Search

Coronary artery calcium (CAC) scans contain valuable information beyond the Agatston Score which is currently reported for predicting coronary heart disease (CHD) only. We examined whether new artificial intelligence (AI) applied to CAC scans can predict non-CHD events, including heart failure, atrial fibrillation, and stroke. We applied AI-enabled automated cardiac chambers volumetry and calcified plaque characterization to CAC scans (AI-CAC) of 5830 asymptomatic individuals (52.2% women, age 61.7 ± 10.2 years) in the multi-ethnic study of atherosclerosis during 15 years of follow-up, 1773 CVD events accrued. The AUC at 1-, 5-, 10-, and 15-year follow-up for AI-CAC vs. Agatston score was (0.784 vs. 0.701), (0.771 vs. 0.709), (0.789 vs. 0.712) and (0.816 vs. 0.729) (p < 0.0001 for all), respectively. AI-CAC plaque characteristics, including number, location, density, plus number of vessels, significantly improved CHD prediction in the CAC 1-100 cohort vs. Agatston Score. AI-CAC significantly improved the Agatston score for predicting all CVD events., (© 2024. The Author(s).)

Background Diagnostic workup of small pulmonary nodules often requires follow-up CT scans to confirm nodule growth before invasive diagnostics or treatment. Purpose To confirm prior results from the International Early Lung Cancer Action Program (I-ELCAP) on quantifying decreases in lung cancer prognosis by using two large databases, the National Lung Screening Trial (NLST) and International Association for the Study of Lung Cancer (IASLC). Materials and Methods In this retrospective study, a model was developed to predict cure rates based on size of solid nodules using the NLST (August 2002 to summer 2007) and IASLC (January 2011 to December 2019) databases, focusing on stage I non-small cell lung cancer (NSCLC). Kaplan-Meier methods were used to calculate 10-year lung cancer-specific survival and 5-year overall survival rates for different tumor sizes. Tumor diameter increases after 90-, 180-, and 365-day delays were estimated using volume doubling times (VDTs) of 60, 120, and 240 days corresponding to fast, moderate, and slow tumor growth. Initial and delayed lung cancer cure rates were assessed across nine scenarios of time delays and tumor growth rates and compared with the previous results of the I-ELCAP database. Results Using regression models based on 166 NLST and 22 590 IASLC patients with NSCLC, 10-year lung cancer-specific survival and 5-year overall survival, respectively, for tumors 4.0-20.0 mm in diameter were estimated. For a 20.0-mm tumor with a 60-day VDT in the NLST database, the lung cancer-specific survival decreased from 83.4% to 76.5%, 66.8%, and 32.3% after 90, 180, and 365 days, respectively. The IASLC database showed similar decreases in 5-year overall survival, from 81.2% to 73.4%, 62.4%, and 23.3% after 90, 180, and 365 days, respectively. Comparison across NLST, IASLC, and I-ELCAP databases revealed minor variations in lung cancer cure rates between 79.9% and 83.4%, with reductions of 6.9%-8.3% after a 180-day delay with a 120-day VDT. Conclusion The NLST and IASLC databases confirmed prior estimates from the I-ELCAP database for the decrease in lung cancer prognosis due to diagnostic delays. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Park and Lee in this issue.

Purpose: Bronchiectasis is associated with loss of lung function, substantial use of health care resources, and increased morbidity and mortality in people with cardiopulmonary diseases. We assessed the frequency of progression or new development of bronchiectasis and predictors of progression in participants in low-dose computed tomography (CT) screening programs., Materials and Methods: We reviewed our prospectively enrolled screening cohort in the Early Lung and Cardiac Action Program cohort of smokers, aged 40 to 90, between 2010 and 2019, and medical records to assess the progression of bronchiectasis after five or more years of follow-up after baseline low-dose CT. Logistic and multivariate-analysis-of-covariance regression analyses were used to examine factors associated with bronchiectasis progression., Results: Among 2182 baseline screening participants, we identified 534 (mean age: 65±9 y; 53.6% women) with follow-up screening of 5+ years (median follow-up: 103.2 mo). Of the 534 participants, 34 (6.4%) participants had progressed (25/126, 19.8%) or newly developed (9/408, 2.2%) bronchiectasis. Significant predictors of progression (progressed+newly developed) were: age (P=0.03), pack-years of smoking (P=0.004), baseline components of the ELCAP Bronchiectasis Score, including the severity of bronchial dilatation (P=0.01), its extent (P=0.01), bronchial wall thickening (P=0.04), and mucoid impaction (P<0.001)., Conclusions: Assuming similar progression rates, ~136 out of 2182 participants are expected to progress on follow-up screening. This study sheds light on bronchiectasis progression and its significant predictors in a low-dose CT screening program. We recommend reporting bronchiectasis as participants who have smoked are at increased risk, and continued assessment over the entire period of participation in the low-dose CT screening program would allow for the identification of possible causes, early warning, and even early treatment., Competing Interests: D.F.Y. is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. D.F.Y. has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging. He is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest. He is on the medical advisory board of Median Technology, which is developing technology related to analyzing pulmonary nodules and is on the medical advisory board of Carestream, a company that develops radiography equipment. D.F.Y. is also on the advisory board of LungLife AI. C.I.H. is a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, C.I.H. has not accepted any financial benefit from these patents, including royalties and any other proceeds related to the patents or patent applications owned by CRF. C.I.H. is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. Recipients include I-ELCAP, among others. The funding comes from a variety of sources, including philanthropic donations, grants, and contracts with agencies (federal and non-federal), imaging, and pharmaceutical companies relating to image processing assessments. The various sources of funding exclude any funding from tobacco companies or tobacco-related sources. C.I.H. is on the advisory board of LungLife AI without compensation. M.M. has received remuneration for serving as a consultant to Insmed, Boehringer-Ingelheim, and Tactile, Inc. He has received remuneration for serving on Data Safety Monitoring Boards for An2 and Renovion. He serves on the Board of Directors for the COPD Foundation. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: To facilitate global implementation of lung cancer (LC) screening and early detection in a quality assured and consistent manner, common terminology is needed. Researchers and clinicians within different specialties may use the same terms but with different meanings or different terms for the same intended meanings., Methods: The Diagnostics Working Group of the International Association for the Study of Lung Cancer Early Detection and Screening Committee has analyzed and discussed relevant terms used on a regular basis and suggests recommendations for consensus definitions of terminology applicable in this setting. We explored how to reach consensus to define relevant and unambiguous terminology for use by health care providers, researchers, patients, screening participants, and family., Results: Terms and definitions for epidemiologic and health-economical purposes included the following: standardized incidence and mortality rates, LC-specific survival, long-term survival and cure rates, overdiagnosis, overtreatment, and undertreatment. Terms and definitions for defining screening findings included the following: positive, false-positive, negative, false-negative, and indeterminate findings and additional and incidental findings. Terms and definitions for describing parameters in screening programs included the following: opportunistic versus programmatic screening, screening rounds, interval or interim diagnoses, and invasive and minimally invasive procedures. Terms and definitions for shared decision-making included the following: LC screening-possible harms and risks and LC risk and modifiers prior and posterior to a measure., Conclusions: A common set of terminology with standard definitions is recommended for describing clinical LC screening programs, the discussion about effectiveness and outcomes, or the clinical setting. The use of the terms should be clearly defined and explained., Competing Interests: Disclosure Dr. Huber participated in advisory boards for Janssen Germany, Merck Germany, Boehringer Ingelheim, Sanofi Germany, Novocure Germany Advisory, is deputy chair of the Early detection and screening committee of IASLC and co-chair of the ERS/ESTS task force Fitness for therapy of lung cancer. Dr. Kitts gets consulting fees from City of Hope, American College of Radiology and Memorial Sloan Kettering and support for attending meetings from Rescue Lung Society and American Cancer Society. Dr. Kitts has patents for Community based Individualized Health Platforms and Individualized Health Platforms, issued to Prosumer Health Founders and leadership roles in Rescue Lung Society, Lung Cancer Policy Network and Prosumer Health (start-up company) and stocks of Johnson & Johnson, Abbvie and Abbot Labs. Dr. Henschke serves on advisory board for Lunglife AI. without compensation and is a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, Dr. Henschke does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF. Dr. Henschke is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. Recipients include, I-ELCAP, among others. The funding comes from a variety of sources including philanthropic donations, grants and contracts with agencies (federal and non-federal), imaging and pharmaceutical companies relating to image processing assessments. The various sources of funding exclude any funding from tobacco companies or tobacco-related sources. Dr. Lam got travel support from IASLC to attend World Conference on Lung Cancer and from the Canadian Partnership Against Cancer and is on its advisory aboard as well as for Nucleix Technologies Inc Medical. Dr. Kazerooni is on the advisory board of the International Lung Screening Trial. Dr. Kerpel-Fronius is on the speaker bureau of Boehringer Ingelheim and MSD. Dr. Yankelevitz owns equity in HeartLung and is on advisory boards for HeartLung, Median Technology, Carestream and Lunglife AI. Dr. Yankelevitz is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. Dr. Yankelevitz has received financial compensation for the licensing of these patents. He is consultant and co-owner of Accumetra. The remaining authors declare no conflict of interest., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Introduction: Coronary artery calcium (CAC) scans contain useful information beyond the Agatston CAC score that is not currently reported. We recently reported that artificial intelligence (AI)-enabled cardiac chambers volumetry in CAC scans (AI-CAC™) predicted incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis (MESA). In this study, we investigated the performance of AI-CAC cardiac chambers for prediction of incident heart failure (HF)., Methods: We applied AI-CAC to 5750 CAC scans of asymptomatic individuals (52% female, White 40%, Black 26%, Hispanic 22% Chinese 12%) free of known cardiovascular disease at the MESA baseline examination (2000-2002). We used the 15-year outcomes data and compared the time-dependent area under the curve (AUC) of AI-CAC volumetry versus NT-proBNP, Agatston score, and 9 known clinical risk factors (age, gender, diabetes, current smoking, hypertension medication, systolic and diastolic blood pressure, LDL, HDL for predicting incident HF over 15 years., Results: Over 15 years of follow-up, 256 HF events accrued. The time-dependent AUC [95% CI] at 15 years for predicting HF with AI-CAC all chambers volumetry (0.86 [0.82,0.91]) was significantly higher than NT-proBNP (0.74 [0.69, 0.77]) and Agatston score (0.71 [0.68, 0.78]) (p ​< ​0.0001), and comparable to clinical risk factors (0.85, p ​= ​0.4141). Category-free Net Reclassification Index (NRI) [95% CI] adding AI-CAC LV significantly improved on clinical risk factors (0.32 [0.16,0.41]), NT-proBNP (0.46 [0.33,0.58]), and Agatston score (0.71 [0.57,0.81]) for HF prediction at 15 years (p ​< ​0.0001)., Conclusion: AI-CAC volumetry significantly outperformed NT-proBNP and the Agatston CAC score, and significantly improved the AUC and category-free NRI of clinical risk factors for incident HF prediction., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Measurements are not exact, so that if a measurement is repeated, one would get a different value each time. The spread of these values is the measurement uncertainty. Understanding measurement uncertainty of pulmonary nodules is important for proper interpretation of size and growth measurements. Larger amounts of measurement uncertainty may require longer follow-up intervals to be confident that any observed growth is due to actual growth rather than measurement uncertainty. We examined the influence of nodule features and software algorithm on measurement uncertainty of small, solid pulmonary nodules., Methods: Volumes of 107 nodules were measured on 4-6 repeated computed tomography (CT) scans (Siemens Somatom AS, 100 kVp, 120 mA, 1.0 mm slice thickness reconstruction) prospectively obtained during CT-guided fine needle aspiration biopsy between 2015-2021 at Department of Diagnostic, Molecular, and Interventional Radiology in Icahn School of Medicine at Mount Sinai, using two different automated volumetric algorithms. For each, the coefficient of variation (standard deviation divided by the mean) of nodule volume measurements was determined. The following features were considered: diameter, location, vessel and pleural attachments, nodule surface area, and extent of the nodule in the three acquisition dimensions of the scanner., Results: Median volume of 107 nodules was 515.23 and 535.53 mm 3 for algorithm #1 and #2, respectively with excellent agreement (intraclass correlation coefficient =0.98). Median coefficient of variation of nodule volume was low for the two algorithms, but significantly different (4.6% vs. 8.7%, P<0.001). Both algorithms had a trend of decreasing coefficient of variation of nodule volume with increasing nodule diameter, though only significant for algorithm #2. Coefficient of variation of nodule volume was significantly associated with nodule volume (P=0.02), attachment to blood vessels (P=0.02), and nodule surface area (P=0.001) for algorithm #2 using a multiple linear regression model. Correlation between the coefficient of variation (CoV) of nodule volume and the CoV of the x, y, z measurements for algorithm #1 were 0.29 (P=0.0021), 0.25 (P=0.009), and 0.80 (P<0.001) respectively, and for algorithm #2, 0.46 (P<0.001), 0.52 (P<0.001), and 0.58 (P<0.001), respectively., Conclusions: Even in the best-case scenario represented in this study, using the same measurement algorithm, scanner, and scanning protocol, considerable measurement uncertainty exists in nodule volume measurement for nodules sized 20 mm or less. We found that measurement uncertainty was affected by interactions between nodule volume, algorithm, and shape complexity., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-1501/coif). A.J. received support as the Principal Investigator from a grant from the Prevent Cancer Foundation for this work. He also served as a co-chair on an unpaid basis of the RSNA QIBA Small Lung Nodule Volume committee from Jan 2023 to Feb 2024. R.Y. received support for this work from a grant from the Prevent Cancer Foundation. K.J.M. served as a co-chair on an unpaid basis of the RSNA QIBA Small Lung Nodule Volume committee from Jan 2023 to Feb 2024. She is the owner of Puente Solutions LLC, a for-profit company. She receives consulting fee from Annalise.ai; HeartLung; InformAI; Median iBiopsy; Malcova; Mt. Sinai School of Medicine; Sira; Voronoi; and VoxelCloud. C.I.H. is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. C.I.H. is also a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, C.I.H. does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF. She is on the advisory board of Lunglife AI without compensation. D.Y. is a named inventor of General Electric on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. He has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging. He is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest. He is on the medical advisory board of Median Technology that is developing technology related to analyzing pulmonary nodules and is on the medical advisory board of Carestream, a company that develops radiography equipment. He is also on the advisory board of Lunglife AI. The other author has no conflicts of interest to declare., (2024 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Background: Coronary artery calcium (CAC) scans contain actionable information beyond CAC scores that is not currently reported., Methods: We have applied artificial intelligence-enabled automated cardiac chambers volumetry to CAC scans (AI-CAC TM ) to 5535 asymptomatic individuals (52.2% women, ages 45-84) that were previously obtained for CAC scoring in the baseline examination (2000-2002) of the Multi-Ethnic Study of Atherosclerosis (MESA). AI-CAC took on average 21 ​s per CAC scan. We used the 5-year outcomes data for incident atrial fibrillation (AF) and assessed discrimination using the time-dependent area under the curve (AUC) of AI-CAC LA volume with known predictors of AF, the CHARGE-AF Risk Score and NT-proBNP. The mean follow-up time to an AF event was 2.9 ​± ​1.4 years., Results: At 1,2,3,4, and 5 years follow-up 36, 77, 123, 182, and 236 cases of AF were identified, respectively. The AUC for AI-CAC LA volume was significantly higher than CHARGE-AF for Years 1, 2, and 3 (0.83 vs. 0.74, 0.84 vs. 0.80, and 0.81 vs. 0.78, respectively, all p ​< ​0.05), but similar for Years 4 and 5, and significantly higher than NT-proBNP at Years 1-5 (all p ​< ​0.01), but not for combined CHARGE-AF and NT-proBNP at any year. AI-CAC LA significantly improved the continuous Net Reclassification Index for prediction of AF over years 1-5 when added to CHARGE-AF Risk Score (0.60, 0.28, 0.32, 0.19, 0.24), and NT-proBNP (0.68, 0.44, 0.42, 0.30, 0.37) (all p ​< ​0.01)., Conclusion: AI-CAC LA volume enabled prediction of AF as early as one year and significantly improved on risk classification of CHARGE-AF Risk Score and NT-proBNP., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery calcium (CAC) scans contain valuable information beyond the Agatston Score which is currently reported for predicting coronary heart disease (CHD) only. We examined whether new artificial intelligence (AI) algorithms applied to CAC scans may provide significant improvement in prediction of all cardiovascular disease (CVD) events in addition to CHD, including heart failure, atrial fibrillation, stroke, resuscitated cardiac arrest, and all CVD-related deaths., Methods: We applied AI-enabled automated cardiac chambers volumetry and automated calcified plaque characterization to CAC scans (AI-CAC) of 5830 individuals (52.2% women, age 61.7±10.2 years) without known CVD that were previously obtained for CAC scoring at the baseline examination of the Multi-Ethnic Study of Atherosclerosis (MESA). We used 15-year outcomes data and assessed discrimination using the time-dependent area under the curve (AUC) for AI-CAC versus the Agatston Score., Results: During 15 years of follow-up, 1773 CVD events accrued. The AUC at 1-, 5-, 10-, and 15-year follow up for AI-CAC vs Agatston Score was (0.784 vs 0.701), (0.771 vs. 0.709), (0.789 vs.0.712) and (0.816 vs. 0.729) (p<0.0001 for all), respectively. The category-free Net Reclassification Index of AI-CAC vs. Agatston Score at 1-, 5-, 10-, and 15-year follow up was 0.31, 0.24, 0.29 and 0.29 (p<.0001 for all), respectively. AI-CAC plaque characteristics including number, location, and density of plaque plus number of vessels significantly improved NRI for CAC 1-100 cohort vs. Agatston Score (0.342)., Conclusion: In this multi-ethnic longitudinal population study, AI-CAC significantly and consistently improved the prediction of all CVD events over 15 years compared with the Agatston score.

