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Background: Lung-RADS classification and CT signs can both help in the differential diagnosis of SPNs. The purpose of this study was to investigate the diagnostic value of these two methods and the combination of the two methods for solitary pulmonary nodules (SPNs). Methods: A total of 296 cases of SPNs were retrospectively analyzed. All the SPNs were classified according to the Lung-RADS grading version 1.1. The scores of each lesion were calculated according to their CT signs. Imaging features, such as the size and margin of the lesions, pleural traction, spiculation, lobulation, bronchial cutoff, air bronchogram, vacuoles, tumor vasculature, and cavity signs, were analyzed. The imaging results were compared with the pathology examination findings. Receiver operating characteristic (ROC) curves were applied to compare the values of the different methods in differentially diagnosing benign and malignant SPNs. Results: The sensitivity, specificity, and accuracy of Lung-RADS grading for diagnosing SPNs were 34.0%, 94.4%, and 47.6%, respectively. The area under the ROC curve (AUC) was 0.600 (p < 0.001). The sensitivity, specificity, and accuracy of the CT sign scores were 56.3%, 70.0%, and 60.5%, respectively, and the AUC was 0.657 (p < 0.001). The sensitivity, specificity, and accuracy of the combination of the two methods for diagnosing SPNs were 93.2%, 61.1%, and 83.5%, and the AUC was 0.777 (p < 0.001). Conclusion: The combination of Lung-RADS classification and CT signs significantly improved the differential diagnosis of SPNs.

Qingcheng Meng,1,* Pengfei Ren,2,* Pengrui Gao,1 Xinmin Dou,1 Xuejun Chen,1 Lanwei Guo,3 Yongping Song4 1Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 2Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 3Department of Cancer Prevention Office, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 4Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yongping SongDepartment of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450008, People’s Republic of ChinaTel/Fax +86 371 65587016Email songyongping001@126.comPurpose: To evaluate the effectiveness of using a modified lung imaging reporting and data system (Lung-RADS) for risk stratification of pure ground-glass nodules (pGGNs) in low-dose computed tomography (LDCT) for lung cancer (LC) screenings in China.Patients and Methods: Eight subjects with nine pGGNs originating from a Cancer Screening Program were enrolled as training set and 32 asymptomatic subjects with 35 pGGNs were selected as validation set from November 2013 to October 2018. The complementary Lung-RADS categories were set based on the GGN-vessel relationship (GVR). The correlations between GGN-vessel relationships and pathology were evaluated, and the diagnostic value of complementary Lung-RADS version 1.1 in discriminating malignant pGGNs were analyzed.Results: The inter-reader agreements for Lung-RADS 1.1 (intraclass correlation coefficient (ICC= 0.999) and complementary Lung-RADS 1.1 (ICC= 0.971) displayed good reliability. The combined incidence of invasive adenocarcinoma in type III and IV was more than that of benign and preinvasive diseases (30% vs 75%, P=0.013). Type II GVR between two benign (66.7%), seven preinvasive (53.8%), and six invasive (21.4%) GGN cases was statistically significant (χ2=5.415, P=0.019). GGN pathological groups and GVR had a significant correlation (r=0.584, P=0.00). Compared to Lung-RADS 1.1, complementary Lung-RADS 1.1 had better performance in the training set, with its sensitivity increased from 33.3% to 88.9%, accuracy increased from 44.4% to 88.9%, false-negative proportion (FNP) decreased from 66.7% to 11.1%, and the sensitivity to predict malignant nodules increased from 13.8% to 93.1%, accuracy increased from 28.6% to 80.0%, and FNP decreased from 86.2% to 6.9% in validation set. The detection rate of preinvasive disease and adenocarcinoma was increased from 12.5% to 90.6% and that of missed diagnosis decreased from 87.5% to 9.4% in the validation set, P=0.004.Conclusion: Complementary Lung-RADS 1.1 is superior to Lung-RADS 1.1 and would be beneficial for LC screening of LDCT in China.Keywords: low-dose computed tomography, lung neoplasms, lung-RADS, mass screening, ground-glass nodules

