Inter-observer agreement on the morphology of screening-detected lung cancer: beyond pulmonary nodules and masses

Objectives: Pulmonary nodules and masses are the typical presentations of lung cancer. However, a spectrum of focal opacities cannot be defined as either “pulmonary nodule” or “mass,” despite representing cancer. We aimed to assess the morphology of screening-detected lung cancers at low-dose computed tomography LDTC and to evaluate inter-observer agreement in their classification. Methods: Four radiologists with different experiences in thoracic imaging retrospectively reviewed 273 screening-detected lung cancers. Readers were asked to assess if morphology at the time of diagnosis was consistent with the Fleischner Society definition of pulmonary “nodule” or “mass.” Cancers not consistent were defined as “non-nodular/non-mass” (NN/NM) and sub-classified as follows: associated with cystic airspaces, stripe-like, scar-like, endobronchial, or not otherwise defined (NOD). Inter-observer agreement was evaluated using Cohen’s K statistic among pairs of readers and modified Fleiss’ kappa statistic for overall agreement. Results: Two hundred forty-one of the 273 (88%) lesions were defined as pulmonary nodule or mass by complete agreement, while 20/273 (7.3%) were defined as NN/NM. Six (2.2%) of 273 were sub-classified as lesions associated with cystic airspace, six (2.2%) as scar-like, five (1.8%) as endobronchial, and one (0.7%) as NOD by complete agreement. The concordance in defining morphology was excellent (261/273; 96%, 95%CI 92–98%; k 0.85, 95%CI 0.75–0.92) and also in the sub-classification (18/20; 90%, 95%CI 68–99%, k 0.93, 95%CI 0.86–1.00). There was incomplete agreement regarding lesion morphology in 4.4% (12/273) of cases. Conclusions: A non-negligible percentage of screening-detected lung cancers has a NN/NM appearance at LDCT. The concordance in defining lesion morphology was excellent. The awareness of various presentations can avoid missed or delayed diagnosis. Key Points: • A non-negligible percentage of screening-detected lung cancers have neither nodular nor mass appearance at low-dose CT. • The awareness of various LDCT presentations of lung cancer can avoid missed or delayed diagnosis. • Optimal protocol management in CT screening should take into consideration lung nodules as well as various other focal abnormalities.