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Lung Cancer/Solitary Pulmonary Nodule


Detterbeck FC, Boffa DJ, Kim AW, et al. The eighth edition lung cancer stage classification. Chest. 2017; 151:193-203. This quick and comprehensive reference is invaluable for determining stage based on the updated TNM classification.
PMID: 27780786
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Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd Ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S-50S. ACCP evidence-based clinical practice guidelines (3rd Edition) reviewing the evidence for both invasive and non-invasive staging of non-small cell lung cancer with CT and PET scanning as well as TTNA, TBNA, EBUS, EUS, VATS, Chamberlain procedure, mediastinoscopy and extended cervical mediastinoscopy.
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Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010;304:2245-52. An RCT of EUS/EBUS/surgical staging vs. surgical staging alone in 241 patients with potentially resectable NSCLC found a sensitivity and NPV of 94% and 93% with the combined approach, a substantial improvement over surgical staging alone (79% and 86%). In the 123 patients assigned to the combined modality arm, endosonography identified mediastinal metastases in half, precluding the need for mediastinoscopy. In the 65 patients with negative EUS/EBUS-FNA, mediastinoscopy identified cancer in six patients. The study was performed at tertiary centers using conscious sedation for endosonography.
PMID: 21098770
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Surgical Risk Assessment:

Donington J, Ferguson M, Mazzone P, et al. American College Of Chest Physicians And Society Of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest 2012; 142:1620-35. This summary is a useful resource for identifying and weighing treatment options for stage I patients unlikely to tolerate lobectomy, including the relative merits of wedge resection vs. segmentectomy, as well as use of adjuvant therapies, radiation therapy, and percutaneous ablative therapy.
PMID: 23208335

Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e166S-90S. These guidelines provide methods of identifying low-risk and high-risk patients for lung resection surgery, as well as appropriate further testing once identified.
PMID: 23649437

Altorki N, Wang X, Kozono D, et al. Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. N Engl J Med. 2023; 388:489-498. This RCT of 697 patients with stage T1aN0 (tumor < 2cm) NSCLC found no difference in disease-free and overall survival with lobar vs. sublobar resection. Patients undergoing sublobar had a 2% higher postoperative FEV1. This study may result in greater use of sublobar resection, but whether it will influence the process for determining suitability for resection in higher-risk patients is unclear.
PMID: 36780674


Schneider BJ, Ismaila N, Aerts J, et al. Lung cancer surveillance after definitive curative-intent therapy: ASCO Guideline. J Clin Oncol. 2020; 38:753-766. The multidisciplinary panel found mostly low-quality evidence to guide recommendations but offer practical expert opinion on who, when, and how these patients should be followed.
PMID: 31829901

Screening for lung cancer:

Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest. 2021; 160:e427-e494. Updated CHEST guidelines on lung cancer screening.
PMID: 34270968

Krist AH, Davidson KW, Mangione CM, et al. Screening for lung cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021; 325:962-970. Noteworthy changes from the previous USPSTF statement include reducing the age of screening from 55 to 50 years of age and reducing pack-year history from 30 to 20.  These changes substantially increase eligibility and have the potential to reduce existing sex, race, and ethnicity-based disparities in lung cancer screening.
PMID: 33687470

National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409. This large trial compared annual CT versus CXR over two years (baseline, one-year, and two-year screening). Analyzing only those who underwent at least one screening test, the absolute risk reduction for lung cancer-associated mortality was 0.3% (relative reduction of 20%), yielding a number needed to screen to prevent one death of approximately 320, with a CT false positive rate of 96.4%. Cost-effectiveness analyses and evaluation of the impact of invasive procedures related to false-positive results have not been clearly defined.
PMID: 21714641
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de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020; 382:503-513. The NELSON randomized trial compared the mortality benefit from volume-based, low dose CT scanning at baseline, 1 year, 3 years, and 5.5 years to no screening in 13,195 men aged 50-74 who were former or current smokers.  After a minimum of 10 years of follow-up, the cumulative rate ratio of death from lung cancer was 0.76 in the screening group (C.I 0.61 – 0.94; P = 0.01).  A total of 2.1% of subjects were diagnosed with lung cancer and the false-positive rate was lower than in the NLST with, on average, less than 10% of subjects requiring additional testing.
PMID 31995683

Rivera MP, Katki HA, Tanner NT, et al. Addressing disparities in lung cancer screening eligibility and healthcare access: An official American Thoracic Society statement. Am J Respir Crit Care Med. 2020; 202:e95-e112. A review of current disparities in lung cancer screening with strategies to increase equity and reduce barriers to care. The concern surrounding lung cancer screening disparities contributed to recent recommendations by the United States Preventive Services Task Force to expand screening to individuals with at least a 20 pack-year smoking history and those aged 50-80 years old.
PMID: 33000953

Solitary pulmonary nodule:

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e93S-120S. Guideline for how best to work up nodule(s) that nicely distills the large number of trials on this topic.
PMID: 23649456

MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT Images: From the Fleischner Society 2017. Radiology. 2017; 284: 228-43. This statement gives recommendations on management of incidental pulmonary nodules. Significant changes include increasing the threshold size of nodules that need follow up and widening the range of timing of follow up scans. These new changes should translate into fewer nodules followed and fewer scans among patients undergoing follow up.
PMID: 28240562
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Lung-RADS Version 1.1 Assessment Categories (2019 Release). Guidelines developed by the American College of Radiology for management of lung nodules in the setting of lung cancer screening CT scans and facilitates standardized reporting of abnormal findings.
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