstitial Lung Disease: A Multicenter Retrospective Study.

BACKGROUND. Treatment options for patients with interstitial lung disease (ILD) who develop stage I-II non-small cell lung cancer (NSCLC) are severely limited, given that surgical resection, radiation, and systemic therapy are associated with significant morbidity and mortality. OBJECTIVE. The aim of this study was to evaluate the safety and efficacy of percutaneous ablation of stage I-II NSCLC in patients with ILD. METHODS. This retrospective study included patients with ILD and stage I-II NSCLC treated with percutaneous ablation in three health systems between October 2004 and February 2023. At each site, a single thoracic radiologist, blinded to clinical outcomes, reviewed preprocedural chest CT examinations for the presence and type of ILD according to 2018 criteria proposed by the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Society. The primary outcome was 90-day major (grade ≥ 3) adverse events, based on Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Secondary outcomes were hospital length of stay (HLOS), local tumor control, and overall survival (OS). RESULTS. The study included 33 patients (19 men, 14 women; median age, 78 years; 16 patients with Eastern Cooperative Oncology Group performance status ≤ 1) with ILD who underwent 42 percutaneous ablation sessions (21 cryoablations, 11 radiofrequency ablations, 10 microwave ablations) of 43 NSCLC tumors ((median tumor size, 1.6 cm; IQR, 1.4-2.5 cm; range, 0.7-5.4 cm; 37 stage I, six stage II). The extent of lung fibrosis was 20% or less in 24 patients; 17 patients had imaging findings of definite or probable usual interstitial pneumonia. The 90-day major adverse event rate was 14% (6/42), including one CTCAE grade 4 event. No acute ILD exacerbation or death occurred within 90 days after ablation. The median HLOS was 1 day (IQR, 0-2 days). Median imaging follow-up for local tumor control was 17 months (IQR, 11-32 months). Median imaging or clinical follow-up for OS was 16 months (IQR, 6-26 months). Local tumor control and OS were 78% and 77%, respectively, at 1 year and 73% and 46% at 2 years. CONCLUSION. Percutaneous ablation appears to be a safe and effective treatment option for stage I-II NSCLC in the setting of ILD after multidisciplinary selection. CLINICAL IMPACT. Patients with ILD and stage I-II NSCLC should be considered for percutaneous ablation given that they are frequently ineligible for surgical resection, radiation, and systemic therapy.

RadioGraphics Update: The 10 Pillars of Lung Cancer Screening-Rationale and Logistics of a Lung Cancer Screening Program.

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

Clinical Intricacies and Advances in Neuroendocrine Tumors: An Organ-Based Multidisciplinary Approach.

ABSTRACT: Neuroendocrine neoplasms (NENs) are rare neoplasms originating from neuroendocrine cells, with increasing incidence due to enhanced detection methods. These tumors display considerable heterogeneity, necessitating diverse management strategies based on factors like organ of origin and tumor size. This article provides a comprehensive overview of therapeutic approaches for NENs, emphasizing the role of imaging in treatment decisions. It categorizes tumors based on their locations: gastric, duodenal, pancreatic, small bowel, colonic, rectal, appendiceal, gallbladder, prostate, lung, gynecological, and others. The piece also elucidates the challenges in managing metastatic disease and controversies surrounding MEN1-neuroendocrine tumor management. The article underscores the significance of individualized treatment plans, underscoring the need for a multidisciplinary approach to ensure optimal patient outcomes.

Management of Lung Cancer in the Patient with Interstitial Lung Disease.

Patients with interstitial lung disease (ILD), especially those with pulmonary fibrosis, are at increased risk of developing lung cancer. Management of lung cancer in patients with ILD is particularly challenging. Diagnosis can be complicated by difficulty differentiating lung nodules from areas of focal fibrosis, and percutaneous biopsy approaches confer an increased risk of complications in those with pulmonary fibrosis. Lung cancer treatment in these patients pose several specific considerations. The degree of lung function impairment may preclude lobectomy or surgical resection of any type. Surgical resection can trigger an acute exacerbation of the underlying ILD. The presence of ILD confers an increased risk of pneumonitis with radiotherapy, and many of the systemic therapies also carry an increased risk of pneumonitis in this population. The safety of immunotherapy in the setting of ILD remains to be fully elucidated and concerns remain as to triggering pneumonitis. The purpose of this review is to summarize the evidence regarding consideration for tissue diagnosis, chemotherapy and immunotherapy, radiotherapy, and surgery, in this patient population and discuss emerging areas of research. We also propose a multidisciplinary approach and practical considerations for monitoring for ILD progression during lung cancer treatment.

