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Cancers in patients deemed lowest risk under Lung-RADS

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More judicious use of S codes key to improving Lung-RADS

The performance of lung cancer screening does not absolve the interpreter from pointing out clinically important findings whether or not they are related to lung cancer. Review of the entire examination for other potentially significant findings should be performed and reported in accordance with applicable standards, says The Joint American College of Radiology and Society of Thoracic Radiology practice parameter for the performance and reporting of lung cancer screening thoracic CT. In addition to adenopathy and pleural effusion, detection of abnormalities such as severe coronary artery calcifications, aortic aneurysms, severe emphysema and suspicious masses in the upper abdomen should be called out not just in the body of the report, but also in the final impression so that it is easily available to the reader of the report.

Lung-RADS recognizes the importance of incidental findings with an additional coding letter, the “S” code. The letter “S” should be attached any time there is an abnormality considered clinically important that is not a pulmonary nodule. For the cases presented in this study, the appropriate code for the subjects should have been Lung-RADS 1S with a specific recommendation for the management of the “S” findings. It is incumbent on individuals interpreting these examinations to appropriately account for and report all significant findings, not simply lung nodules, and to be familiar with and understand Lung-RADS. Judicious use of the Lung-RADS “S” code along with specific discussion of the report’s final impression is recommended as a means of improving communication.

James Ravenel, MD; Nichole Tanner, MD, MSCR, FCCP; and Gerard Silvestri, MD, MS, FCCP, are with the Medical University of South Carolina, Charleston. Dr. Tanner also is with the Ralph H. Johnson Veterans Affairs Hospital, Charleston.

These comments have been modified from an editorial accompanying Dr. Mehta and his colleagues’ study in CHEST (Chest. 2017 March;151[3]:539-43). The authors disclosed no conflicts of interest related to their editorial.


 

FROM CHEST*

A reporting system for lung cancer screening with low-dose computed tomography may underemphasize important abnormal findings other than nodules, researchers say, potentially leading to missed malignancies.

The American College of Radiology Lung Imaging Reporting and Data System, or Lung-RADS, was introduced in 2014 to standardize reporting for low-dose CT findings and also to reduce false-positive rates, by applying tighter criteria that was used in the National Lung Screening Trial.

Lung-RADS does not have specific reporting categories for patients with isolated hilar and mediastinal adenopathy or pleural effusion in the absence of lung nodules, even though these can indicate malignancy. It does allow for the inclusion of what is called an “S” code to indicate clinically significant findings other than nodules.

In the March 2017 issue of CHEST, Hiren Mehta, MD, and his colleagues at the University of Florida in Gainesville, report on four cases from their center in which patients with these pathologies had their scans read as Lung-RADS category 1, indicating a less than 1% likelihood of malignancy. No S codes were added to their reports. Subsequent testing in these patients revealed cancers (CHEST. 2017 March;151[3]:525-26).

The four cases were:

  • A 56-year-old male with hilar and mediastinal adenopathy who was recommended for repeat screening at 12 months. The patient presented 6 months later with pneumonia; biopsy revealed large cell lung cancer.
  • A 76-year-old male with paratracheal lymph nodes and a solitary subcarinal lymph node. A subsequent biopsy revealed adenocarcinoma.
  • A 67-year-old male whose scan showed bulky hilar and mediastinal adenopathy. Subsequent testing revealed Hodgkin’s lymphoma.
  • A 75-year-old female whose scan showed a small pleural effusion and no nodules. Repeat scanning at 1 year showed enlargement of the effusion and lung adenocarcinoma.

Dr. Mehta and colleagues noted in their analysis that Lung-RADS has not been studied prospectively in real practice settings and that the four cases – two of which involved delayed diagnosis – reveal “a significant limitation” of Lung-RADS.

“Based on our experience, we believe that particular caution should be exercised in reporting Lung-RADS 1 category for patients with adenopathy/pleural effusion with no lung nodules, as a majority of the lung cancer screening scans will be ordered by [primary care providers] ... [As] with any new system, an ongoing evaluation of the performance of Lung-RADS should be conducted so that the sensitivity and mortality benefit seen in the [National Lung Screening Trial] is not compromised.”

We strongly believe, based on our experience with these 4 cases that the new version of Lung-RADS 2.0 should [account for shortcomings of the current Lung-RADS] and have a separate category for findings that are highly suspicious for malignancy but do not have an accompanying lung nodule,” they wrote.

The investigators did not disclose outside funding or conflicts of interest related to their findings.

*This story was updated March 16, 2017, with the correct journal source.

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