NCCN Clinical Practice Guidelines: Lung Cancer Screening 2022.2 (Chinese)

Table of contents for this article

a.
It is recommended that medical institutions that perform lung cancer screening adopt a multidisciplinary collaborative approach
including thoracic radiology, respiratory medicine, and surgical surgery.

b.
Lung cancer screening is available for high-risk potential treatment targets
for lung cancer.
Chest X-ray is not recommended for lung cancer screening
.

c.
Although age and smoking history are used for risk assessment, other potential risk factors for lung cancer (e.
g.
, occupational exposure, radon exposure, cancer history, family history, lung history)
may be discussed in a shared decision-making process.

d.
All current smokers should be advised to quit, and former smokers should be advised to stay away
.
For more smoking cessation support and resources, smokers can refer to _istranslated="1">.
Lung cancer screening should not be considered a substitute for
smoking cessation.
A smoking history should document the smoker's previous exposure (in pack-years) and the length of
time he or she has quit.
See also the NCCN Guidelines
for Smoking Cessation.

e.
Documented sustained and substantially increased radon exposure
.

f.
Clearly identified pulmonary carcinogens are: silica, cadmium, asbestos, arsenic, beryllium, chromium, diesel fumes, nickel, soot and soot
.

g.
Increased risk of new primary lung cancer in survivors of lymphoma, head and neck cancer, or
smoking-related cancers.

h.
Carcinogenicity heterogeneity of secondhand smoke exposure is strong, and the exposure is highly variable, and evidence for increased risk varies
.
Therefore, secondhand smoke is not independently considered an adequate risk factor
for recommended lung cancer screening.

i.
Curative treatments include surgery, stereotactic radiosurgery (SBRT), or ablation
.
SBRT or ablation can be used in medically inoperable patients
with heart disease or severe chronic obstructive pulmonary disease (COPD).

j.
Although evidence from randomised trials supports screening up to 77 years of age, the need for screening in people over 77 years of age is inconclusive
.
It is currently believed that as long as the target is a potential lung cancer treatment target, it can be included in the screening population
.

Studies have shown that African-American smokers who smoke less have a similar
risk of lung cancer as white smokers who smoke more.
The increased risk for African Americans should be considered
in shared decision-making and risk assessment.
Aldrich M, et al.
JAMA Oncol 2019; 5:1318-1324

See Tammemagi Lung Cancer Risk Calculator
.

Shared decision aids can help determine whether screening
should be performed.
Example of a decision aid: style="white-space: normal;">n.
All screening and follow-up chest CT should be performed at low doses (100-120 kVp and 40-60 mAs or less) unless contrast-enhanced CT is required to assess for mediastinal abnormalities or lymph nodes, where standard-dose CT plus venous enhancement may be appropriate (see LCS-A).

There should be a systematic process for appropriate follow-up
.

n.
All screening and follow-up chest CT should be performed at low doses (100-120 kVp and 40-60 mAs or less) unless contrast-enhanced CT is required to assess for mediastinal abnormalities or lymph nodes, where standard-dose CT plus venous enhancement may be appropriate (see LCS-A).

There should be a systematic process for appropriate follow-up
.

o.
NCCN lung cancer screening guidelines are consistent with the Lung Imaging Reporting and Data System (lung-RADS), rounding measurements to the nearest whole number (mm).


。

p.
No benign calcifications, intranodular fat suggestive of hamartoma, or suggestive of inflammatory causes
.
When multiple nodules or other findings suggest a possible occult infection or inflammation, follow-up LDCT
within 1 to 3 months is recommended.

q.
It is uncertain
how long screening should last and after what age it is no longer suitable for screening.

r.
Nodules are round, opaque, up to 3 cm
in diameter.
Solid nodules have uniform soft tissue attenuation, ground-glass nodules (also known as non-solid nodules) have attenuation of increased haze density that does not obscure bronchial and vascular margins, and some solid nodules have both solid and ground-glass nodule components
.
Nodules should be evaluated and measured
on the CT lung window.
When viewed on a soft tissue window, the size of all nodules is underestimated, and some nodules may not even be visible, especially ground-glass nodules and small nodules
.
Bankier AA, et al.
Radiology 2017; 285:584-600.

LDCT initial screening is solid nodules, partially solid nodules, and non-solid nodules (LCS3-5)

n.
All screening and follow-up chest CT should be performed at low doses (100-120 kVp and 40-60 mAs or less) unless contrast-enhanced CT is required to assess for mediastinal abnormalities or lymph nodes, where standard-dose CT plus venous enhancement may be appropriate (see LCS-A).