Purpose: Because incidental thyroid nodules (ITNs) are common extrapulmonary findings in low-dose computed tomography (LDCT) scans for lung cancer screening, we aimed to investigate the frequency of ITNs on LDCT scans separately on baseline and annual repeat scans, the frequency of malignancy among the ITNs, and any association with demographic, clinical, CT characteristics., Methods: Retrospective case series of all 2309 participants having baseline and annual repeat screening in an Early Lung and Cardiac Action Program (MS-ELCAP) LDCT lung screening program from January 2010 to December 2016 was performed. Frequency of ITNs in baseline and annual repeat rounds were determined. Multivariable regression analysis was performed to identify significant predictors., Results: Dominant ITNs were seen in 2.5 % of 2309 participants on baseline and in 0.15 % of participants among 4792 annual repeat LDCTs. The low incidence of new ITNs suggests slow growth as it would take approximately an average of 16.8 years for a new ITN to be detected on annual rounds of screening. Newly detected ITNs on annual repeat LDCT were all smaller than 15 mm. Regression analysis showed that the increasing of age, coronary artery calcifications score and breast density grade were significant predictors for females having an ITN. No significant predictors were found for ITNs in males., Conclusion: ITNs are detected at LDCT however, no malignancy was found. Certain predictors for ITNs in females have been identified including breast density, which may point towards a common causal pathway., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Yankelevitz is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. Dr. Yankelevitz has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging. He is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest. He is on the medical advisory board of Median Technology that is developing technology related to analyzing pulmonary nodules and is on the medical advisory board of Carestream, a company that develops radiography equipment and has consulted for Genentech, AstraZeneca and Pfizer. Dr. Claudia Henschke is a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, Dr. Henschke does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF. Dr. Henschke is the President and serve on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. Recipients include, I-ELCAP, among others. The funding comes from a variety of sources including philanthropic donations, grants and contracts with agencies (federal and non-federal), imaging and pharmaceutical companies relating to image processing assessments. The various sources of funding exclude any funding from tobacco companies or tobacco-related sources. Dr. Claudia Henschke is on the advisory board of LungLife AI without compensation. All other authors have no competing interests to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The risk factors for lung cancer screening eligibility, age as well as smoking history, are also present for osteoporosis. This study aims to develop a visual scoring system to identify osteoporosis that can be applied to low-dose CT scans obtained for lung cancer screening., Materials and Methods: We retrospectively reviewed 1000 prospectively enrolled participants in the lung cancer screening program at the Mount Sinai Hospital. Optimal window width and level settings for the visual assessment were chosen based on a previously described approach. Visual scoring of osteoporosis and automated measurement using dedicated software were compared. Inter-reader agreement was conducted using six readers with different levels of experience who independently visually assessed 30 CT scans., Results: Based on previously validated formulas for choosing window and level settings, we chose osteoporosis settings of Width = 230 and Level = 80. Of the 1000 participants, automated measurement was successfully performed on 774 (77.4 %). Among these, 138 (17.8 %) had osteoporosis. There was a significant correlation between the automated measurement and the visual score categories for osteoporosis (Kendall's Tau = -0.64, p < 0.0001; Spearman's rho = -0.77, p < 0.0001). We also found substantial to excellent inter-reader agreement on the osteoporosis classification among the 6 radiologists (Fleiss κ = 0.91)., Conclusions: Our study shows that a simple approach of applying specific window width and level settings to already reconstructed sagittal images obtained in the context of low-dose CT screening for lung cancer is highly feasible and useful in identifying osteoporosis., Competing Interests: Declaration of competing interest, (Copyright © 2024 Elsevier Inc. All rights reserved.)

Lung cancer screening involves the use of thoracic CT for both detection and measurements of suspicious lung nodules to guide the screening management. Since lung cancer screening eligibility typically requires age over 50 years along with >20 pack-year tobacco exposure, thoracic CT scans also frequently reveal evidence for pulmonary emphysema as well as coronary artery calcification. These three thoracic diseases are collectively three of the leading causes of premature death across the world. Screening for the major thoracic diseases in this heavily tobacco-exposed cohort is broadening the focus of lung cancer screening to a more comprehensive health evaluation including discussing the relevance of screen-detected findings of the heart and lung parenchyma. The status and implications of these emerging issues were reviewed in a multidisciplinary workshop focused on the process of quantitative imaging in the lung cancer screening setting to guide the evolution of this important new area of public health., (© 2023 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Objectives: Time-to-treatment initiation is an important consideration for patients undergoing thoracic surgery for early-stage lung cancer because delays have the potential to adversely affect outcomes. This study seeks to quantify time-to-treatment initiation for patients with clinical stage I lung cancer, explore patient factors and predictors that lead to an increased time-to-treatment initiation, and compare surgeon perception of appropriate time-to-treatment initiation to the results., Methods: Time-to-treatment initiation was determined for patients enrolled in the Mount Sinai Initiative for Early Lung Cancer Research on Treatment study who underwent surgical resection for clinical stage I lung cancer between March 2016 and December 2021. The following dates were determined: (1) date of first suspicious radiologic imaging, (2) date of first biopsy, and (3) date of surgery. A total of 15 thoracic surgeons who participated in the Mount Sinai Initiative for Early Lung Cancer Research on Treatment were assessed on their perception on time-to-treatment initiation., Results: For 638 patients, median time from first suspicious imaging findings to biopsy was 40 days, biopsy to surgery was 37 days, and suspicious imaging to surgery was 84 days. Significant factors that resulted in longer time-to-treatment initiation in the multivariate analysis were African American or Black race ( P  = .005), vascular disease ( P  = .01), and median household income less than $75,000 ( P  = .04). Although the surgeon's perception was that the average time from biopsy to surgery was 28 days, it was longer for 63.5% of participants; surgeon perception of maximum time between diagnosis and surgery was 84 days and longer for 28.7% of participants., Conclusions: Patient factors such as race, income, and comorbidities were found to have differences in time-to-treatment initiation. Delays to surgery exceeded the expectations of thoracic surgeons., Competing Interests: D.F.Y. is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules; has received financial compensation for the licensing of these patents; is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging; is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest; is on the medical advisory board of Median Technology that is developing technology related to analyzing pulmonary nodules; and is on the medical advisory board of Carestream, a company that develops radiography equipment and has consulted for Genentech, AstraZeneca, and Pfizer. C.I.H. is an inventor of the patents and pending patents owned by Cornell Research Foundation (as of April 2009, she has divested herself of all royalties and other interests arising from these) and is on the medical advisory board for LungLife AI. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

The American College of Radiology created the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screen-detected pulmonary nodules. Lung-RADS was updated to version 1.1 in 2019 and revised size thresholds for nonsolid nodules, added classification criteria for perifissural nodules, and allowed for short-interval follow-up of rapidly enlarging nodules that may be infectious in etiology. Lung-RADS v2022, released in November 2022, provides several updates including guidance on the classification and management of atypical pulmonary cysts, juxtapleural nodules, airway-centered nodules, and potentially infectious findings. This new release also provides clarification for determining nodule growth and introduces stepped management for nodules that are stable or decreasing in size. This article summarizes the current evidence and expert consensus supporting Lung-RADS v2022., (Copyright © 2024 American College of Radiology and American College of Chest Physicians. Published by Elsevier Inc on behalf of American College of Radiology and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: We aimed to compare outcomes of patients with first primary clinical T1a-bN0M0 NSCLC treated with surgery or stereotactic body radiation therapy (SBRT)., Methods: 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., Results: 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)., Conclusions: 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., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