Qingcheng Meng,1,* Pengfei Ren,2,* Pengrui Gao,1 Xinmin Dou,1 Xuejun Chen,1 Lanwei Guo,3 Yongping Song4 1Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 2Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 3Department of Cancer Prevention Office, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China; 4Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yongping SongDepartment of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450008, People’s Republic of ChinaTel/Fax +86 371 65587016Email songyongping001@126.comPurpose: To evaluate the effectiveness of using a modified lung imaging reporting and data system (Lung-RADS) for risk stratification of pure ground-glass nodules (pGGNs) in low-dose computed tomography (LDCT) for lung cancer (LC) screenings in China.Patients and Methods: Eight subjects with nine pGGNs originating from a Cancer Screening Program were enrolled as training set and 32 asymptomatic subjects with 35 pGGNs were selected as validation set from November 2013 to October 2018. The complementary Lung-RADS categories were set based on the GGN-vessel relationship (GVR). The correlations between GGN-vessel relationships and pathology were evaluated, and the diagnostic value of complementary Lung-RADS version 1.1 in discriminating malignant pGGNs were analyzed.Results: The inter-reader agreements for Lung-RADS 1.1 (intraclass correlation coefficient (ICC= 0.999) and complementary Lung-RADS 1.1 (ICC= 0.971) displayed good reliability. The combined incidence of invasive adenocarcinoma in type III and IV was more than that of benign and preinvasive diseases (30% vs 75%, P=0.013). Type II GVR between two benign (66.7%), seven preinvasive (53.8%), and six invasive (21.4%) GGN cases was statistically significant (χ2=5.415, P=0.019). GGN pathological groups and GVR had a significant correlation (r=0.584, P=0.00). Compared to Lung-RADS 1.1, complementary Lung-RADS 1.1 had better performance in the training set, with its sensitivity increased from 33.3% to 88.9%, accuracy increased from 44.4% to 88.9%, false-negative proportion (FNP) decreased from 66.7% to 11.1%, and the sensitivity to predict malignant nodules increased from 13.8% to 93.1%, accuracy increased from 28.6% to 80.0%, and FNP decreased from 86.2% to 6.9% in validation set. The detection rate of preinvasive disease and adenocarcinoma was increased from 12.5% to 90.6% and that of missed diagnosis decreased from 87.5% to 9.4% in the validation set, P=0.004.Conclusion: Complementary Lung-RADS 1.1 is superior to Lung-RADS 1.1 and would be beneficial for LC screening of LDCT in China.Keywords: low-dose computed tomography, lung neoplasms, lung-RADS, mass screening, ground-glass nodules

The National Lung Cancer Screening Trial (NLST) demonstrated the use of low dose helical computed tomography (LDCT) scans for lung cancer screening. However, the NLST was implemented in urban hospitals and prior to the Lung CT Screening Reporting and Data System (Lung-RADS). In this retrospective cohort study, 774 eligible patients received LDCT screening using Lung-RADS criteria. Eighty-four patients (10.9%) had subsequent testing performed compared to 24.2% in the NLST study. Of those with subsequent testing, 21.4% were diagnosed with lung cancer compared to only 4.6% in the NLST study. Lung-RADS significantly reduced unnecessary testing while identifying higher rates of lung cancer compared to the NLST.

Background Lung assessment is highly recommended in the management of oncology patients as it is the commonest affected site in metastatic dissemination. The low-dose CT with nodule reporting system based on Lung Reporting and Data System (lung-RADS) is a promising non-invasive tool for the characterization of incidentally detected pulmonary nodules. The authors aimed to assess the accuracy of the “lung-RADS” classification system as a non-invasive tool for the characterization of any newly developed pulmonary nodules among oncology patients. Ethics committee approval and informed written consent were obtained from the studied patients. A non-contrast LDCT study was performed on all patients with a nodule reporting system based on the lung-RADS classification system applied for evaluation of each detected pulmonary nodule. Diagnoses were established using the help of either histopathology or follow-up clinical results as a gold standard. Results In this prospective study, we enrolled 187 known malignancy patients with 200 suspicious newly developed pulmonary nodules. Their mean patient age was 48.4 ± 9.7 years. The studied 200 pulmonary nodular lesions were categorized using a nodule reporting system based on the lung-RADS into 6 sub-groups with 122 lesions found to be malignant and 78 lesions were of benign etiology, which showed a high sensitivity of 92.08%, specificity of 78.79%, and accuracy of 85.50% with 81.58% positive predictive value and 90.70% negative predictive value in the diagnosis of pulmonary nodules in cancer patients. Conclusion Low-density CT with a nodule reporting system based on the lung-RADS classification system was found to be an accurate non-invasive tool to characterize and to risk stratify pulmonary nodules in oncology patients.