There should be a systematic process for appropriate follow-up
.

o.
NCCN lung cancer screening guidelines are consistent with the Lung Imaging Reporting and Data System (lung-RADS), rounding measurements to the nearest whole number (mm).


。

p.
No benign calcifications, intranodular fat suggestive of hamartoma, or suggestive of inflammatory causes
.
When multiple nodules or other findings suggest a possible occult infection or inflammation, follow-up LDCT
within 1 to 3 months is recommended.

q.
It is uncertain
how long screening should last and after what age it is no longer suitable for screening.

R.
Nodules are round, opaque, up to 3 cm
in diameter.
Solid nodules have uniform soft tissue attenuation, ground-glass nodules (also known as non-solid nodules) have attenuation of increased haze density that does not obscure bronchial and vascular margins, and some solid nodules have both solid and ground-glass nodule components
.
Nodules should be evaluated and measured
on the CT lung window.
When viewed on a soft tissue window, the size of all nodules is underestimated, and some nodules may not even be visible, especially ground-glass nodules and small nodules
.
Bankier AA, et al.
Radiology 2017; 285:584-600.

Nodule size should be measured on the lung window and recorded as an average diameter rounded to the nearest whole number; for spherical nodules, only one diameter
needs to be measured.
The mean diameter is the average of the longest and vertical diameters of
the nodule.

t.
PET-CT has a lower sensitivity to nodules with a
solid composition less than 8 mm and small nodules close to the diaphragm.
PET/CT is only one consideration in several criteria to determine whether a nodule has a high risk of lung cancer
.
In areas where mycosis is endemic, PET-CT has a higher rate of false
positives.

Evaluation of suspected lung cancer requires a multidisciplinary team with expertise in the management of pulmonary nodules, including thoracic radiology, respiratory medicine, and thoracic surgery
.
This may include the use of a pulmonary nodule risk calculator to assist in determining probabilities
.
The use of a risk calculator does not replace nodule management
in a multidisciplinary team.
Geography and other factors can greatly affect the accuracy
of a nodule calculator.

v.
Biopsy tissue sample size needs to be sufficient for histological and molecular testing
.
Travis WD, et al.
In: WHO Classification of Thoracic Tumors, 5th Ed.
Lyon: International Agency for Research on Cancer; 2021:29-36.

If a single biopsy fails to complete the diagnosis and suspicion for cancer remains high, repeat biopsy/surgical resection or follow-up with LDCT at short intervals (3 months)
is recommended.

x.
See the NCCN guidelines for diagnostic evaluation of lung nodules (DIAG-1 to DIAG-A).

In many cases, patients with clinically strong suspicion of stage I or II lung cancer (based on risk factors and imaging findings) do not require a biopsy
prior to surgery.
Biopsy increases time, cost, and operational risk, and is often unnecessary
for treatment decisions.
The surgeon and/or patient may prefer a preoperative biopsy
prior to surgery.
Preoperative biopsy may be appropriate
if there is a strong suspicion of a non-lung cancer diagnosis (which can be diagnosed by bronchoscopy, percutaneous needle biopsy, or fine needle aspiration (FNA)), or if intraoperative diagnosis seems difficult or very dangerous.
If a preoperative histologic diagnosis is not obtained, intraoperative procedures (i.
e.
, wedge resection or needle biopsy) should be performed prior to lobectomy, double lobectomy, or total pneumonectomy to confirm the cancer diagnosis
.
See Principles of diagnostic evaluation in NCCN guidelines for non-small cell lung cancer
.

It is critical
to perform a thin-layer (<1.
5 mm) scan of all non-solid lesions to exclude any substantial components.
Any solid component of the nodule requires management of the lesion as recommended for partial solidity (LCS-9).

aa.
Lung-RADS1.
1 has increased the size of non-solid nodules that can continue to be screened annually to <30mm, instead of the <20mm
recommended in previous versions.
The NCCN Guidelines Expert Group has not harmonized this part of the Lung-RADS update because Panel members believe that baseline or new non-solid nodules > 20 mm should be assessed
earlier at 6 months.
Hammer MM, et al.
Radiology 2021; 300:586-593.

New nodules, solid nodules, partially solid nodules, nonsolid nodules at follow-up or annual LDCT (LCS6-10)

n.
All screening and follow-up chest CT should be performed at low doses (100-120 kVp and 40-60 mAs or less) unless contrast-enhanced CT is required to assess for mediastinal abnormalities or lymph nodes, where standard-dose CT plus venous enhancement may be appropriate (see LCS-A).

