Low-Dose CT Screening for Lung Cancer: Computer-Aided Detection of Missed Lung Cancers
M. Liang, et al.
Journal Club 1/31/17
Jason Hostetter, MD
- Low-dose CT screening shown to decrease mortality → early diagnosis
- 85% of cancers found on screening clinical stage I, 10 yr survival 88%
- 75% of diagnosed cancers present on earlier scan
Introduction
- CAD approved for use as second reader
- Little prior investigation into sens/spec of CAD with regard to previously missed cancers
- Interval improvement in technology and increased screening
Introduction
- International Early Lung Cancer Action Program (I-ELCAP)
- 1994-2003
- solid nodules only (more aggressive, CAD for solid nodules more mature)
Methods
- 50 cancers
- Path proven
- Missed on prior scan
- Slice thickness <= 1.25mm
- Solid nodules only
- Time 1: First detected by radiologist
- Time 0: Prior screening round, retrospectively detected
Methods
- Independently reviewed by 2 radiologists (6 & 10 years experience)
- Differences resolved by consensus or by 3rd radiologist tiebreaker
Methods - Image review
- 4 CAD systems
- CAD 1: Lung VCAR (GE)
- Size limit: 3mm
- CAD 2: ImageChecker CT (R2 Technologies)
- Limit: 4mm
- CAD 3: Syngovia Via Va 20 (Siemens)
- Limit: 3mm
- CAD 4: Cornell Via (Cornell U)
- Limit: 3mm (manually set)
- CAD 1: Lung VCAR (GE)
Methods - CAD systems
- All CAD annotated images reviewed by 2 radiologists for true and false positives
- True nodules:
- Nodules found by initial interpreting radiologist
- CAD found nodules confirmed by reviewers
- Additional nodules found by reviewers
- True nodules:
Methods - CAD performance
- Interobserver agreement: κ statistic
- Nodule diameter: paired t-test
- CAD agreement on detection and FP rates: Multirater κ statistics
- Fair: κ = 0.2 - 0.4
- Moderate: κ = 0.41 - 0.6
- Substantial: κ = 0.61 - 0.8
- Very good: κ > 0.8
Statistics
Results - Cancer characteristics
Reviewers: moderate - substantial agreement
Avg 4.8 → 11.4 mm
Results - CAD detection
Results - CAD detection of actionable nodules at time 0
Of 37 actionable cancers:
CAD 1: 62%
CAD 2: 84%
CAD 3: 70%
CAD 4: 70%
Results - False positives at time 0
- Percent of identified nodules accepted
- 34.5% - 85.4%
- Avg # rejected marks per scan
- 0.6 - 7.4 (CAD 2, 1)
Results - CAD Detection of Cancers at time 1
- Fair agreement between systems
- Range from 74-82% (CAD 1, (2,3))
- None identified all that interpreting radiologist identified
Results - CAD Matchup
System | Time 0 Sens | Time 1 Sens | FP |
---|---|---|---|
CAD 1 | 56% | 74% | 7.4/scan |
CAD 2 | 70% | 82% | 1.7/scan |
CAD 3 | 68% | 82% | 0.6/scan |
CAD 4 | 60% | 78% | 4.5/scan |
Discussion
- CAD detected 56 - 70% of missed cancers
- All were smaller at time 0, suggesting size as factor for human reader performance
- CAD also performs much better when nodules > 3 mm (69-78% vs 0-17%)
- 3 of 4 CAD systems better with 3-6mm nodules than >6 mm
- >6 mm category triggers add'nl workup on baseline scan
- At time 1, CAD missed up to 26% of cancers (not ready as primary/concurrent reader)
Limitations
- Relatively small n (50)
- Only analyzed performance with missed cancers rather than all cancers
Conclusion
- Most appropriate role of CAD is as a second reader
- Capability of the CAD system to detect at least some missed cancers is compelling
My thoughts
- What strategies do these algorithms use?
- Could they be combined into a super-CAD?
- Illustrates how far CAD still has to go before our jobs are at risk
- Few more ideal problems for CAD/CV in radiology, esp cross sectional imaging
- What is the threshold for acceptance of CAD?
Lung Screening CAD
By Jason Hostetter
Lung Screening CAD
- 259