Optimizing molecular testing of lung cancer needle biopsy specimens: potential solutions from an interdisciplinary qualitative study.

BACKGROUND: Molecular testing can detect actionable genomic alterations and tumor cell surface proteins in patients with non-small cell lung cancer (NSCLC). However, utilization remains suboptimal, representing missed treatment opportunities. This study aimed to identify challenges and potential solutions to obtaining percutaneous lung needle biopsy specimens for successful molecular testing in patients with advanced NSCLC. METHODS: This interdisciplinary qualitative study included ten radiologists and four pathologists from academic and community settings across the United States who routinely perform and analyze percutaneous lung needle biopsies. Participants underwent semi-structured one-on-one interviews (Phase 1). Interview questionnaires were constructed based on a literature review of key lines of inquiry and conducted by professional market researchers using the theoretical domains framework. Primary barriers to molecular testing were identified using thematic analysis. Subsequently, multidisciplinary focus groups were convened to identify potential solutions (Phase 2). RESULTS: Four themes emerged as barriers to molecular testing and were matched to the clinical workflow: (1) biopsy request, (2) biopsy procedure, (3) specimen analysis, and (4) communication. The nineteen potential solutions included adding a "checkbox" to indicate molecular testing in the biopsy request, leveraging pre-procedural imaging to guide biopsies, conserving tissue through appropriate allocation strategies and next generation sequencing panels instead of sequential single-gene assays, instituting reflex-molecular testing upon NSCLC diagnosis, tracking and communicating biopsy outcomes at multidisciplinary tumor boards, and improving integration of radiologists and pathologists into oncology care teams. CONCLUSIONS: Potential solutions exist to increase successful molecular testing of lung needle biopsy specimens in patients with advanced NSCLC.

Risk of persistent air leaks following percutaneous cryoablation and microwave ablation of peripheral lung tumors.

OBJECTIVES: To compare the incidence of persistent air leak (PAL) following cryoablation vs MWA of lung tumors when the ablation zone includes the pleura. METHODS: This bi-institutional retrospective cohort study evaluated consecutive peripheral lung tumors treated with cryoablation or MWA from 2006 to 2021. PAL was defined as an air leak for more than 24 h after chest tube placement or an enlarging postprocedural pneumothorax requiring chest tube placement. The pleural area included by the ablation zone was quantified on CT using semi-automated segmentation. PAL incidence was compared between ablation modalities and a parsimonious multivariable model was developed to assess the odds of PAL using generalized estimating equations and purposeful selection of predefined covariates. Time-to-local tumor progression (LTP) was compared between ablation modalities using Fine-Gray models, with death as a competing risk. RESULTS: In total, 260 tumors (mean diameter, 13.1 mm ± 7.4; mean distance to pleura, 3.6 mm ± 5.2) in 116 patients (mean age, 61.1 years ± 15.3; 60 women) and 173 sessions (112 cryoablations, 61 MWA) were included. PAL occurred after 25/173 (15%) sessions. The incidence was significantly lower following cryoablation compared to MWA (10 [9%] vs 15 [25%]; p = .006). The odds of PAL adjusted for the number of treated tumors per session were 67% lower following cryoablation (odds ratio = 0.33 [95% CI, 0.14-0.82]; p = .02) vs MWA. There was no significant difference in time-to-LTP between ablation modalities (p = .36). CONCLUSIONS: Cryoablation of peripheral lung tumors bears a lower risk of PAL compared to MWA when the ablation zone includes the pleura, without adversely affecting time-to-LTP. KEY POINTS: • The incidence of persistent air leaks after percutaneous ablation of peripheral lung tumors was lower following cryoablation compared to microwave ablation (9% vs 25%; p = .006). • The mean chest tube dwell time was 54% shorter following cryoablation compared to MWA (p = .04). • Local tumor progression did not differ between lung tumors treated with percutaneous cryoablation compared to microwave ablation (p = .36).

