Difficulties encountered managing nodules detected during a computed tomography lung cancer screening program Giulia Veronesi, MD, Massimo Bellomi, MD,

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Difficulties encountered managing nodules detected during a computed tomography lung cancer screening program Giulia Veronesi, MD, Massimo Bellomi, MD, Paolo Scanagatta, MD, Lorenzo Preda, MD, Cristiano Rampinelli, MD, Juliana Guarize, MD, Giuseppe Pelosi, PhD, Patrick Maisonneuve, ScD, Francesco Leo, MD, Piergiorgio Solli, MD, Michele Masullo, MD, Lorenzo Spaggiari, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 3, Pages 611-617 (September 2008) DOI: 10.1016/j.jtcvs.2008.02.082 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Overall survival in 89 screening-detected lung cancers. CI, Confidence interval. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 611-617DOI: (10.1016/j.jtcvs.2008.02.082) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Two false-negatives arising from the diagnostic protocol. A–D, LD-CT images of a centrally located lesion of the right lower lobe taken every 3 months. CT-PET after the second LD-CT was negative (SUV < 2). The lesion was diagnosed as cancer from the fourth LD-CT scan. A and B, A 7-mm lesion of the right upper lobe that remained stable in maximum diameter at 3 months follow-up LD-CT after baseline scan. Nine months after follow-up, the screening scan shows a small increase in diameter, indicating cancer. At surgery, the lesion was T2N1 squamous cell carcinoma. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 611-617DOI: (10.1016/j.jtcvs.2008.02.082) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Distribution of the volume doubling time of 24 lung cancers diagnosed as malignant after first annual screening but detected at baseline. The extreme value of 7900 days represents a patient with a tumor stable in size that showed increased density. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 611-617DOI: (10.1016/j.jtcvs.2008.02.082) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Examples of false-positives. In both cases, a centrally located nodule had increased in size and volume compared with baseline (a) on repeat scan (b); both were benign at surgical biopsy. A, The lesion had a doubling time of 162 days and negative PET scan. Lobectomy was necessary for removal. Histology showed chronic inflammation. B, The lesion was removed via a small lateral thoracotomy, and pathologic examination documented a scissural lymph node. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 611-617DOI: (10.1016/j.jtcvs.2008.02.082) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions