title: Difficulties encountered managing nodules detected during a computed tomography lung cancer screening program.
abstract: OBJECTIVE
  The main challenge of screening a healthy population with low-dose computed tomography is to balance the excessive use of diagnostic procedures with the risk of delayed cancer detection. We evaluated the pitfalls, difficulties, and sources of mistakes in the management of lung nodules detected in volunteers in the Cosmos single-center screening trial.
  
  
  METHODS
  A total of 5201 asymptomatic high-risk volunteers underwent screening with multidetector low-dose computed tomography. Nodules detected at baseline or new nodules at annual screening received repeat low-dose computed tomography at 1 year if less than 5 mm, repeat low-dose computed tomography 3 to 6 months later if between 5 and 8 mm, and fluorodeoxyglucose positron emission tomography if more than 8 mm. Growing nodules at the annual screening received low-dose computed tomography at 6 months and computed tomography-positron emission tomography or surgical biopsy according to doubling time, type, and size.
  
  
  RESULTS
  During the first year of screening, 106 patients underwent lung biopsy and 91 lung cancers were identified (70% were stage I). Diagnosis was delayed (false-negative) in 6 patients (stage IIB in 1 patient, stage IIIA in 3 patients, and stage IV in 2 patients), including 2 small cell cancers and 1 central lesion. Surgical biopsy revealed benign disease (false-positives) in 15 cases (14%). Positron emission tomography sensitivity was 88% for prevalent cancers and 70% for cancers diagnosed after first annual screening. No needle biopsy procedures were performed in this cohort of patients.
  
  
  CONCLUSIONS
  Low-dose computed tomography screening is effective for the early detection of lung cancers, but nodule management remains a challenge. Computed tomography-positron emission tomography is useful at baseline, but its sensitivity decreases significantly the subsequent year. Multidisciplinary management and experience are crucial for minimizing misdiagnoses.
authors.affiliation: Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy. giulia.veronesi@ieo.it
authors.forename: Giulia
authors.initials: G
authors.lastname: Veronesi
authors.forename: Massimo
authors.initials: M
authors.lastname: Bellomi
authors.forename: Paolo
authors.initials: P
authors.lastname: Scanagatta
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Preda
authors.forename: Cristiano
authors.initials: C
authors.lastname: Rampinelli
authors.forename: Juliana
authors.initials: J
authors.lastname: Guarize
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Pelosi
authors.forename: Patrick
authors.initials: P
authors.lastname: Maisonneuve
authors.forename: Francesco
authors.initials: F
authors.lastname: Leo
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Solli
authors.forename: Michele
authors.initials: M
authors.lastname: Masullo
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Spaggiari
mesh_terms: D019788:Fluorodeoxyglucose F18; D006801:Humans; D008171:Lung Diseases / Q000000981:diagnostic imaging; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D003074:Solitary Pulmonary Nodule / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed / Q000379:methods
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18