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Lung Cancers Missed at Low-Dose Helical CT Screening in a General Population: Comparison of Clinical, Histopathologic, and Imaging Findings¹

¹ From the Kurt Rossmann Laboratories for Radiologic Image Research, Department of Radiology, MC-2026, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637 (F.L., H.A., H.M., S.G.A., K.D.); and Azumi General Hospital, Ikeda, Nagano, Japan (S.S.). From the 2001 RSNA scientific assembly. Received August 13, 2001; revision requested September 20; final revision received July 3, 2002; accepted July 10. Supported in part by United States Public Health Service grant CA62625. Address correspondence to F.L. (e-mail: fli@kurt.bsd.uchicago.edu).

View larger version (139K): [in a new window]   Figure 1a. Transverse CT scans of well-differentiated stage IA adenocarcinoma in a 63-year-old nonsmoking woman. (a) Low-dose CT scan obtained in December 1996 shows an area of pure GGO (arrow) in the right upper lobe. The lesion was judged to be very subtle and was not detected. (b) Low-dose CT scan obtained in October 1997, the year the cancer was detected, shows that the lesion increased slightly in size. (c) Thin-section CT scan obtained in November 1997 shows the lesion as an area of pure GGO.

View larger version (140K): [in a new window]   Figure 1b. Transverse CT scans of well-differentiated stage IA adenocarcinoma in a 63-year-old nonsmoking woman. (a) Low-dose CT scan obtained in December 1996 shows an area of pure GGO (arrow) in the right upper lobe. The lesion was judged to be very subtle and was not detected. (b) Low-dose CT scan obtained in October 1997, the year the cancer was detected, shows that the lesion increased slightly in size. (c) Thin-section CT scan obtained in November 1997 shows the lesion as an area of pure GGO.

View larger version (145K): [in a new window]   Figure 1c. Transverse CT scans of well-differentiated stage IA adenocarcinoma in a 63-year-old nonsmoking woman. (a) Low-dose CT scan obtained in December 1996 shows an area of pure GGO (arrow) in the right upper lobe. The lesion was judged to be very subtle and was not detected. (b) Low-dose CT scan obtained in October 1997, the year the cancer was detected, shows that the lesion increased slightly in size. (c) Thin-section CT scan obtained in November 1997 shows the lesion as an area of pure GGO.

View larger version (132K): [in a new window]   Figure 2a. Transverse low-dose CT scans of moderately differentiated stage IA adenocarcinoma in a 64-year-old man with a 30-pack-year smoking history. (a) CT scan obtained in May 1996 shows a small nodular opacity (arrow) in the right middle lobe. This lesion was considered to be similar to a pulmonary vessel or chronic inflammatory lesion and was not detected. (b) CT scan obtained in May 1997 depicts the nodule in a, which increased in size.

View larger version (128K): [in a new window]   Figure 2b. Transverse low-dose CT scans of moderately differentiated stage IA adenocarcinoma in a 64-year-old man with a 30-pack-year smoking history. (a) CT scan obtained in May 1996 shows a small nodular opacity (arrow) in the right middle lobe. This lesion was considered to be similar to a pulmonary vessel or chronic inflammatory lesion and was not detected. (b) CT scan obtained in May 1997 depicts the nodule in a, which increased in size.

View larger version (113K): [in a new window]   Figure 3a. Transverse CT scans of moderately differentiated stage IA adenocarcinoma in a 70-year-old nonsmoking woman. (a) Low-dose CT scan obtained in June 1996 shows a subtle lesion with mixed GGO (arrow) in the right lower lobe. This lesion was not detected, probably because it overlaps with pulmonary vessels. (b) Low-dose CT scan obtained in June 1997, the year the cancer was detected, shows the lesion increased slightly in size and attenuation. (c) Thin-section CT scan obtained in August 1997 shows the lesion as an area of mixed GGO.

View larger version (117K): [in a new window]   Figure 3b. Transverse CT scans of moderately differentiated stage IA adenocarcinoma in a 70-year-old nonsmoking woman. (a) Low-dose CT scan obtained in June 1996 shows a subtle lesion with mixed GGO (arrow) in the right lower lobe. This lesion was not detected, probably because it overlaps with pulmonary vessels. (b) Low-dose CT scan obtained in June 1997, the year the cancer was detected, shows the lesion increased slightly in size and attenuation. (c) Thin-section CT scan obtained in August 1997 shows the lesion as an area of mixed GGO.

View larger version (114K): [in a new window]   Figure 3c. Transverse CT scans of moderately differentiated stage IA adenocarcinoma in a 70-year-old nonsmoking woman. (a) Low-dose CT scan obtained in June 1996 shows a subtle lesion with mixed GGO (arrow) in the right lower lobe. This lesion was not detected, probably because it overlaps with pulmonary vessels. (b) Low-dose CT scan obtained in June 1997, the year the cancer was detected, shows the lesion increased slightly in size and attenuation. (c) Thin-section CT scan obtained in August 1997 shows the lesion as an area of mixed GGO.

View larger version (139K): [in a new window]   Figure 4a. Transverse low-dose CT scans of poorly differentiated stage IIIA adenocarcinoma in a 56-year-old man with a 30-pack-year smoking history. (a) CT scan obtained in August 1996 shows a subtle nodule with mixed GGO (arrow) behind the right hilum and adjacent to the mediastinum. This lesion was not detected. (b) CT scan obtained in August 1997, the year the cancer was detected, clearly shows the lesion (arrow) increased in size and attenuation.

