European Conference on Interventional Oncology
ECIO countries

April 13-16 | Rotterdam, NL

April 13-16 | Rotterdam, NL

April 13-16 | Rotterdam, NL

April 13-16 | Rotterdam, NL

April 13-16 | Rotterdam, NL

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ProgrammeSneak peeksEarly lung cancer: Detection and management

Early lung cancer: Detection and management

Three things you will learn at my lecture

    1. Surgery or thermal ablation can potentially cure early lung cancer; in particular adenocarcinoma when detected at the adenocarcinoma in-situ (AIS) or minimally invasive adenocarcinoma (MIA) stages.
    2. Low dose and now ultralow dose lung CT screening can detect such early lung cancers, aided especially by AI, either by improving quality at reduced radiation dose or by nodule detection via computer aided detection software.
    3. The interventional radiologist plays a vital role in definitive management of such early lung cancers either by pre-operative CT-guided radiological tattooing of the lesions with methylene blue or by thermal ablation of the lesion if the patient is unfit for surgery.

Dr. Peter Goh Yu-Tang
Speaker bio
 

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In Singapore, lung cancer is the third most common cancer. There is a different lung cancer epidemiology between Western and Asian countries. 80-85% of lung cancers are non-small cell lung carcinoma (NSCLC), of which the overwhelming majority are adenocarcinoma. In the US, 38.6% are due to adenocarcinoma while in Singapore, it comprised 87.3% in 2018. While many of the adenocarcinomas are seen in previous smokers, the most common subtype is the never-smoker. Approximately 48% of lung cancers are seen in never-smokers compared to 10-15% in other parts of the world. Many of the lung cancer patients are aged <55 years and female. Only 9.1% of females were smokers. [1]

If based on the National Lung Screening Trial (NLST) by age and smoking criteria, only 38.1% of patients with lung cancer would be picked up by the lung screening trial. Only 15.5% of female patients with lung cancer met the NLST criteria; their low smoking quantity being a significant contributing factor for exclusion. Of those who met the NLST criteria, 85.4% presented with advanced stage and 54.6% were dead within a year. [1]

Based on the revised lung adenocarcinoma classification – an imaging guide, we now classify early lung cancers accordingly [2],[3]:

Atypical Adenomatous Hyperplasia AAH <5mm GGO; bronchial and vascular marking preserved
Adenocarcinoma in-situ (AIS) 5-20mm; up to 30mm GGO: purely lepidic growth ; higher attenuation than AAH Stage 0: TisN0M0
Minimally Invasive Adenocarcinoma (MIA) <30mm Part solid GGO with invasive component <5mm; indistinct margin Stage IA1: T1miN0M0; no larger than 30mm or the part invading into deeper lung tissue is <5mm; not reaching pleura or affecting main branches of the bronchi
Invasive Aden carcinoma (IADC) including lepidic predominant adenocarcinoma (LPA) Solid or mostly solid Solid or mostly solid with solid focus >5mm Stage IA1 no larger than 1cm across
Stage IA2 >1cm, <2cm
Stage IA3 >2cm,<3cm
Not reaching pleura or affecting main branches of the bronchi

For MIA and AIS, patients have an approximately 100% 5-year survival rate following resection, no statistically significant differences for disease-free survival (DFS) and overall survival (OS). For IADC stage IA1, OS rate is insignificant compared to MIA but 10-20% IADC relapse. [4] 

Low dose CT lung screens enable detection of early lung cancers and early surgery. Artificial intelligence aids in early detection both by improving imaging with deep learning algorithms (DLA) and with computer aided detection (CAD) of lung nodules. Improved scanners with filters and DLA as well as new detectors such as in Siemens Photon Counting CT (PCCT) have resulted in ultra-low dose CT lung screens, with doses as low as the equivalent of less than 2 CXRs.

In the Parkway Radiology group which services the four largest private hospitals in Singapore, ultralow dose lung CTs are performed on the Canon Aquilion One, Prism edition and the Siemens Naeotom PCCT; both with similar ultralow doses achieved.

The use of AI in CAD reduces the reading time and increases the detection rate of lung nodules, functioning either as a concurrent or second-reader. [5], [8]

In our group, we are the first in the country to use a Health Sciences Authority (HSA) AI system in reporting our CT lung screens. Initially, we employed AI to check our reports, but of late, it has become the other way around; AI detects the nodules and our radiologists review these.

Once detected, we employ either the Fleischner Society 2017 [6] or the ACR’s Lung Rads v 2022 [7] criteria for follow-up and management.