Factors Associated with Hospital Length of Stay and Adverse Events following Percutaneous Ablation of Lung Tumors.

PURPOSE: To explore the association between risk factors established in the surgical literature and hospital length of stay (HLOS), adverse events, and hospital readmission within 30 days after percutaneous image-guided thermal ablation of lung tumors. MATERIALS AND METHODS: This bi-institutional retrospective cohort study included 131 consecutive adult patients (67 men [51%]; median age, 65 years) with 180 primary or metastatic lung tumors treated in 131 sessions (74 cryoablation and 57 microwave ablation) from 2006 to 2019. Age-adjusted Charlson Comorbidity Index, sex, performance status, smoking status, chronic obstructive pulmonary disease (COPD), primary lung cancer versus pulmonary metastases, number of tumors treated per session, maximum axial tumor diameter, ablation modality, number of pleural punctures, anesthesia type, pulmonary artery-to-aorta ratio, lung densitometry, sarcopenia, and adipopenia were evaluated. Associations between risk factors and outcomes were assessed using univariable and multivariable generalized linear models. RESULTS: In univariable analysis, HLOS was associated with current smoking (incidence rate ratio [IRR], 4.54 [1.23-16.8]; P = .02), COPD (IRR, 3.56 [1.40-9.04]; P = .01), cryoablations with ≥3 pleural punctures (IRR, 3.13 [1.07-9.14]; P = .04), general anesthesia (IRR, 10.8 [4.18-27.8]; P < .001), and sarcopenia (IRR, 2.66 [1.10-6.44]; P = .03). After multivariable adjustment, COPD (IRR, 3.56 [1.57-8.11]; P = .003) and general anesthesia (IRR, 12.1 [4.39-33.5]; P < .001) were the only risk factors associated with longer HLOS. No associations were observed between risk factors and adverse events in multivariable analysis. Tumors treated per session were associated with risk of hospital readmission (P = .03). CONCLUSIONS: Identified preprocedural risk factors from the surgical literature may aid in risk stratification for HLOS after percutaneous ablation of lung tumors, but were not associated with adverse events.

Safety and Effectiveness of Percutaneous Image-Guided Thermal Ablation of Juxtacardiac Lung Tumors.

PURPOSE: To evaluate the safety and effectiveness of percutaneous image-guided thermal ablation (IGTA) for juxtacardiac lung tumors. MATERIALS AND METHODS: This bi-institutional retrospective cohort study included 23 consecutive patients (13 [57%] male; mean age, 55 years ± 18) with 30 juxtacardiac lung tumors located ≤10 mm from the pericardium treated in 28 IGTA sessions (25 sessions of cryoablation and 3 sessions of microwave ablation) between April 2008 and August 2022. The primary outcome was any adverse cardiac event within 90 days after ablation. Secondary outcomes included noncardiac adverse events, local tumor progression-free survival (LT-PFS), and the cumulative incidence of local tumor progression with death as a competing risk. Two tumors treated without curative intent or follow-up imaging were considered in the safety analysis but not in the progression analysis. RESULTS: The median imaging follow-up duration was 22 months (interquartile range [IQR], 10-53 months). Primary technical success was achieved in 25 (89%) ablations. No adverse cardiac events attributable to IGTA occurred. One patient experienced a phrenic nerve injury. The median LT-PFS duration was 59 months (IQR, 32-73 months). At 1, 3, and 5 years, LT-PFS was 90% (95% CI, 78%-100%), 74% (CI, 53%-100%), and 45% (CI, 20%-97%), respectively, and the cumulative incidence of local tumor progression was 4.3% (CI, 0.29%-19%), 11% (CI, 1.6%-30%), and 26% (CI, 3.3%-58%), respectively. CONCLUSIONS: IGTA is safe and effective for lung tumors located ≤10 mm from the pericardium. No adverse cardiac events were not observed within 90 days after ablation.

Utility of Normalized Body Composition Areas, Derived From Outpatient Abdominal CT Using a Fully Automated Deep Learning Method, for Predicting Subsequent Cardiovascular Events.