Background Recently, lung cancer screenings based on age and smoking history using low-dose computed tomography (LDCT) have begun in Korea. This study aimed to evaluate the distribution of lung imaging reporting and data system (Lung-RADS) categories in shipyard workers exposed to lung carcinogens such as nickel, chromium, and welding fumes according to job type, to provide basic data regarding indications for LDCT in shipyard workers. Methods This study included 6,326 workers from a single shipyard, who underwent health examinations with LDCT between January 2010 and December 2018. Data on age, smoking status and history, medical history, and job type were investigated. The participants were categorized into high-exposure, low-exposure, and non-exposure job groups based on the estimated exposure level of nickel, chromium, and welding fumes according to job type. Cox proportional hazard regression analysis was used to determine the difference between exposure groups in Lung-RADS category ≥ 3 (3, 4A, and 4B). Results Out of all participants, 97 (1.5%) participants were classified into Lung-RADS category ≥ 3 and 7 (0.1%) participants were confirmed as lung cancer. The positive predictive value (ratio of diagnosed lung cancer cases to Lung-RADS category ≥ 3) was 7.2%. The hazard ratio (HR) of Lung-RADS category ≥ 3 was 1.451 (95% confidence interval [CI]: 0.911-2.309) in low-exposure and 1.692 (95% CI: 1.007-2.843) in high-exposure job group. Adjusting for age and pack-years, the HR was statistically significant only in the high-exposure job group (HR: 1.689; 95% CI: 1.004-2.841). Conclusions Based on LDCT and Lung-RADS, among male shipyard workers, Lung-RADS category ≥ 3 were significantly higher in the high-exposure job group. Their HR tended to be > 1.0 and was statistically significant in the high-exposure job group. Additional studies should be conducted to establish more elaborate LDCT indications for occupational health examination.

Simple Summary The great majority of pulmonary nodules on screening CT scans are benign (95%). Due to inaccurate diagnoses of granulomas from adenocarcinomas on CT scans, many patients with benign nodules are subjected to unnecessary surgical procedures. The aim of this retrospective study is to evaluate the discriminability of a new radiomic feature, nodule edge/interface sharpness (NIS), for distinguishing lung adenocarcinomas from benign granulomas on non-contrast CT scans. Moreover, we aim to evaluate whether NIS can improve the performance of Lung-RADS, by reclassifying benign nodules that were initially assessed as suspicious. In a cohort of 352 patients with diagnostic non-contrast CT scans, NIS radiomics was able to classify nodules with an area under the receiver operating characteristic curve (ROC AUC) of 0.77, and when combined with intra-tumoral textural and shape features, classification performance increased to AUC of 0.84. Additionally, the NIS classifier correctly reclassified 46% of those lesions that were actually benign but deemed suspicious by Lung-RADS. Combining NIS with Lung-RADS has the potential to alter patient management by significantly decreasing unnecessary biopsies/follow up imaging. Abstract The aim of this study is to evaluate whether NIS radiomics can distinguish lung adenocarcinomas from granulomas on non-contrast CT scans, and also to improve the performance of Lung-RADS by reclassifying benign nodules that were initially assessed as suspicious. The screening or standard diagnostic non-contrast CT scans of 362 patients was divided into training (St, N = 145), validation (Sv, N = 145), and independent validation (Siv, N = 62) sets from different institutions. Nodules were identified and manually segmented on CT images by a radiologist. A series of 264 features relating to the edge sharpness transition from the inside to the outside of the nodule were extracted. The top 10 features were used to train a linear discriminant analysis (LDA) machine learning classifier on St. In conjunction with the LDA classifier, NIS radiomics classified nodules with an AUC of 0.82 ± 0.04, 0.77, and 0.71 respectively on St, Sv, and Siv. We evaluated the ability of the NIS classifier to determine the proportion of the patients in Sv that were identified initially as suspicious by Lung-RADS but were reclassified as benign by applying the NIS scores. The NIS classifier was able to correctly reclassify 46% of those lesions that were actually benign but deemed suspicious by Lung-RADS alone on Sv.

