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J Thorac Cardiovasc Surg 2008;136:611-617
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

Difficulties encountered managing nodules detected during a computed tomography lung cancer screening program

^a Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy
^b Department of Radiology, European Institute of Oncology, Milan, Italy
^c School of Medicine, University of Milan, Milan, Italy
^d Department of Pathology, European Institute of Oncology, Milan, Italy
^e Department of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy

Received for publication June 29, 2007; revisions received January 20, 2008; accepted for publication February 7, 2008.

^_* Address for reprints: Giulia Veronesi, MD, Division of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, I-20141, Milan, Italy. (Email: giulia.veronesi{at}ieo.it).

Objective: The main challenge of screening a healthy population with low-dose computed tomography is to balance the excessive use of diagnostic procedures with the risk of delayed cancer detection. We evaluated the pitfalls, difficulties, and sources of mistakes in the management of lung nodules detected in volunteers in the Cosmos single-center screening trial.

Methods: A total of 5201 asymptomatic high-risk volunteers underwent screening with multidetector low-dose computed tomography. Nodules detected at baseline or new nodules at annual screening received repeat low-dose computed tomography at 1 year if less than 5 mm, repeat low-dose computed tomography 3 to 6 months later if between 5 and 8 mm, and fluorodeoxyglucose positron emission tomography if more than 8 mm. Growing nodules at the annual screening received low-dose computed tomography at 6 months and computed tomography-positron emission tomography or surgical biopsy according to doubling time, type, and size.

Results: During the first year of screening, 106 patients underwent lung biopsy and 91 lung cancers were identified (70% were stage I). Diagnosis was delayed (false-negative) in 6 patients (stage IIB in 1 patient, stage IIIA in 3 patients, and stage IV in 2 patients), including 2 small cell cancers and 1 central lesion. Surgical biopsy revealed benign disease (false-positives) in 15 cases (14%). Positron emission tomography sensitivity was 88% for prevalent cancers and 70% for cancers diagnosed after first annual screening. No needle biopsy procedures were performed in this cohort of patients.

Conclusion: Low-dose computed tomography screening is effective for the early detection of lung cancers, but nodule management remains a challenge. Computed tomography-positron emission tomography is useful at baseline, but its sensitivity decreases significantly the subsequent year. Multidisciplinary management and experience are crucial for minimizing misdiagnoses.