BACKGROUND. CT-based body composition (BC) measurements have historically been too resource intensive to analyze for widespread use and have lacked robust comparison with traditional weight metrics for predicting cardiovascular risk. OBJECTIVE. The aim of this study was to determine whether BC measurements obtained from routine CT scans by use of a fully automated deep learning algorithm could predict subsequent cardiovascular events independently from weight, BMI, and additional cardiovascular risk factors. METHODS. This retrospective study included 9752 outpatients (5519 women and 4233 men; mean age, 53.2 years; 890 patients self-reported their race as Black and 8862 self-reported their race as White) who underwent routine abdominal CT at a single health system from January 2012 through December 2012 and who were given no major cardiovascular or oncologic diagnosis within 3 months of undergoing CT. Using publicly available code, fully automated deep learning BC analysis was performed at the L3 vertebral body level to determine three BC areas (skeletal muscle area [SMA], visceral fat area [VFA], and subcutaneous fat area [SFA]). Age-, sex-, and race-normalized reference curves were used to generate z scores for the three BC areas. Subsequent myocardial infarction (MI) or stroke was determined from the electronic medical record. Multivariable-adjusted Cox proportional hazards models were used to determine hazard ratios (HRs) for MI or stroke within 5 years after CT for the three BC area z scores, with adjustment for normalized weight, normalized BMI, and additional cardiovascular risk factors (smoking status, diabetes diagnosis, and systolic blood pressure). RESULTS. In multivariable models, age-, race-, and sex-normalized VFA was associated with subsequent MI risk (HR of highest quartile compared with lowest quartile, 1.31 [95% CI, 1.03-1.67], p = .04 for overall effect) and stroke risk (HR of highest compared with lowest quartile, 1.46 [95% CI, 1.07-2.00], p = .04 for overall effect). In multivariable models, normalized SMA, SFA, weight, and BMI were not associated with subsequent MI or stroke risk. CONCLUSION. VFA derived from fully automated and normalized analysis of abdominal CT examinations predicts subsequent MI or stroke in Black and White patients, independent of traditional weight metrics, and should be considered an adjunct to BMI in risk models. CLINICAL IMPACT. Fully automated and normalized BC analysis of abdominal CT has promise to augment traditional cardiovascular risk prediction models.

Imaging Follow-Up of Nonsurgical Therapies for Lung Cancer: AJR Expert Panel Narrative Review.

Lung cancer continues to be the most common cause of cancer-related death worldwide. In the past decade, with the implementation of lung cancer screening programs and advances in surgical and nonsurgical therapies, the survival of patients with lung cancer has increased, as has the number of imaging studies that these patients undergo. However, most patients with lung cancer do not undergo surgical re-section, because they have comorbid disease or lung cancer in an advanced stage at diagnosis. Nonsurgical therapies have continued to evolve with a growing range of systemic and targeted therapies, and there has been an associated evolution in the imaging findings encountered at follow-up examinations after such therapies (e.g., with respect to posttreatment changes, treatment complications, and recurrent tumor). This AJR Expert Panel Narrative Review describes the current status of nonsurgical therapies for lung cancer and their expected and unexpected imaging manifestations. The goal is to provide guidance to radiologists regarding imaging assessment after such therapies, focusing mainly on non-small cell lung cancer. Covered therapies include systemic therapy (conventional chemotherapy, targeted therapy, and immunotherapy), radiotherapy, and thermal ablation.

Imaging Techniques to Determine Degree of Sarcopenia and Systemic Inflammation in Advanced Renal Cell Carcinoma.

PURPOSE OF REVIEW: The purpose of this review is to provide an up-to-date understanding regarding the literature on sarcopenia and inflammation as prognostic factors in the context of renal cell carcinoma (RCC). RECENT FINDINGS: Sarcopenia is increasingly recognized as a prognostic factor in RCC. Emerging literature suggests monitoring quantity of muscle on successive imaging and examining muscle density may be additionally informative. Inflammation has prognostic ability in RCC and is also considered a key contributor to development and progression of both RCC and sarcopenia. Recent studies suggest these two prognostic factors together may provide additional prognostic ability when used in combination. Ongoing developments include quality control regarding sarcopenia research and imaging, improving understanding of muscle loss mechanisms, and enhancing clinical incorporation of sarcopenia via improving imaging analysis practicality (i.e., artificial intelligence) and feasible biomarkers. Sarcopenia and systemic inflammation are complementary prognostic factors for adverse outcomes in patients with RCC. Further study on high-quality sarcopenia assessment standardization and expedited sarcopenia assessment is desired for eventual routine clinical incorporation of these prognostic factors.