The ACR created the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screen-detected pulmonary nodules. Lung-RADS was updated to version 1.1 in 2019 and revised size thresholds for nonsolid nodules, added classification criteria for perifissural nodules, and allowed for short-interval follow-up of rapidly enlarging nodules that may be infectious in etiology. Lung-RADS v2022, released in November 2022, provides several updates including guidance on the classification and management of atypical pulmonary cysts, juxtapleural nodules, airway-centered nodules, and potentially infectious findings. This new release also provides clarification for determining nodule growth and introduces stepped management for nodules that are stable or decreasing in size. This article summarizes the current evidence and expert consensus supporting Lung-RADS v2022., (Copyright © 2024 American College of Radiology and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have examined the differential impact of stereotactic body radiotherapy (SBRT) and surgery for early-stage non-small cell lung cancer (NSCLC) on quality of life (QoL) during the first post-treatment year., Methods: A prospective cohort of stage IA NSCLC patients undergoing surgery or SBRT at Mount Sinai Health System had QoL measured before treatment, and 2, 6, and 12 months post-treatment using: 12-item Short Form Health Survey version 2 (SF-12 v2 ) [physical component summary (PCS) and mental component summary (MCS)], Functional Assessment of Cancer Therapy-Lung Cancer Subscale (FACT-LCS), and the Patient Health Questionnaire-4 (PHQ-4) measuring depression and anxiety. Locally weighted scatterplot smoothing (LOWESS) was fitted to identify the best interval knot for the change in the QoL trends post-treatment, adjusted piecewise linear mixed effects model was developed to estimate differences in baseline, 2- and 12-month scores, and rates of change., Results: In total, 503 (88.6%) patients received surgery and 65 (11.4%) SBRT. LOWESS plots suggested QoL changed at 2 months post-surgery. Worsening in PCS was observed for both surgery and SBRT within 2 months after treatment but was only significant for surgical patients (-2.11, P<0.001). Two months later, improvements were observed for surgical but not SBRT patients (0.63 vs. -0.30, P<0.001). Surgical patients had significantly better PCS (P<0.001) and FACT-LCS (P<0.001) scores 1-year post-treatment compared to baseline, but not SBRT patients. Both surgical and SBRT patients reported significantly less anxiety 1-year post-treatment compared to baseline (P<0.001 and P=0.03). Decrease in depression from baseline to 1-year post-treatment was only significant for surgical patients (P<0.001)., Conclusions: Post-treatment, surgical patients exhibited improvements in physical health and reductions in lung cancer symptoms following initial deterioration within the first two months; in contrast, SBRT patients showed persistent decline in these areas throughout the year. Nonetheless, improved mental health was noted across both patient categories post-treatment. Targeted interventions and continuous monitoring are recommended during the initial 2 months post-surgery and throughout the year post-SBRT to alleviate physical and mental distress in patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1201/coif). All authors report that this study was supported by generous grants from the Simons Foundation (International, Ltd.). D.F.Y. is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. D.F.Y. has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging. He is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest. He is on the medical advisory board of Median Technology that is developing technology related to analyzing pulmonary nodules and is on the medical advisory board of Carestream, a company that develops radiography equipment. C.I.H. is also an inventor of the patents and pending patents owned by Cornell Research Foundation. As of April 2009, she has divested herself of all royalties and other interests arising from these. She is on the medical advisory board for LungLife Al. The authors have no other conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background CT-defined visceral pleural invasion (VPI) is an important indicator of prognosis for non-small cell lung cancer (NSCLC). However, there is a lack of studies focused on small subpleural NSCLCs (≤30 mm). Purpose To identify CT features predictive of VPI in patients with subpleural NSCLCs 30 mm or smaller. Materials and Methods This study is a retrospective review of patients enrolled in the Initiative for Early Lung Cancer Research on Treatment (IELCART) at Mount Sinai Hospital between July 2014 and February 2023. Subpleural nodules 30 mm or smaller were classified into two groups: a pleural-attached group and a pleural-tag group. Preoperative CT features suggestive of VPI were evaluated for each group separately. Multivariable logistic regression analysis adjusted for sex, age, nodule size, and smoking status was used to determine predictive factors for VPI. Model performance was analyzed with the area under the receiver operating characteristic curve (AUC), and models were compared using Akaike information criterion (AIC). Results Of 379 patients with NSCLC with subpleural nodules, 37 had subsolid nodules and 342 had solid nodules. Eighty-eight patients (22%) had documented VPI, all in solid nodules. Of the 342 solid nodules (46% in male patients, 54% in female patients; median age, 71 years; IQR: 66, 76), 226 were pleural-attached nodules and 116 were pleural-tag nodules. VPI was more frequent for pleural-attached nodules than for pleural-tag nodules (31% [69 of 226] vs 16% [19 of 116], P = .005). For pleural-attached nodules, jellyfish sign (odds ratio [OR], 21.60; P < .001), pleural thickening (OR, 6.57; P < .001), and contact surface area (OR, 1.05; P = .01) independently predicted VPI. The jellyfish sign led to a better VPI prediction (AUC, 0.84; 95% CI: 0.78, 0.90). For pleural-tag nodules, multiple tags to different pleura surfaces enabled independent prediction of VPI (OR, 9.30; P = .001). Conclusions For patients with solid NSCLC (≤30 mm), CT predictors of VPI were the jellyfish sign, pleural thickening, contact surface area (pleural-attached nodules), and multiple tags to different pleura surfaces (pleural-tag nodules). © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Nishino in this issue.

Introduction: With global adoption of computed tomography (CT) lung cancer screening, there is increasing interest to use artificial intelligence (AI) deep learning methods to improve the clinical management process. To enable AI research using an open-source, cloud-based, globally distributed, screening CT imaging data set and computational environment that are compliant with the most stringent international privacy regulations that also protect the intellectual properties of researchers, the International Association for the Study of Lung Cancer sponsored development of the Early Lung Imaging Confederation (ELIC) resource in 2018. The objective of this report is to describe the updated capabilities of ELIC and illustrate how this resource can be used for clinically relevant AI research., Methods: In this second phase of the initiative, metadata and screening CT scans from two time points were collected from 100 screening participants in seven countries. An automated deep learning AI lung segmentation algorithm, automated quantitative emphysema metrics, and a quantitative lung nodule volume measurement algorithm were run on these scans., Results: A total of 1394 CTs were collected from 697 participants. The LAV950 quantitative emphysema metric was found to be potentially useful in distinguishing lung cancer from benign cases using a combined slice thickness more than or equal to 2.5 mm. Lung nodule volume change measurements had better sensitivity and specificity for classifying malignant from benign lung nodules when applied to solid lung nodules from high-quality CT scans., Conclusions: These initial experiments revealed that ELIC can support deep learning AI and quantitative imaging analyses on diverse and globally distributed cloud-based data sets., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Background Pulmonary noncalcified nodules (NCNs) attached to the fissural or costal pleura with smooth margins and triangular or lentiform, oval, or semicircular (LOS) shapes at low-dose CT are recommended for annual follow-up instead of immediate workup. Purpose To determine whether management of mediastinal or diaphragmatic pleura-attached NCNs (M/DP-NCNs) with the same features as fissural or costal pleura-attached NCNs at low-dose CT can follow the same recommendations. Materials and Methods This retrospective study reviewed chest CT examinations in participants from two databases. Group A included 1451 participants who had lung cancer that was first present as a solid nodule with an average diameter of 3.0-30.0 mm. Group B included 345 consecutive participants from a lung cancer screening program who had at least one solid nodule with a diameter of 3.0-30.0 mm at baseline CT and underwent at least three follow-up CT examinations. Radiologists reviewed CT images to identify solid M/DP-NCNs, defined as nodules 0 mm in distance from the mediastinal or diaphragmatic pleura, and recorded average diameter, margin, and shape. General descriptive statistics were used. Results Among the 1451 participants with lung cancer in group A, 163 participants (median age, 68 years [IQR, 61.5-75.0 years]; 92 male participants) had 164 malignant M/DP-NCNs 3.0-30.0 mm in average diameter. None of the 164 malignant M/DP-NCNs had smooth margins and triangular or LOS shapes (upper limit of 95% CI of proportion, 0.02). Among the 345 consecutive screening participants in group B, 146 participants (median age, 65 years [IQR, 59-71 years]; 81 female participants) had 240 M/DP-NCNs with average diameter 3.0-30.0 mm. None of the M/DP-NCNs with smooth margins and triangular or LOS shapes were malignant after a median follow-up of 57.8 months (IQR, 46.3-68.1 months). Conclusion For solid M/DP-NCNs with smooth margins and triangular or LOS shapes at low-dose CT, the risk of lung cancer is extremely low, which supports the recommendation of Lung Imaging Reporting and Data System version 2022 for annual follow-up instead of immediate workup. © RSNA, 2024 See also the editorial by Goodman and Baruah in this issue.

Background The low-dose CT (≤3 mGy) screening report of 1000 Early Lung Cancer Action Program (ELCAP) participants in 1999 led to the International ELCAP (I-ELCAP) collaboration, which enrolled 31 567 participants in annual low-dose CT screening between 1992 and 2005. In 2006, I-ELCAP investigators reported the 10-year lung cancer-specific survival of 80% for 484 participants diagnosed with a first primary lung cancer through annual screening, with a high frequency of clinical stage I lung cancer (85%). Purpose To update the cure rate by determining the 20-year lung cancer-specific survival of participants diagnosed with first primary lung cancer through annual low-dose CT screening in the expanded I-ELCAP cohort. Materials and Methods For participants enrolled in the HIPAA-compliant prospective I-ELCAP cohort between 1992 and 2022 and observed until December 30, 2022, Kaplan-Meier survival analysis was used to determine the 10- and 20-year lung cancer-specific survival of participants diagnosed with first primary lung cancer through annual low-dose CT screening. Eligible participants were aged at least 40 years and had current or former cigarette use or had never smoked but had been exposed to secondhand tobacco smoke. Results Among 89 404 I-ELCAP participants, 1257 (1.4%) were diagnosed with a first primary lung cancer (684 male, 573 female; median age, 66 years; IQR, 61-72), with a median smoking history of 43.0 pack-years (IQR, 29.0-60.0). Median follow-up duration was 105 months (IQR, 41-182). The frequency of clinical stage I at pretreatment CT was 81% (1017 of 1257). The 10-year lung cancer-specific survival of 1257 participants was 81% (95% CI: 79, 84) and the 20-year lung cancer-specific survival was 81% (95% CI: 78, 83), and it was 95% (95% CI: 91, 98) for 181 participants with pathologic T1aN0M0 lung cancer. Conclusion The 10-year lung cancer-specific survival of 80% reported in 2006 for I-ELCAP participants enrolled in annual low-dose CT screening and diagnosed with a first primary lung cancer has persisted, as shown by the updated 20-year lung cancer-specific survival for the expanded I-ELCAP cohort. © RSNA, 2023 See also the editorials by Grenier and by Sequist and Olazagasti in this issue.