There should be a systematic process for appropriate follow-up
.

o.
NCCN lung cancer screening guidelines are consistent with the Lung Imaging Reporting and Data System (lung-RADS), rounding measurements to the nearest whole number (mm).


。

q.
It is uncertain
how long screening should last and after what age it is no longer suitable for screening.

R.
Nodules are round, opaque, up to 3 cm
in diameter.
Solid nodules have uniform soft tissue attenuation, ground-glass nodules (also known as non-solid nodules) have attenuation of increased haze density that does not obscure bronchial and vascular margins, and some solid nodules have both solid and ground-glass nodule components
.
Nodules should be evaluated and measured
on the CT lung window.
When viewed on a soft tissue window, the size of all nodules is underestimated, and some nodules may not even be visible, especially ground-glass nodules and small nodules
.
Bankier AA, et al.
Radiology 2017; 285:584-600.

t.
PET-CT has a lower sensitivity to nodules with a
solid composition less than 8 mm and small nodules close to the diaphragm.
PET/CT is only one consideration in several criteria to determine whether a nodule has a high risk of lung cancer
.
In areas where mycosis is endemic, PET-CT has a higher rate of false
positives.

Evaluation of suspected lung cancer requires a multidisciplinary team with expertise in the management of pulmonary nodules, including thoracic radiology, respiratory medicine, and thoracic surgery
.
This may include the use of a pulmonary nodule risk calculator to assist in determining probabilities
.
The use of a risk calculator does not replace nodule management
in a multidisciplinary team.
Geography and other factors can greatly affect the accuracy
of a nodule calculator.

v.
Biopsy tissue sample size needs to be sufficient for histological and molecular testing
.
Travis WD, et al.
In: WHO Classification of Thoracic Tumors, 5th Ed.
Lyon: International Agency for Research on Cancer; 2021:29-36.

If a single biopsy fails to complete the diagnosis and suspicion for cancer remains high, repeat biopsy/surgical resection or follow-up with LDCT at short intervals (3 months)
is recommended.

See the diagnostic evaluation of lung nodules (DIAG-1 to DIAG-A)
in the NCCN guidelines for non-small cell lung cancer.

It is critical
to perform a thin-layer (<1.
5 mm) scan of all non-solid lesions to exclude any substantial components.
Any solid component of the nodule requires management of the lesion as recommended for partial solidity (LCS-9).

aa.
Lung-RADS1.
1 has increased the size of non-solid nodules that can continue to be screened annually to <30mm, instead of the <20mm
recommended in previous versions.
The NCCN Guidelines Expert Group has not harmonized this part of the Lung-RADS update because Panel members believe that baseline or new non-solid nodules > 20 mm should be assessed
earlier at 6 months.
Hammer MM, et al.
Radiology 2021; 300:586-593.

Rapid increase in lesion size should raise suspicion of inflammatory etiology or malignancy other than small cell lung cancer (see LCS-6).

cc.
New nodules are defined as mean diameter ≥ 4 mm
.

r.
Nodules are round, opaque, up to 3 cm
in diameter.
Solid nodules have uniform soft tissue attenuation, ground-glass nodules (also known as non-solid nodules) have attenuation of increased haze density that does not obscure bronchial and vascular margins, and some solid nodules have both solid and ground-glass nodule components
.
Nodules should be evaluated and measured
on the CT lung window.
When viewed on a soft tissue window, the size of all nodules is underestimated, and some nodules may not even be visible, especially ground-glass nodules and small nodules
.
Bankier AA, et al.
Radiology 2017; 285:584-600.

Nodule size should be measured on the lung window and recorded as an average diameter rounded to the nearest whole number; For spherical nodules, only one diameter
needs to be measured.
The mean diameter is the average of the longest and vertical diameters of
the nodule.

It is essential
to perform a thin-layer (<1.
5 mm) scan of all non-solid lesions to exclude any substantial components.
Any solid component of the nodule requires management of the lesion as recommended for partial solidity (LCS-9).

bb.
Rapidly increasing lesion size should raise suspicion of inflammatory etiology or malignancy other than small cell lung cancer (see LCS-6).

cc.
New nodules are defined as mean diameter ≥ 4 mm
.

All partially solid nodules ≥ 6 mm should be identified and the solid area
measured.

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