View larger version (134K): [in a new window]   Figure 4b. Transverse low-dose CT scans of poorly differentiated stage IIIA adenocarcinoma in a 56-year-old man with a 30-pack-year smoking history. (a) CT scan obtained in August 1996 shows a subtle nodule with mixed GGO (arrow) behind the right hilum and adjacent to the mediastinum. This lesion was not detected. (b) CT scan obtained in August 1997, the year the cancer was detected, clearly shows the lesion (arrow) increased in size and attenuation.

View larger version (127K): [in a new window]   Figure 5a. Transverse low-dose CT scans of well-differentiated stage IIA adenocarcinoma in a 53-year-old man with an 80-pack-year smoking history. (a) CT scan obtained in May 1996 shows a subtle area of pure GGO (arrow) obscured by the pulmonary vessel branches in the parahilar region; this lesion was not detected. (b) CT scan obtained in March 1997 clearly shows the lesion (arrow) increased in size and attenuation, but it still was not detected. (c) On the CT scan obtained in March 1998, the lesion (arrow) became more obvious and was detected.

View larger version (133K): [in a new window]   Figure 5b. Transverse low-dose CT scans of well-differentiated stage IIA adenocarcinoma in a 53-year-old man with an 80-pack-year smoking history. (a) CT scan obtained in May 1996 shows a subtle area of pure GGO (arrow) obscured by the pulmonary vessel branches in the parahilar region; this lesion was not detected. (b) CT scan obtained in March 1997 clearly shows the lesion (arrow) increased in size and attenuation, but it still was not detected. (c) On the CT scan obtained in March 1998, the lesion (arrow) became more obvious and was detected.

View larger version (143K): [in a new window]   Figure 5c. Transverse low-dose CT scans of well-differentiated stage IIA adenocarcinoma in a 53-year-old man with an 80-pack-year smoking history. (a) CT scan obtained in May 1996 shows a subtle area of pure GGO (arrow) obscured by the pulmonary vessel branches in the parahilar region; this lesion was not detected. (b) CT scan obtained in March 1997 clearly shows the lesion (arrow) increased in size and attenuation, but it still was not detected. (c) On the CT scan obtained in March 1998, the lesion (arrow) became more obvious and was detected.

View larger version (116K): [in a new window]   Figure 6a. Transverse low-dose CT scans of well-differentiated adenocarcinoma in an 89-year-old nonsmoking man. (a) CT scan obtained in August 1996 shows a linear lesion (arrow) in the left lower lobe. The lesion was incorrectly diagnosed as an inflammatory lesion. Interpretation errors also occurred with low-dose CT scans obtained in (b) August 1997 and (c) October 1998. Although the lesion increased in size at low-dose CT in the second (b) and third (c) years of the study, according to radiologic findings, it was stage IA cancer. The tumor increased in size at routine CT (not shown) performed 15 months later and was judged after surgery to be stage IB cancer.

View larger version (111K): [in a new window]   Figure 6b. Transverse low-dose CT scans of well-differentiated adenocarcinoma in an 89-year-old nonsmoking man. (a) CT scan obtained in August 1996 shows a linear lesion (arrow) in the left lower lobe. The lesion was incorrectly diagnosed as an inflammatory lesion. Interpretation errors also occurred with low-dose CT scans obtained in (b) August 1997 and (c) October 1998. Although the lesion increased in size at low-dose CT in the second (b) and third (c) years of the study, according to radiologic findings, it was stage IA cancer. The tumor increased in size at routine CT (not shown) performed 15 months later and was judged after surgery to be stage IB cancer.

View larger version (129K): [in a new window]   Figure 6c. Transverse low-dose CT scans of well-differentiated adenocarcinoma in an 89-year-old nonsmoking man. (a) CT scan obtained in August 1996 shows a linear lesion (arrow) in the left lower lobe. The lesion was incorrectly diagnosed as an inflammatory lesion. Interpretation errors also occurred with low-dose CT scans obtained in (b) August 1997 and (c) October 1998. Although the lesion increased in size at low-dose CT in the second (b) and third (c) years of the study, according to radiologic findings, it was stage IA cancer. The tumor increased in size at routine CT (not shown) performed 15 months later and was judged after surgery to be stage IB cancer.

View larger version (109K): [in a new window]   Figure 7a. Transverse low-dose CT scans of stage IB squamous cell carcinoma in a 78-year-old man with a 45-pack-year smoking history. (a) CT scan obtained in September 1996 shows an irregular lesion (arrow) among preexisting chronic obstructive pulmonary disease changes that was detected in the right lower lobe but incorrectly interpreted as an inflammatory lesion. Similar lesions (arrowhead) are present in the left lower lobe. (b) CT scan obtained in October 1997, the year the cancer was detected, clearly shows the cancer, which increased in size, in the right lower lobe. A noncancerous lesion in the left lower lobe, which decreased in size, also is seen.

View larger version (110K): [in a new window]   Figure 7b. Transverse low-dose CT scans of stage IB squamous cell carcinoma in a 78-year-old man with a 45-pack-year smoking history. (a) CT scan obtained in September 1996 shows an irregular lesion (arrow) among preexisting chronic obstructive pulmonary disease changes that was detected in the right lower lobe but incorrectly interpreted as an inflammatory lesion. Similar lesions (arrowhead) are present in the left lower lobe. (b) CT scan obtained in October 1997, the year the cancer was detected, clearly shows the cancer, which increased in size, in the right lower lobe. A noncancerous lesion in the left lower lobe, which decreased in size, also is seen.