The large GGOs and the semisolid GGOs are then surgically resected. As these are sometimes extremely small, radiological localization is routinely performed. In our practice, CT guided tattooing of the nodule with methylene blue is performed half an hour before the surgery. The surgeon then resects the blue spot. This is also useful for the pathologist, as they often are unable to find the lesion and they have to be advised to cut on the blue.

Should the patient be unfit for surgery, cryoablation of the GGO is performed; with good local control and low recurrence rates. [9], [10]

Peter Goh Yu-Tang

Mount Elizabeth Hospital, Singapore/SG

Dr Goh is the Group Medical Director of Parkway Radiology, the largest private radiology group in Singapore, servicing 4 private hospitals. He is a senior consultant Vascular and Interventional Radiologist and head of Interventional Radiology in Parkway Radiology. He graduated from the National University of Singapore in 1987 and has been a radiologist since obtaining his FRCR (UK) in 1994. He has been practicing Interventional Radiology for 31 years. From 1997 to 1998, Dr Goh was a fellow in Interventional Radiology at Guy’s and St Thomas Hospital, London under the guidance of Professor Andy Adam and Dr John Reidy His subspecialty interests are interventional oncology including transarterial chemoembolization of liver cancer and tumour ablation, embolotherapy, angioplasty and stenting, musculoskeletal, hepatobiliary and urological interventions. He was regional proctor for EVAR and TEVAR for Medtronic and for SIRT for Sirtex. He has lectured extensively on these topics and conducted numerous workshops and masterclasses on TACE, RF ablation, Cryoablation, Vertebroplasty and Nucleoplasty. He held the chair of the Cardiovascular and Interventional Radiology subsection of the Singapore Radiological Society from 2004 -2010. He currently holds membership in the Singapore Radiological Society, Society of Interventional Radiology (SIR), the Asia-Pacific Society of Cardiovascular and Interventional Radiology (APSCVIR) and is a fellow of the Cardiovascular and Interventional Society of Europe (CIRSE). He is a founding member of the Asia-Pacific Congress of Interventional Oncology.

 

References

  1. Loh CH, Koh PW, Ang DJM, Lee WC, Chew WM, Koh JMK. Characteristics of Singapore lung cancer patients who miss out on lung cancer screening recommendations. Singapore Med J 2024; 65: 279-287
  2. Gardiner N, Jogai S, Wallis A. The revised lung adenocarcinoma classification – an imaging guide. J Thorac Dis 2014; 6(S5): S537-546
  3. American Joint Committee on Cancer. Lung. AJCC Cancer Staging Manual. 8th New York, NY Springer; 2017: 431-456
  4. Chen T, Luo J, Gu H, Gu Y, Huang J, Luo Q, Yang Y. Should minimally invasice lung adenocarcinoma be transferred from stage IA1 to stage 0 in future updates of the TNM staging system ?. J Thorac Dis 2018;10(11):6247-6253
  5. Cellina M, Cacioppa LM, Ce M, Chiarpenello V, Costa M, Vincenzo Z, Pais D, Bausano MV, Rossini N, Bruno A and Floridi C. Artificial Intelligence in lung cancer screening: The future is now. Cancers 2023, 15,4334
  6. MacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR, Mehta AC, Ohno Y, Powell CA, Prokop M, Rubin GD, Schaefer-Prokop CM, Travis WD, Van Schill PE, Bankier AA. Guidelines for management of incidental pulmonary nodules detected on CT Images: From the Fleishner Soceity 2017. Radiology 2017; 284(1): 228-243
  7. American College of Radiology Committee on Lung-RADS. Lung-RADS 2022. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022
  8. Geppert J, Asgharzadeh A, Brown A et al. Software using artificial intelligence for nodule and cancer detection in CT lung screening: systemic review of test accuracy studies. Thorax 2024;79:1040-1049
  9. Liu S, Liang B, Li Y, Xu J, Qian W, Lin M, Xu M, Niu L CT-guided percutaneous cryoablation in patients with lung nodules mainly composed of ground-glass opacities. J Vasc Interv Radiol 2022; 33:942-948
  10. Zhang YS, Niu LZ, Zhan K, Li ZH, Huang YG, Yang Y, Chen JB, Xu KC. Percutaneous imaging-guided cryoablation for lung cancer. J Thorac Dis 2016,8(Suppl 9)S705-S709
  11. Yamauchi Y, Izumi Y, Hashimoto K, Yashiro H, Inoue M, et al.(2012) Percutaneous cryoablation for the treatment of medically inoperable stage I non-small cell lung cancer. PLoS ONE 7(3): e33223.doi:10.1371/journal.pone.0033223