Introduction: Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization., Methods: Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role., Results: The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles., Conclusions: Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization., (Published by Elsevier Inc.)

Background: A calibration phantom-based method has been developed for predicting small lung nodule volume measurement bias and precision that is specific to a particular computed tomography (CT) scanner and acquisition protocol., Methods: The approach involves CT scanning a simple reference object with a specific acquisition protocol, analyzing the scan to estimate the fundamental imaging properties of the CT acquisition system, generating numerous simulated images of a target geometry using the fundamental imaging properties, measuring the simulated images with a standard nodule volume segmentation algorithm, and calculating bias and precision performance statistics from the resulting volume measurements. We evaluated the ability of this approach to predict volume measurement bias and precision of Teflon spheres (diameters =4.76, 6.36, and 7.94 mm) placed within an anthropomorphic chest phantom when using 3M Scotch Magic™ tape as the reference object. CT scanning of the spheres was performed with 0.625, 1.25, and 2.5 mm slice thickness and spacing., Results: The study demonstrated good agreement between predicted volumetric performance and observed volume measurement performance for both volumetric measurement bias and precision. The predicted and observed volume mean for all slice thicknesses was found to be 28% and 13% lower on average than the manufactured sphere volume, respectively. When restricted to 0.625 and 1.25 mm slice thickness scans, which are recommended for small lung nodule volume measurement, we found that the difference between predicted and observed volume coefficient of variation was less than 1.0 %. The approach also showed a resilience to varying CT image acquisition protocols, a critical capability when deploying in a real-world clinical setting., Conclusions: This is the first report of a calibration phantom-based method's ability to predict both small lung nodule volume measurement bias and precision. Volume measurement bias and precision for small lung nodules can be predicted using simple low-cost reference objects to estimate fundamental CT image characteristics and modeling and simulation techniques. The approach demonstrates an improved method for predicting task specific, clinically relevant measurement performance using advanced and fully automated image analysis techniques and low-cost reference objects., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-22-320/coif). Ricardo Avila is the CEO and owns stock in Accumetra. Accumetra also holds and submits patents in the area of CT image quality. He is also the owner of Paraxial, LLC which develops imaging software and other technologies. Ricardo Avila’s wife (Lisa Avila) is the CEO of Kitware which also develops imaging software and other technologies. Karthik Krishnan is an independent consultant of Accumetra, LLC. NO collaborates with QIBA as a statistical consultant through a contract between her institution and RSNA. AJ received a 2-year $100k grant from the Prevent Cancer Foundation for a project to model factors influencing nodule measurement uncertainty. The grant was paid to my institution and ended in Jan 2021. This is not directly related to this manuscript other than the overarching theme of trying to make better measurements. DY is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. He has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of CT imaging. He is on the advisory board and owns equity in HeartLung, a company that develops software related to CT scans of the chest. He is on the medical advisory board of Median Technology that is developing technology related to analyzing pulmonary nodules and is on the medical advisory board of Carestream, a company that develops radiography equipment and has consulted for Genentech, AstraZeneca and Pfizer. The other author has no conflicts of interest to declare., (2023 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Introduction: To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members., Methods: Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation., Results: A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior., Discussion: Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings., Competing Interests: JAL and LBS serve on the Steering Committee for the VA Tennessee Valley Healthcare System; JAL is a co-director of her VA's lung cancer screening program. None of the authors receive financial compensation for these roles. JAL is a board member of the Rescue Lung Rescue Life Society, a non-profit dedicated to the implementation of CT lung screening and does not receive financial compensation for this role. DFY is a named inventor on a number of patents and patent applications relating to the evaluation of diseases of the chest including measurement of nodules. Some of these, which are owned by Cornell Research Foundation (CRF), are non-exclusively licensed to General Electric. As an inventor of these patents, DFY is entitled to a share of any compensation which CRF may receive from its commercialization of these patents. He is also an equity owner in Accumetra, a privately held technology company committed to improving the science and practice of image-based decision making. DFY also serves on the advisory board of GRAIL. CIH is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. CIH is also a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest which are owned by Cornell Research Foundation (CRF). Since 2009, CIH does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Lewis, Bonnet, Schlundt, Byerly, Lindsell, Henschke, Yankelevitz, York, Hendler, Dittus, Vogus, Kripalani, Moghanaki, Audet, Roumie and Spalluto.)

Purpose: Computed tomography is the standard method by which pulmonary nodules are detected. Greater than 40% of pulmonary biopsies are not lung cancer and therefore not necessary, suggesting that improved diagnostic tools are needed. The LungLB™ blood test was developed to aid the clinical assessment of indeterminate nodules suspicious for lung cancer. LungLB™ identifies circulating genetically abnormal cells (CGACs) that are present early in lung cancer pathogenesis., Methods: LungLB™ is a 4-color fluorescence in-situ hybridization assay for detecting CGACs from peripheral blood. A prospective correlational study was performed on 151 participants scheduled for a pulmonary nodule biopsy. Mann-Whitney, Fisher's Exact and Chi-Square tests were used to assess participant demographics and correlation of LungLB™ with biopsy results, and sensitivity and specificity were also evaluated., Results: Participants from Mount Sinai Hospital (n = 83) and MD Anderson (n = 68), scheduled for a pulmonary biopsy were enrolled to have a LungLB™ test. Additional clinical variables including smoking history, previous cancer, lesion size, and nodule appearance were also collected. LungLB™ achieved 77% sensitivity and 72% specificity with an AUC of 0.78 for predicting lung cancer in the associated needle biopsy. Multivariate analysis found that clinical and radiological factors commonly used in malignancy prediction models did not impact the test performance. High test performance was observed across all participant characteristics, including clinical categories where other tests perform poorly (Mayo Clinic Model, AUC = 0.52)., Conclusion: Early clinical performance of the LungLB™ test supports a role in the discrimination of benign from malignant pulmonary nodules. Extended studies are underway., (© 2023. The Author(s).)

Rationale and Objectives: We previously reported a novel manual method for measuring bone mineral density (BMD) in coronary artery calcium (CAC) scans and validated our method against Dual X-Ray Absorptiometry (DEXA). Furthermore, we have developed and validated an artificial intelligence (AI) based automated BMD (AutoBMD) measurement as an opportunistic add-on to CAC scans that recently received FDA approval. In this report, we present evidence of equivalency between AutoBMD measurements in cardiac vs lung CT scans., Materials and Methods: AI models were trained using 132 cases with 7649 (3 mm) slices for CAC, and 37 cases with 21918 (0.5 mm) slices for lung scans. To validate AutoBMD against manual measurements, we used 6776 cases of BMD measured manually on CAC scans in the Multi-Ethnic Study of Atherosclerosis (MESA). We then used 165 additional cases from Harbor UCLA Lundquist Institute to compare AutoBMD in patients who underwent both cardiac and lung scans on the same day., Results: Mean±SD for age was 69 ± 9.4 years with 52.4% male. AutoBMD in lung and cardiac scans, and manual BMD in cardiac scans were 153.7 ± 43.9, 155.1 ± 44.4, and 163.6 ± 45.3 g/cm 3 , respectively (p = 0.09). Bland-Altman agreement analysis between AutoBMD lung and cardiac scans resulted in 1.37 g/cm 3 mean differences. Pearson correlation coefficient between lung and cardiac AutoBMD was R 2 = 0.95 (p < 0.0001)., Conclusion: Opportunistic BMD measurement using AutoBMD in CAC and lung cancer screening scans is promising and yields similar results. No extra radiation plus the high prevalence of asymptomatic osteoporosis makes AutoBMD an ideal screening tool for osteopenia and osteoporosis in CT scans done for other reasons., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Morteza Naghavi reports financial support was provided by American Technologies LLC and HeartLung.AI. Morteza Naghavi reports a relationship with American Technologies LLC and HeartLung.AI that includes: board membership, consulting or advisory, employment, and equity or stocks. Song Shou Mao reports a relationship with The Lundquist Institute that includes: consulting or advisory. Venkat Manubolu reports a relationship with HeartLung.AI that includes: consulting or advisory. Dong Li reports a relationship with HeartLung.AI that includes: consulting or advisory. Thomas Atlas reports a relationship with HeartLung.AI that includes: consulting or advisory. Anthony Reeves reports a relationship with HeartLung.AI that includes: consulting or advisory. Claudia Henschke reports no financial relationship with HeartLung.AI or American Heart Technologies LLC. David Yankelevitz reports a relationship with HeartLung.AI that includes: consulting or advisory. Matthew Budoff reports a relationship with HeartLung.AI that includes: consulting or advisory. Amirhossein Jaberzadeh reports a relationship with HeartLung.AI that includes: employment. Chenyu Zhang reports a relationship with HeartLung.AI that includes: employment. Marlon Montes reports a relationship with HeartLung.AI that includes: employment. Mathew Budoff has patent #US 9119,590 B2 issued to Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA. Mathew Budoff has patent #US 10,695,022,B2 issued to Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA., (© 2023 Published by Elsevier Ltd.)