Multilevel Body Composition Analysis on Chest Computed Tomography Predicts Hospital Length of Stay and Complications After Lobectomy for Lung Cancer: A Multicenter Study.

OBJECTIVE: To investigate the impact of thoracic body composition on outcomes after lobectomy for lung cancer. SUMMARY AND BACKGROUND DATA: Preoperative identification of patients at risk for adverse outcomes permits treatment modification. The impact of body composition on lung resection outcomes has not been investigated in a multicenter setting. METHODS: A total of 958 consecutive patients undergoing lobectomy for lung cancer at 3 centers from 2014 to 2017 were retrospectively analyzed. Muscle and adipose tissue cross-sectional area at the fifth, eighth, and tenth thoracic vertebral body was quantified. Prospectively collected outcomes from a national database were abstracted to characterize the association between sums of muscle and adipose tissue and hospital length of stay (LOS), number of any postoperative complications, and number of respiratory postoperative complications using multivariate regression. A priori determined covariates were forced expiratory volume in 1 second and diffusion capacity of the lungs for carbon monoxide predicted, age, sex, body mass index, race, surgical approach, smoking status, Zubrod and American Society of Anesthesiologists scores. RESULTS: Mean patient age was 67 years, body mass index 27.4 kg/m2 and 65% had stage i disease. Sixty-three percent underwent minimally invasive lobectomy. Median LOS was 4 days and 34% of patients experienced complications. Muscle (using 30 cm2 increments) was an independent predictor of LOS (adjusted coefficient 0.972; P = 0.002), any postoperative complications (odds ratio 0.897; P = 0.007) and postoperative respiratory complications (odds ratio 0.860; P = 0.010). Sarcopenic obesity was also associated with LOS and adverse outcomes. CONCLUSIONS: Body composition on preoperative chest computed tomography is an independent predictor of LOS and postoperative complications after lobectomy for lung cancer.

Comparison of expected imaging findings following percutaneous microwave and cryoablation of pulmonary tumors: ablation zones and thoracic lymph nodes.

OBJECTIVE: To compare temporal changes of ablation zones and lymph nodes following lung microwave ablation (MWA) and cryoablation. METHODS: This retrospective cohort study compared lung ablation zones and thoracic lymph nodes following MWA and cryoablation performed 2006-2020. In the ablation zone cohort, ablation zone volumes were measured on serial CT for 12 months. In the lymph node cohort, the sum of bidimensional products of lymph node diameters was measured before (baseline) and up to 6 months following ablation. Cumulative incidence curves estimated the time to 75% ablation zone reduction and linear mixed-effects regression models compared the temporal distribution of ablation zones and lymph node sizes between modalities. RESULTS: Ablation zones of 59 tumors treated in 45 sessions (16 MWA, 29 cryoablation) in 36 patients were evaluated. Differences in the time to 75% volume reduction between modalities were not detected. Following MWA, half of the ablation zones required an estimated time of 340 days to achieve a 75% volume reduction compared to 214 days following cryoablation (p = .30). Thoracic lymph node sizes after 33 sessions (13 MWA, 20 cryoablation) differed between modalities (baseline-32 days, p = .01; 32-123 days, p = .001). Following MWA, lymph nodes increased on average by 38 mm2 (95%CI, 5.0-70.7; p = .02) from baseline to 32 days, followed by an estimated decrease of 50 mm2 (32-123 days; p = .001). Following cryoablation, changes in lymph nodes were not detected (baseline-32 days, p = .33). CONCLUSION: The rate of ablation zone volume reduction did not differ between MWA and cryoablation. Thoracic lymph nodes enlarged transiently after MWA but not after cryoablation. KEY POINTS: • Contrary to current belief, the rate of lung ablation zone volume reduction did not differ between microwave and cryoablation. • Transient enlargement of thoracic lymph nodes after microwave ablation was not associated with regional tumor spread and decreased within six months following ablation. • No significant thoracic lymph node enlargement was observed following cryoablation.

Update on Image-Guided Thermal Lung Ablation: Society Guidelines, Therapeutic Alternatives, and Postablation Imaging Findings.