Background: Lung cancer screening in high-risk population increases the proportion of patients diagnosed at a resectable stage. Aims: To optimize the selection criteria and quality indicators for lung cancer screening by low-dose CT (LDCT) in the Czech population of high-risk individuals. To compare the influence of screening on the stage of lung cancer at the time of the diagnosis with the stage distribution in an unscreened population. To estimate the impact on life-years lost according to the stage-specific cancer survival and stage distribution in the screened population. To calculate the cost-effectiveness of the screening program. Methods: Based on the evidence from large national trials - the National Lung Screening Trial in the USA (NLST), the NELSON study, the recent recommendations of the Fleischner society, the American College of Radiology, and I-ELCAP action group, we developed a protocol for a single-arm prospective study in the Czech Republic for the screening of high-risk asymptomatic individuals. The study commenced in August 2020. Results: The inclusion criteria are: age 55 to 74 years; smoking: ≥30 pack-years; smoker or ex-smoker

Purpose The aim of this study was to compare results of National Comprehensive Cancer Network (NCCN) high-risk group 2 with those of NCCN high-risk group 1 in a clinical CT lung screening program. Methods The results of consecutive clinical CT lung screening examinations performed from January 2012 through December 2013 were retrospectively reviewed. All examinations were interpreted by radiologists credentialed in structured CT lung screening reporting, following the NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012). Positive results required a solid nodule ≥4 mm, a ground-glass nodule ≥5 mm, or a mediastinal or hilar lymph node >1 cm, not stable for >2 years. Significant incidental findings and findings suspicious for pulmonary infection were also recorded. Results A total of 1,760 examinations were performed (464 in group 2, 1,296 in group 1); no clinical follow-up was available in 432 patients (28%). Positive results, clinically significant incidental findings, and suspected pulmonary infection were present in 25%, 6%, and 6% in group 2 and 28.2%, 6.2%, and 6.6% in group 1, respectively. Twenty-three cases of lung cancer were diagnosed (6 in group 2, 17 in group 1), for annualized rates of malignancy of 1.8% in group 2 and 1.6% in group 1. Conclusion NCCN group 2 results were substantively similar to those for group 1 and closely resemble those reported in the National Lung Screening Trial. Similar rates of positivity and lung cancer diagnosis in both groups suggest that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.

Objective To report the radiological results of a pilot study for the Korean Lung Cancer Screening project conducted to evaluate the feasibility of lung cancer screening using low-dose chest computed tomography (LDCT) in Korea. Materials and Methods The National Cancer Center and three regional cancer centers participated in this study. Asymptomatic current or ex-smokers aged 55–74 years with a smoking history of at least 30 pack-years who had used tobacco within the last 15 years were considered eligible. In total, 256 participants underwent LDCT November 2016 through March 2017. The American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) was used to categorize the LDCT findings. Results In total, 57%, 35.5%, 3.9%, and 3.5% participants belonged to Lung-RADS categories 1, 2, 3, and 4, respectively. Accordingly, 7.4% participants exhibited positive findings (category 3 or 4). Lung cancer was diagnosed in one participant (stage IA, small cell lung cancer). Other LDCT findings included pulmonary emphysema (32.8%), coronary artery calcification (30.9%), old pulmonary tuberculosis (11.7%), bronchiectasis (12.9%), interstitial lung disease with a usual interstitial pneumonia pattern (1.2%), and pleural effusion (0.8%). Conclusion Even though the size of our study population was small, the positive rate of 7.4% was like or lower than those in other lung cancer screening studies. Early lung cancer was detected using LDCT screening in one participant. Lung-RADS may be applicable to participants in Korea, where pulmonary tuberculosis is endemic.

Purpose The aim of this study was to assess the effect of applying ACR Lung-RADS in a clinical CT lung screening program on the frequency of positive and false-negative findings. Methods Consecutive, clinical CT lung screening examinations performed from January 2012 through May 2014 were retroactively reclassified using the new ACR Lung-RADS structured reporting system. All examinations had initially been interpreted by radiologists credentialed in structured CT lung screening reporting following the National Comprehensive Cancer Network's Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012), which incorporated positive thresholds modeled after those in the National Lung Screening Trial. The positive rate, number of false-negative findings, and positive predictive value were recalculated using the ACR Lung-RADS-specific positive solid/part-solid nodule diameter threshold of 6 mm and nonsolid (ground-glass) threshold of 2 cm. False negatives were defined as cases reclassified as benign under ACR Lung-RADS that were diagnosed with malignancies within 12 months of the baseline examination. Results A total of 2,180 high-risk patients underwent baseline CT lung screening during the study interval; no clinical follow-up was available in 577 patients (26%). ACR Lung-RADS reduced the overall positive rate from 27.6% to 10.6%. No false negatives were present in the 152 patients with >12-month follow-up reclassified as benign. Applying ACR Lung-RADS increased the positive predictive value for diagnosed malignancy in 1,603 patients with follow-up from 6.9% to 17.3%. Conclusions The application of ACR Lung-RADS increased the positive predictive value in our CT lung screening cohort by a factor of 2.5, to 17.3%, without increasing the number of examinations with false-negative results.