Introduction: Growth assessment for pulmonary nodules is an important diagnostic tool; however, the impact on prognosis due to time delay for follow-up diagnostic scans needs to be considered., Methods: Using the data between 2003 and 2019 from the International Early Lung Cancer Action Program, a prospective cohort study, we determined the size-specific, 10-year Kaplan-Meier lung cancer (LC) survival rates as surrogates for cure rates. We estimated the change in LC diameter after delays of 90, 180, and 365 days using three representative LC volume doubling times (VDTs) of 60 (fast), 120 (moderate), and 240 (slow). We then estimated the decrease in the LC cure rate resulting from time between computed tomography scans to assess for growth during the diagnostic workup., Results: Using a regression model of the 10-year LC survival rates on LC diameter, the estimated LC cure rate of a 4.0 mm LC with fast (60-d) VDT is 96.0% (95% confidence interval [CI]: 95.2%-96.7%) initially, but it would decrease to 94.3% (95% CI: 93.2%-95.0%), 92.0% (95% CI: 90.5%-93.4%), and 83.6%(95% CI: 80.6%-86.6%) after delays of 90, 180, and 365 days, respectively. A 20.0-mm LC with the same VDTs has a lower LC cure rate of 79.9% (95% CI: 76.2%-83.5%) initially and decreases more rapidly to 71.5% (95% CI: 66.4%-76.7%), 59.8% (95% CI: 52.4%-67.1%), and 17.9% (95% CI: 3.0%-32.8%) after the same delays of 90, 180, and 365 days, respectively., Conclusions: Time between scans required to measure growth of lung nodules affects prognosis with the effect being greater for fast growing and larger cancers. Quantifying the extent of change in prognosis is required to understand efficiencies of different management protocols., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Background & Aims: The prevalence and aetiology of liver fibrosis vary over time and impact racial/ethnic groups unevenly. This study measured time trends and identified factors associated with advanced liver fibrosis in the United States., Methods: Standardised methods were used to analyse data on 47,422 participants (≥20 years old) in the National Health and Nutrition Examination Survey (1999-2018). Advanced liver fibrosis was defined as Fibrosis-4 ≥2.67 and/or Forns index ≥6.9 and elevated alanine aminotransferase., Results: The estimated number of people with advanced liver fibrosis increased from 1.3 million (95% CI 0.8-1.9) to 3.5 million (95% CI 2.8-4.2), a nearly threefold increase. Prevalence was higher in non-Hispanic Black and Mexican American persons than in non-Hispanic White persons. In multivariable logistic regression analysis, cadmium was an independent risk factor in all racial/ethnic groups. Smoking and current excessive alcohol use were risk factors in most. Importantly, compared with non-Hispanic White persons, non-Hispanic Black persons had a distinctive set of risk factors that included poverty (odds ratio [OR] 2.09; 95% CI 1.44-3.03) and susceptibility to lead exposure (OR 3.25; 95% CI 1.95-5.43) but did not include diabetes (OR 0.88; 95% CI 0.61-1.27; p  =0.52). Non-Hispanic Black persons were more likely to have high exposure to lead, cadmium, polychlorinated biphenyls, and poverty than non-Hispanic White persons., Conclusions: The number of people with advanced liver fibrosis has increased, creating a need to expand the liver care workforce. The risk factors for advanced fibrosis vary by race/ethnicity. These differences provide useful information for designing screening programmes. Poverty and toxic exposures were associated with the high prevalence of advanced liver fibrosis in non-Hispanic Black persons and need to be addressed., Impact and Implications: Because liver disease often produces few warning signs, simple and inexpensive screening tests that can be performed by non-specialists are needed to allow timely diagnosis and linkage to care. This study shows that non-Hispanic Black persons have a distinctive set of risk factors that need to be taken into account when designing liver disease screening programs. Exposure to exogenous toxins may be especially important risk factors for advanced liver fibrosis in non-Hispanic Black persons., Competing Interests: All authors declare no relevant or material financial interests that relate to the research described in this paper. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2023 The Author(s).)

In addition to lung cancer, other thoracic abnormalities, such as emphysema, can be visualized within low-dose CT scans that were initially obtained in cancer screening programs, and thus, opportunistic evaluation of these diseases may be highly valuable. However, manual assessment for each scan is tedious and often subjective, thus we have developed an automatic, rapid computer-aided diagnosis system for emphysema using attention-based multiple instance deep learning and 865 LDCTs. In the task of determining if a CT scan presented with emphysema or not, our novel Transfer AMIL approach yielded an area under the ROC curve of 0.94 ± 0.04, which was a statistically significant improvement compared to other methods evaluated in our study following the Delong Test with correction for multiple comparisons. Further, from our novel attention weight curves, we found that the upper lung demonstrated a stronger influence in all scan classes, indicating that the model prioritized upper lobe information. Overall, our novel Transfer AMIL method yielded high performance and provided interpretable information by identifying slices that were most influential to the classification decision, thus demonstrating strong potential for clinical implementation., (© 2023. The Author(s).)

Background: Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative., Methods: We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories., Results: We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process., Conclusions: Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Margin distance contributes to survival and recurrence during wedge resections for early-stage non-small cell lung cancer. The Initiative for Early Lung Cancer Research on Treatment sought to standardize a surgeon-measured margin intraoperatively., Methods: Lung cancer patients who underwent wedge resection were reviewed. Margins were measured by the surgeon twice as per a standardized protocol. Intraobserver variability as well as surgeon-pathologist variability were compared., Results: Forty-five patients underwent wedge resection. Same-surgeon measurement analysis indicated good reliability with a small mean difference and narrow limit of agreement for the two measures. The median surgeon-measured margin was 18.0 mm, median pathologist-measured margin was 16.0 mm and the median difference between the surgeon-pathologist margin was -1.0 mm, ranging from -18.0 to 12.0 mm. Bland-Altman analysis for margin measurements demonstrated a mean difference of 0.65 mm. The limit of agreement for the two approaches were wide, with the difference lying between -16.25 and 14.96 mm., Conclusions: A novel protocol of surgeon-measured margin was evaluated and compared with pathologist-measured margin. High intraobserver agreement for repeat surgeon measurements yet low-to-moderate correlation or directionality between surgeon and pathologic measurements were found., Discussion: A standardized protocol may reduce variability in pathologic assessment. These findings have critical implications considering the impact of margin distance on outcomes., (© 2022 Wiley Periodicals LLC.)

Objectives: To determine whether radiographic measures of tumor aggressiveness differ by smoking status., Materials and Methods: All patients diagnosed with non-small-cell lung cancer(NSCLC) ≤ 30 mm in maximum diameter, without clinical evidence of metastasis who had both pre-treatment PET scans and two CT scans at least 90 days apart in a prospective cohort, the Initiative for Early Lung Cancer Research on Treatment(IELCART) at Mount Sinai between 2016 and 2020 were identified. Comparison of two measures of tumor aggressiveness, positron emission tomography(PET) SUVmax and tumor volume doubling time(VDT) by smoking status was performed., Results: Of 417 patients identified, 158 patients had pre-treatment PET scans and at least two CT scans available. The two measures of tumor aggressiveness, SUVmax and VDT values were significantly different between patients who had never smoked and those who smoked: patients who never smoked had lower median SUVmax[2.5(IQR: 1.1-4.8) vs. 4.2(IQR:2.1-9.2),p = 0.002] and longer median VDT[(372.6 days vs. 225.6 days,p = 0.001)] compared to those who smoked. Using multivariable analyses, when adjusting for age and sex alone, SUVmax(p = 0.004) and VDT(p = 0.0001) remained significantly different by smoking status. The final multivariable analysis, adjusted for all three co-variates(sex, age and tumor histology) showed no significant difference in SUVmax and VDT by smoking status [SUVmax(p = 0.25) and VDT(p = 0.06)]., Conclusion: Smoking history does not influence VDT or PET SUVmax measures of lung cancer aggressiveness., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background Bronchiectasis is associated with loss of lung function, substantial use of health care resources, and increased morbidity and mortality in people with cardiopulmonary diseases. Purpose To assess the frequency and severity of bronchiectasis and related clinical findings of participants in a low-dose CT (LDCT) screening program. Materials and Methods The Early Lung and Cardiac Action Program (ELCAP) bronchiectasis score (range, 0-42; higher values indicate more severe bronchiectasis) was developed to facilitate bronchiectasis assessment. This quantitative scoring system screened participants based on accumulated knowledge and improved CT imaging capabilities. Secondary review of LDCT studies from smokers aged 40-90 years was performed when they were initially enrolled in the prospective Mount Sinai ELCAP screening study between 2010 and 2019. Medical records were reviewed to identify associated respiratory symptoms and acute respiratory events during the 2 years after LDCT. Logistic regression analysis was performed to examine factors associated with bronchiectasis. Results LDCT studies of 2191 screening participants (mean age, 65 years ± 9; 1140 [52%] women) were obtained, and bronchiectasis was identified in 504 (23%) participants. Median ELCAP bronchiectasis score was 12 (interquartile range, 9-16). Bronchiectasis was most common in the lower lobes for all participants, and lower lobe prevalence was greater with higher ELCAP score (eg, 91% prevalence with an ELCAP score of 16-42). In the fourth quartile, however, midlung involvement was higher compared with lower lung involvement (128 of 131 participants [98%] vs 122 of 131 participants [93%]). Bronchiectasis was more frequent with greater age (odds ratio [OR] = 2.0 per decade; 95% CI: 1.7, 2.4); being a former smoker (OR = 1.33; 95% CI: 1.01, 1.73); and having self-reported chronic obstructive pulmonary disease (OR = 1.38; 95% CI: 1.02, 1.88), an elevated hemidiaphragm (OR = 4; 95% CI: 2, 11), or consolidation (OR = 5; 95% CI: 3, 11). It was less frequent in overweight (OR = 0.7; 95% CI: 0.5, 0.9) or obese (OR = 0.6; 95% CI: 0.4, 0.8) participants. Two years after baseline LDCT, respiratory symptoms, acute respiratory events, and respiratory events that required hospitalization were more frequent with increasing severity of the ELCAP bronchiectasis score ( P < .005 for all trends). Conclusion Prevalence of bronchiectasis in smokers undergoing low-dose CT screening was high, and respiratory symptoms and acute events were more frequent with increasing severity of the Early Lung and Cardiac Action Program Bronchiectasis score. © RSNA, 2022 See also the editorial by Verschakelen in this issue.