Percutaneous image-guided thermal ablation (IGTA) has been endorsed by multiple societies as a safe and effective lung-preserving treatment of primary lung cancer and metastases involving the lung and chest wall. This article reviews the role of IGTA in the care continuum of patients with thoracic neoplasms and discusses strategies to identify the optimal local therapy considering patient and tumor characteristics. The advantages and disadvantages of percutaneous thermal ablation compared with surgical resection and stereotactic body radiotherapy are summarized. Principles of radiofrequency ablation, microwave ablation, and cryoablation, as well as the emerging use of transbronchial thermal ablation, are described. Specific considerations are presented regarding the role of thermal ablation for early-stage non-small cell lung cancer (NSCLC), multifocal primary NSCLC, pulmonary metastases, salvage of recurrent NSCLC after surgery or radiation, and pain palliation for tumors involving the chest wall. Recent changes to professional society guidelines regarding the role of thermal ablation in the lung, including for treatment of oligometastatic disease, are highlighted. Finally, recommendations are provided for imaging follow-up after thermal ablation of lung tumors, accompanied by examples of expected postoperative findings and patterns of disease recurrence.

Utility of Noncancerous Chest CT Features for Predicting Overall Survival and Noncancer Death in Patients With Stage I Lung Cancer Treated With Stereotactic Body Radiotherapy.

BACKGROUND. Noncancerous imaging markers can be readily derived from pre-treatment diagnostic and radiotherapy planning chest CT examinations. OBJECTIVE. The purpose of this article was to explore the ability of noncancerous features on chest CT to predict overall survival (OS) and noncancer-related death in patients with stage I lung cancer treated with stereotactic body radiation therapy (SBRT). METHODS. This retrospective study included 282 patients (168 female, 114 male; median age, 75 years) with stage I lung cancer treated with SBRT between January 2009 and June 2017. Pretreatment chest CT was used to quantify coronary artery calcium (CAC) score, pulmonary artery (PA)-to-aorta ratio, emphysema, and body composition in terms of the cross-sectional area and attenuation of skeletal muscle and subcutaneous adipose tissue at the T5, T8, and T10 vertebral levels. Associations of clinical and imaging features with OS were quantified using a multivariable Cox proportional hazards (PH) model. Penalized multivariable Cox PH models to predict OS were constructed using clinical features only and using both clinical and imaging features. The models' discriminatory ability was assessed by constructing time-varying ROC curves and computing AUC at prespecified times. RESULTS. After a median OS of 60.8 months (95% CI, 55.8-68.0), 148 (52.5%) patients had died, including 83 (56.1%) with noncancer deaths. Higher CAC score (11-399: hazard ratio [HR], 1.83 [95% CI, 1.15-2.91], p = .01; ≥ 400: HR, 1.63 [95% CI, 1.01-2.63], p = .04), higher PA-to-aorta ratio (HR, 1.33 [95% CI, 1.16-1.52], p < .001, per 0.1-unit increase), and lower thoracic skeletal muscle index (HR, 0.88 [95% CI, 0.79-0.98], p = .02, per 10-cm2/m2 increase) were independently associated with shorter OS. Discriminatory ability for 5-year OS was greater for the model including clinical and imaging features than for the model including clinical features only (AUC, 0.75 [95% CI, 0.68-0.83] vs 0.61 [95% CI, 0.53-0.70]; p < .01). The model's most important clinical or imaging feature according to mean standardized regression coefficients was the PA-to-aorta ratio. CONCLUSION. In patients undergoing SBRT for stage I lung cancer, higher CAC score, higher PA-to-aorta ratio, and lower thoracic skeletal muscle index independently predicted worse OS. CLINICAL IMPACT. Noncancerous imaging features on chest CT performed before SBRT improve survival prediction compared with clinical features alone.

Comparison of Percutaneous Image-Guided Microwave Ablation and Cryoablation for Sarcoma Lung Metastases: A 10-Year Experience.

