Rationale and Objectives
This study aimed to review the current understanding and capabilities regarding use of imaging for noninvasive lesion characterization and its relationship to lung cancer screening and treatment.
Materials and Methods
Our review of the state of the art was broken down into questions about the different lung cancer image phenotypes being characterized, the role of imaging and requirements for increasing its value with respect to increasing diagnostic confidence and quantitative assessment, and a review of the current capabilities with respect to those needs.
Results
The preponderance of the literature has so far been focused on the measurement of lesion size, with increasing contributions being made to determine the formal performance of scanners, measurement tools, and human operators in terms of bias and variability. Concurrently, an increasing number of investigators are reporting utility and predictive value of measures other than size, and sensitivity and specificity is being reported. Relatively little has been documented on quantitative measurement of non-size features with corresponding estimation of measurement performance and reproducibility.
Conclusions
The weight of the evidence suggests characterization of pulmonary lesions built on quantitative measures adds value to the screening for, and treatment of, lung cancer. Advanced image analysis techniques may identify patterns or biomarkers not readily assessed by eye and may also facilitate management of multidimensional imaging data in such a way as to efficiently integrate it into the clinical workflow.
Introduction
Classic methods of image interpretation for early detection of lung cancer are based on lesion measurement and growth . More recently, investigators have published much on the utility and methods of lesion volumetry in multiple settings . In parallel, various measures other than size have long been proposed . This review explores the perspective that advanced image analysis techniques can identify and quantify imaging biomarkers, including but not limited to size, will likely offer great assistance to clinicians in assessing lesions. Taking the view that a systematic rather than ad hoc approach to quantitative analysis of imaging features grounded in an understanding of tumor biology will yield the most useful tools and approaches, we organize our review by first considering the biology to define the assessment or measurement task, identify the requirements for the settings in which this task is undertaken, and summarize the current state of the art with respect to these settings.
Lung cancer begins with neoplastic tissue arising within the cells of the airway of the lung. Primary lung cancer can be divided into two main groups: small cell lung cancers (SCLC) and non–small cell lung cancers. This grouping is done for therapeutic purposes, and the difference is also reflected by the standard “Tumor-Node-Metastasis” staging paradigm . The names are derived from histopathologic presentation:
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The Role of Imaging for Lung Cancer
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Imaging’s Role in Cancer Screening
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TABLE 1
Summary of Fleischner Society Guidelines \*
Nodule type (assessed with contiguous CT sections of ≤1 mm) RecommendationSolitary pure GGO ≤5 mm No follow up >5 mm Follow up with CT at 3 months, and then yearly monitoring for a minimum of 3 years if persistent and unchanged. (FDG-PET is of limited value and therefore not recommended)Subsolid GGOs <5 mm Follow up with CT at 3 months to confirm persistence. If persistent and solid measuring <5 mm, then yearly CT monitoring for a minimum of 3 years ≥5 mm Follow up with CT at 3 months to confirm persistence. If persistent and solid measuring ≥5 mm, then biopsy or surgical resection should be considered. If subsolid nodules measure >10 mm FDG PET should be considered for further evaluationMultiple subsolid nodules Pure GGOs ≤5 mm Follow up with CT at 3 months to confirm persistence. Follow up CT at 2 and 4 years to monitor. If persistent and solid measuring <5 mm, then yearly CT monitoring for a minimum of 3 years Pure GGOs >5 mm with no dominant lesion Follow up with CT at 3 months to confirm persistence. If persistent biopsy or surgical resection should be considered, especially if lesion has a >5 mm solid component
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Imaging’s Role in Cancer Treatment
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Requirements for Increasing the Value of Imaging
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What Is Currently Attainable with Imaging
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Discussion
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