Background: Patients with early-stage non-small-cell lung cancer (NSCLC) have high survival rates, but patients often say they did not anticipate the effect of the surgery on their postsurgical quality of life (QoL). This study adds to the literature regarding patient and surgeon interactions and highlights the areas where the current approach is not providing good communication., Design: Since its start in 2016, the Initiative for Early Lung Cancer Research on Treatment (IELCART), a prospective cohort study, has enrolled 543 patients who underwent surgery for stage I NSCLC within the Mount Sinai Health System. Presurgical patient and surgeon surveys were available for 314 patients, postsurgical surveys for 420, and both pre- and postsurgical surveys for 285., Results: Of patients with presurgical surveys, 31.2% said that their surgeon recommended multiple types of treatment. Of patients with postsurgical surveys, 85.0% felt very well prepared and 11.4% moderately well prepared for their postsurgical recovery. The median Functional Assessment of Cancer Therapy-Lung Cancer score and social support score of the patients who felt very well prepared was significantly higher than those moderately or not well prepared (24.0 v. 22.0, P < 0.001) and (5.0 [interquartile range: 4.7-5.0] v. 5.0 [IQR: 4.2-5.0], p = 0.015)., Conclusions: This study provides insight into the areas where surgeons are communicating well with their patients as well as the areas where patients still feel uninformed. Most surgeons feel that they prepare their patients well or very well for surgical recovery, whereas some patients still feel that their surgeons did not prepare them well for postsurgical recovery. Surgeons may want to spend additional time emphasizing postsurgical recovery and QoL with their patients or provide their patients with additional avenues to get their questions and concerns addressed., Highlights: Pretreatment discussions could help surgeons understand patient priorities and patients understand the anticipated outcomes for their surgeries.There is an association between feeling prepared for surgery and higher quality of life and social support scores after adjustment for confounders.Despite these pretreatment discussions, patients still feel that they are not well prepared about what to expect during their postsurgical recovery., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. David Yankelevitz is a named inventor on a number of patents and patent applications related to the evaluation of chest diseases including measurements of chest nodules. Dr. Yankelevitz has received financial compensation for the licensing of these patents. In addition, he is a consultant and co-owner of Accumetra, a private company developing tools to improve the quality of computed tomography imaging, and is on the medical advisory board of Carestream, a company that develops radiography equipment and has consulted for Genentech, AstraZeneca, and Pfizer. Dr. Henschke is also an inventor of the patents and pending patents owned by Cornell Research Foundation (CRF). As of April 2009, she has divested herself of all royalties and other interests arising from these. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this study was provided by the Simons Foundation International, Ltd. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. IELCART investigators: Icahn School of Medicine, New York, NY: Raja Flores, Andrew Kaufman, Dong-Seok Lee, Daniel Nicastri, Andrea Wolf, Kenneth Rosenzweig, Jorge Gomez, Mary Beth Beasley, Maureen Zakowski, Michael Chung, David F. Yankelevitz, Claudia Henschke, Emanuela Taioli, Rebecca Schwartz, Huiwen Chan, Jeffrey Zhu, Sydney Kantor, Shana Adler; Mount Sinai West, New York, NY: Daniel Nicastri, Wissam Raad, Pathology: Zrzu Buyuk, Adie Friedman, Ronald Dreifuss, Stacey Verzosa, Mariya Yakubox, Karina Aloferdova, Patricia Stacey, Simone De Nobrega, Jeffrey Zhu, Sydney Kantor, Shana Adler; Mount Sinai Brooklyn, Brooklyn, NY: Ardeshir Hakami, Jeffrey Zhu, Sydney Kantor, Shana Adler; New York University Medical Center, New York, NY: Harvey Pass, Benjamin Cooper, Andre Moreirea, Audrey Sorensen; State University of New York, Syracuse, NY: Leslie Kohman, Robert Dunton, Jason Wallen, Christopher Curtiss, Ernest Scalzetti, Linda Ellinwood; Vassar Brothers, Poughkeepsie, NY: Clifford P. Connery, Emilo Torres, Dan Cruzer, Bruce Gendron, Sonya Alyea, Daniel Lackaye, Lauren Studer; Lahey Hospital, Burlington, MA: Syed Quadri, Elliot Servais, Cameron Stock, Andrea McKee, Brady McKee, Shawn Regis; Northwell Health, New Hyde Park, NY: Paul Lee, Kevin Hyman, Julisa Jurado, David Zeltman, Lawrence Glassman, Rajiv Sharma, Vijay Singh, Efstathia Milhelis, Danielle Gibson; IELCART Coordinating Center: principal investigators (PIs): Raja Flores, Claudia Henschke, co-PIs: Emanuela Taioli, David Yankelevitz, Investigators: Rebecca Schwartz, Betsy Becker, Artit Jirapatnakul, Rowena Yip, Huiwen Chan., (© The Author(s) 2022.)

Rationale: Lung cancer surgical morbidity has been decreasing, increasing attention to quality-of-life measures. A chronic sequela of lung cancer surgery is the use of postoperative oxygen at home after discharge. Prospective studies are needed to identify risk predictors for home oxygen (HO 2 ) use after curative lung cancer surgery. Objectives: To prospectively assess risk factors for postoperative oxygen use and postsurgical morbidity in patients undergoing curative lung cancer surgery. We hypothesized that obesity, poor preoperative pulmonary function, and smoking status would contribute to the risk of postoperative oxygen use. Methods: This study included patients undergoing surgery for a first primary non-small cell lung cancer at Mount Sinai from 2016 to 2020. Univariate, multivariable logistic regression analyses and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were assessed. Results: Of the 433 patients with diagnosed pathologic stage I non-small cell lung cancer, 63 (14.5%) were discharged with HO 2 . By using multivariable analyses, we found that the body mass index (BMI) (OR for a BMI of 25-30 kg/m 2 , 4.0; 95% CI, 1.6-11.2; OR for a BMI ⩾30 kg/m 2 , 6.1; 95% CI, 2.4-17.5) and the preoperative diffusing capacity of the lung for carbon monoxide (Dl CO ) (OR for a Dl CO of <40%, 24.9; 95% CI, 3.6-234.1; OR for a Dl CO of 40-59%,  3.1; 95% CI, 1.3-7.2) were significant independent risk factors associated with the risk of HO 2 use after adjusting for other covariates. Although current smoking significantly increased the risk in the univariate analysis, it was no longer significant in the multivariable model. Conclusions: Obesity and the Dl CO were significant as risk factors for oxygen use at home after discharge. These findings allow for identification of patients at risk of being discharged with HO 2 after lung resection surgery.

Objective: The study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia., Methods: 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., Results: 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)., Conclusions: 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., (© 2022 The Authors.)