BACKGROUND. To our knowledge, outcomes between percutaneous microwave ablation (MWA) and cryoablation of sarcoma lung metastases have not been compared. OBJECTIVE. The purpose of this study was to compare technical success, complications, local tumor control, and overall survival (OS) after MWA versus cryoablation of sarcoma lung metastases. METHODS. This retrospective cohort study included 27 patients (16 women, 11 men; median age, 64 years; Eastern Cooperative Oncology Group performance score, 0-2) who, from 2009 to 2021, underwent 39 percutaneous CT-guided ablation sessions (21 MWA and 18 cryoablation sessions; one to four sessions per patient) to treat 65 sarcoma lung metastases (median number of tumors per patient, one [range, one to 12]; median tumor diameter, 11.0 mm [range, 5-33 mm]; 25% of tumors were nonperipheral). We compared complications according to ablation modality by use of generalized estimating equations. We evaluated ablation modality, tumor size, and location (peripheral vs nonperipheral) in relation to local tumor progression by use of proportional Cox hazard models, with death as the competing risk. We estimated OS using the Kaplan-Meier method. RESULTS. Primary technical success was 97% for both modalities. Median follow-up was 23 months (range, one to 102 months; interquartile range, 12-44 months). A total of seven of 61 tumors (11%) showed local progression. Estimated 1-year and 2-year local control rates were, for tumors 1 cm or smaller, 97% and 95% after MWA versus 99% and 98% after cryoablation, and for tumors larger than 1 cm, 74% and 62% after MWA versus 86% and 79% after cryoablation. Tumor size of 1 cm or smaller was associated with a decreased cumulative incidence of local progression (p = .048); ablation modality and tumor location were not associated with progression (p = .86 and p = .54, respectively). Complications (Common Terminology Criteria for Adverse Events [CTCAE] grade, ≤ 3) occurred in 17 of 39 sessions (44%), prompting chest tube placement in nine (23%). There were no CTCAE grade 4 or 5 complications. OS at 1, 2, and 3 years was 100%, 89%, and 82%, respectively. CONCLUSION. High primary technical success, local control, and OS support the use of MWA and cryoablation for treating sarcoma lung metastases. Ablation modality and tumor location did not affect local progression. The rate of local tumor progression was low, especially for small tumors. No life-threatening complications occurred. CLINICAL IMPACT. Percutaneous MWA and cryoablation are both suited for the treatment of sarcoma lung metastases, especially for tumors 1 cm or smaller, whether peripheral or nonperipheral. Complications, if they occur, are not life-threatening.

Muscle Loss Is Associated with Overall Survival in Patients with Metastatic Colorectal Cancer Independent of Tumor Mutational Status and Weight Loss.

BACKGROUND: Survival in patients with metastatic colorectal cancer (mCRC) has been associated with tumor mutational status, muscle loss, and weight loss. We sought to explore the combined effects of these variables on overall survival. MATERIALS AND METHODS: We performed an observational cohort study, prospectively enrolling patients receiving chemotherapy for mCRC. We retrospectively assessed changes in muscle (using computed tomography) and weight, each dichotomized as >5% or ≤5% loss, at 3, 6, and 12 months after diagnosis of mCRC. We used regression models to assess relationships between tumor mutational status, muscle loss, weight loss, and overall survival. Additionally, we evaluated associations between muscle loss, weight loss, and tumor mutational status. RESULTS: We included 226 patients (mean age 59 ± 13 years, 53% male). Tumor mutational status included 44% wild type, 42% RAS-mutant, and 14% BRAF-mutant. Patients with >5% muscle loss at 3 and 12 months experienced worse survival controlling for mutational status and weight (3 months hazard ratio, 2.66; p < .001; 12 months hazard ratio, 2.10; p = .031). We found an association of >5% muscle loss with BRAF-mutational status at 6 and 12 months. Weight loss was not associated with survival nor mutational status. CONCLUSION: Increased muscle loss at 3 and 12 months may identify patients with mCRC at risk for decreased overall survival, independent of tumor mutational status. Specifically, >5% muscle loss identifies patients within each category of tumor mutational status with decreased overall survival in our sample. Our findings suggest that quantifying muscle loss on serial computed tomography scans may refine survival estimates in patients with mCRC. IMPLICATIONS FOR PRACTICE: In this study of 226 patients with metastatic colorectal cancer, it was found that losing >5% skeletal muscle at 3 and 12 months after the diagnosis of metastatic disease was associated with worse overall survival, independent of tumor mutational status and weight loss. Interestingly, results did not show a significant association between weight loss and overall survival. These findings suggest that muscle quantification on serial computed tomography may refine survival estimates in patients with metastatic colorectal cancer beyond mutational status.