Patients with lung cancer are especially vulnerable to coronavirus disease 2019 (COVID-19) with a greater than sevenfold higher rate of becoming infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19, a greater than threefold higher hospitalization rate with high complication rates, and an estimated case fatality rate of more than 30%. The reasons for the increased vulnerability are not known. In addition, beyond the direct impact of the pandemic on morbidity and mortality among patients with lung cancer, COVID-19, with its disruption of patient care, has also resulted in substantial impact on lung cancer screening and treatment/management.COVID-19 vaccines are safe and effective in people with lung cancer. On the basis of the available data, patients with lung cancer should continue their course of cancer treatment and get vaccinated against the SARS-CoV-2 virus. For unknown reasons, some patients with lung cancer mount poor antibody responses to vaccination. Thus, boosting vaccination seems urgently indicated in this subgroup of vulnerable patients with lung cancer. Nevertheless, many unanswered questions regarding vaccination in this population remain, including the magnitude, quality, and duration of antibody response and the role of innate and acquired cellular immunities for clinical protection. Additional important knowledge gaps also remain, including the following: how can we best protect patients with lung cancer from developing COVID-19, including managing care in patient with lung cancer and the home environment of patients with lung cancer; are there clinical/treatment demographics and tumor molecular demographics that affect severity of COVID-19 disease in patients with lung cancer; does anticancer treatment affect antibody production and protection; does SARS-CoV-2 infection affect the development/progression of lung cancer; and are special measures and vaccine strategies needed for patients with lung cancer as viral variants of concern emerge., (Copyright © 2021 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Purpose: Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans., Methods: A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used., Results: In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window., Conclusions: Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer., (Published by Elsevier Inc.)

Background Solid costal pleura-attached noncalcified nodules (CP-NCNs) less than 10.0 mm with lentiform, oval, or semicircular (LOS) or triangular shapes and smooth margins on baseline low-dose CT scans from the Mount Sinai Early Lung and Cardiac Action Program (MS-ELCAP) were reviewed, and it was determined that they can be followed up at the first annual screening rather than having a shorter-term work-up. Purpose To determine whether the same criteria could be used for solid CP-NCNs newly identified at annual screening examinations. Materials and Methods With use of the same MS-ELCAP database, all new solid CP-NCNs measuring 30.0 mm or less were identified at 4425 annual screening examinations between 2010 and 2019. In addition, to ensure that no malignant CP-NCNs met the criteria, all solid malignant CP-NCNs of 30.0 mm or less in the International Early Lung Cancer Action Program, or I-ELCAP, database of 111 102 annual screening examinations from the 76 participating institutions between 1992 and 2019 were identified; Mount Sinai is one of these institutions. All identified solid CP-NCNs were reviewed-with the radiologists blinded to diagnosis-for shape (triangular, LOS, polygonal, round, or irregular), margin (smooth or nonsmooth), pleural attachment (broad or narrow), and the presence of emphysema and/or fibrosis within 10.0 mm of each CP-NCN. Intra- and interreader readings were performed, and agreements were determined by using the B-statistic. Results Of the 76 new solid CP-NCNs, 21 were lung cancers. Benign CP-NCNs were smaller than malignant ones (median diameter, 4.2 mm vs 11 mm; P < .001), had a different shape distributions, more frequently had smooth margins (67% vs 14%; P < .001), and less frequently had emphysema (38% vs 81%; P = .003) or fibrosis (3.6% vs 19%; P = .045) within a 10.0 mm radius. All 22 solid CP-NCNs less than 10.0 mm in average diameter with triangular or LOS shapes and smooth margins were benign, and none of the 21 solid malignant CP-NCNs had these characteristics. Intra- and interobserver agreement for triangular or LOS-shaped CP-NCNs with smooth margins was almost perfect (0.77 and 0.69, respectively). Conclusion The same follow-up recommendation developed for baseline costal pleura-attached noncalcified nodules (CP-NCNs) can be used for CP-NCNs newly identified at annual screening rounds. © RSNA, 2021.

Background: Osteoporotic fractures are a major contributor to late life morbidity and mortality, and impose a substantial societal cost, yet osteoporosis remains substantially underdiagnosed and undertreated. The purpose of this meta-analysis was to assess the pooled diagnostic sensitivity and specificity of computed tomography (CT) images for diagnosing osteoporosis in patients who meet WHO dual X-ray absorptiometry (DXA) osteoporosis criteria using specific Hounsfield unit (HU) values as a threshold., Methods: Systematic literature searches in PubMed, Embase, Web of Science and Google Scholar were performed from the earliest available date through 1 July 2018, restricted to publications in English. Participants in all studies underwent CT scans that included the lumbar and/or thoracic spine for different indications and HU measurements were used to identify osteoporosis. DXA scans served as the reference standard., Results: Ten eligible studies were identified. The mean area under the hierarchical summary receiver operating characteristic (ROC) curve for diagnosis osteoporosis was 0.84 (95% CI: 0.81, 0.87). The pooled diagnostic sensitivity and specificity of CT images to identify osteoporosis were 0.83 (95% CI: 0.73, 0.90) and 0.74 (95% CI: 0.69, 0.79). The positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratio were 3.4 (95% CI: 2.7, 4.5), 0.21 (95% CI: 0.12, 0.36), and 16.4 (95% CI: 7.8, 34.3), respectively. The bias-adjusted sensitivity and specificity of CT were 0.73 and 0.71. Meta-regression demonstrated that country of study, DXA criteria and scanner manufacturer were significant factors associated with the sensitivity of CT in detecting osteoporosis while scanner manufacturer was the only factor associated with specificity of CT., Conclusions: This meta-analysis showed reasonable pooled sensitivity and specificity for using threshold values measured on CT scans to identify osteoporosis opportunistically., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Introduction: Computed tomography (CT) and fluorodeoxyglucose-positron-emission-tomography (FDG-PET) measurements of mediastinal lymph nodes (MLNs) of patients with non-small-cell-lung-cancers (NSCLCs) ≤ 30 mm in maximum diameter are recommended for pre-surgical prediction of MLN metastases., Methods: We reviewed all patients at Mount Sinai Health System enrolled in the Initiative for Early Lung Cancer Research on Treatment (IELCART), prospective cohort between 2016 and 2020, who had pre-surgical FDG-PET and underwent surgery with MLN resection and/or pre-operative endobronchial ultrasound (EBUS) for a first primary NSCLC ≤ 30 mm in maximum diameter on pre-surgical CT., Results: Among 470 patients, none with part-solid (n = 63) or nonsolid (n = 23) NSCLCs had MLN metastases. Solid NSCLCs were identified in 384 patients, none in typical carcinoid (n = 48) or NSCLC ≤ 10 mm in maximum diameter (n = 47, including 8 typical carcinoids) had MLN metastases. Among the remaining 297 patients with solid NSCLCs 10.1-30.0 mm, 7 (2.4%) had MLN metastases. Area-under-the-curve (AUC) for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm, using the CT maximum short-axis MLN diameter was 0.62 (95% CI:0.44-0.81, p = 0.18) and using the highest SUVmax of any MLN, AUC was 0.58 (95% CI:0.39-0.78,p = 0.41). Neither AUCs were significantly different from chance alone. Optimal cutoff for prediction of MLN metastases was ≥ 18.9 mm for CT maximum short-axis diameter [sensitivity 14.3% (95%CI:0.0%-57.9%); specificity 100.0% (95%CI:98.9%-100.0%)] and for highest SUVmax was ≥ 11.7 [sensitivity 14.3% (95%CI:0.0%-57.9%) and specificity 99.7% (95%CI:98.3%-100.0%)]., Conclusions: CT and SUVmax had low sensitivity but high specificity for predicting MLN metastases in solid NSCLCs 10.1-30.0 mm. Clinical Stage IA NSCLCs ≤ 30 mm should be based on CT maximum tumor diameter and MLN maximum short-axis diameter ≤ 20 mm., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: To evaluate whether the extent of COVID-19 pneumonia on CT scans using quantitative CT imaging obtained early in the illness can predict its future severity., Methods: We conducted a retrospective single-center study on confirmed COVID-19 patients between January 18, 2020 and March 5, 2020. A quantitative AI algorithm was used to evaluate each patient's CT scan to determine the proportion of the lungs with pneumonia (VR) and the rate of change (RAR) in VR from scan to scan. Patients were classified as being in the severe or non-severe group based on their final symptoms. Penalized B-splines regression modeling was used to examine the relationship between mean VR and days from onset of symptoms in the two groups, with 95% and 99% confidence intervals., Results: Median VR max was 18.6% (IQR 9.1-32.7%) in 21 patients in the severe group, significantly higher (P < 0.0001) than in the 53 patients in non-severe group (1.8% (IQR 0.4-5.7%)). RAR was increasing with a median RAR of 2.1% (IQR 0.4-5.5%) in severe and 0.4% (IQR 0.1-0.9%) in non-severe group, which was significantly different (P < 0.0001). Penalized B-spline analyses showed positive relationships between VR and days from onset of symptom. The 95% confidence limits of the predicted means for the two groups diverged 5 days after the onset of initial symptoms with a threshold of 11.9%., Conclusion: Five days after the initial onset of symptoms, CT could predict the patients who later developed severe symptoms with 95% confidence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: 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., Methods: 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., Results: 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 (OR age10  = 0.72, p < 0.0001), lower pack-years of smoking (OR 10pack-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 OR moderate  = 0.58(p = 0.0007) and for severe emphysema, it was OR severe  = 0.23(p < 0.0001)., Conclusion: 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., (Copyright © 2021. Published by Elsevier Inc.)