Monica L. Mullin

Background: Timely diagnosis is critical for improving lung cancer outcomes, yet diagnostic pathways in England remain complex and variable. Real-world evidence examining imaging use, delays and emergency care during the diagnostic interval is limited. Methods: We conducted a national retrospective cohort study using linked Hospital Episode Statistics and Diagnostic Imaging Dataset for adults newly diagnosed with lung cancer between April 2018 and March 2019. Diagnostic intervals were defined from first chest imaging to diagnosis. We assessed imaging utilisation, diagnostic pathways and A&E attendance, with subgroup analyses by ethnicity, deprivation and diagnostic interval. Results: Among 21 052 patients, the median diagnostic interval was 56 days: 25% experienced intervals ≥113 days. Patients underwent a median of three chest scans, and 25% received four or more. Multimodality imaging was strongly associated with prolonged intervals. One-third of patients attended A&E during the diagnostic pathway, rising to 45% among those with the longest intervals. Asian patients experienced the longest diagnostic intervals (median: 67 days). Patterns were consistent across deprivation quintiles, with diagnostic intervals and high A&E attendance observed across all strata, indicating systemic gaps in coordinated diagnostic pathways. Conclusion: A substantial proportion of patients with lung cancer in England experience prolonged diagnostic intervals, often accompanied by high emergency care utilisation. Prolonged diagnostic intervals may reflect underlying differences in patient pathways. Multimodality imaging was associated with longer diagnostic timelines, which could represent clinical complexity, diagnostic challenges or possibly fragmentation of diagnostic pathways. These findings highlight the need for streamlined imaging processes, timely follow-up after initial chest imaging and stronger primary care engagement to support earlier diagnosis and alignment with the National Optimal Lung Cancer Pathway.

Introduction: Lung cancer is the leading cause of cancer-related death worldwide. Low-dose CT (LDCT) screening improves outcomes by detecting early-stage cancers as pulmonary nodules. As most are benign, diagnosing these nodules is challenging and often requires surveillance imaging. The aim of this study is to assess the frequency of cancer progression in a lung cancer screening study as measured by tumour stage (T-stage). Methods: SUMMIT is a prospective cohort study assessing implementation of lung cancer screening with LDCT in a high-risk population. Screen-detected lung cancers with clinical tumour stage cT1a–c at time of referral were included. Upstaging was defined as an increase in T-stage from referral to treatment. The date of death was obtained from the National Cancer Registration and Analysis Service. Cox proportional hazards analysis with adjustment for age, sex, Charlson Comorbidity Index and pack years was used to assess mortality between groups. Results: 390 screen-detected cancers were stage cT1a–c at time of referral. Upstaging occurred more frequently in cT1a (n=48, 56%) compared with cT1b (n=83, 38%) or cT1c (n=34, 40%), p=0.01. The proportion of part-solid nodules was similar between groups (upstaged-N=47, 27%, vs not upstaged-N=45, 21%, p=0.19). 43% of tumours increased T-stage from referral to first treatment (n=165). In participants upstaged, time from referral to treatment was longer (upstaged: 84 days, 46–298 vs not upstaged: 72 days, 43–211, p=0.04). Adjusted overall survival analyses showed an association between upstaging and mortality (HR 1.68, 95% CI 1.13 to 2.51, p=0.01). Conclusion: Tumour upstaging occurred in nearly half of early-stage cases in a lung cancer screening population. Tumour upstaging was associated with longer time to treatment and poorer outcomes in this population. Trial registration number: NCT03934866 .

Summary: Bronchoscopic procedures are increasingly performed with shape‐sensing robotic‐assisted bronchoscopy under general anaesthesia, allowing biopsy of small and distal pulmonary lesions. We performed a retrospective cohort study at a single centre of patients undergoing robotic bronchoscopy to describe the peri‐operative care. The primary outcome measure was post‐procedural length of hospital stay, with secondary outcomes including complication rates and diagnostic success of biopsy. A total of 200 patients were recruited over a 12‐month period. Median ([IQR] range) post‐procedural length of stay was 4 h ([2.5–24.5] 0.5–75) with 106/200 (53%) of patients performed as a day case. Cardiorespiratory comorbidities were common, 65% of patients had an ASA physical status 3 or 4. Higher ASA physical status and chronic obstructive pulmonary disease were associated with increased post‐procedural admission rate. All patients underwent general anaesthesia with target‐controlled infusion of propofol. Neuromuscular blocking agents were used in 194/200 (97%) and remifentanil was used for 185/200 patients (93%). Median PEEP was 10 cmH ₂ O (range 5–15 cmH ₂ O). The incidence of peri‐procedural complications requiring intervention was 6%. Our findings suggest that robotic‐assisted bronchoscopy could be delivered safely as a day case procedure in a population with a high incidence of comorbidities, with low peri‐procedural complication rates.

Background: Interstitial lung abnormalities (ILAs) are common incidental findings in lung cancer screening (LCS). However, challenges remain in identifying clinically relevant ILAs as highlighted in a joint statement by a European multidisciplinary task force led by the European Respiratory Society (ERS). To address these challenges, we analysed ILAs identified in one of Europe’s largest LCS studies. Methods: Of 11 635 LCS individuals, 417 screen-detected ILAs were evaluated using a new visual classification system focused on traction bronchiolectasis: non-fibrotic ILA (no traction bronchiolectasis), fibrotic ILA (traction bronchiolectasis in ≤2 lobes); undiagnosed interstitial lung disease (traction bronchiolectasis in >2 lobes). Observer agreement was compared with Fleischner Society ILA classification using Cohen’s Kappa. An age, sex and smoking history-matched control group allowed the examination of associations between baseline ILA/UILD and comorbidities, forced vital capacity (FVC), hospitalisations (Student’s t-tests) and mortality (univariable and multivariable Cox proportional hazards models). Findings: Our visual ILA classification showed superior interobserver agreement (K=0.76) versus the Fleischner ILA classification (K=0.64). ILA/UILD subjects had more prevalent comorbidities, increasing (vs controls) approximately 10 years prior to ILA/UILD diagnosis. Compared with controls, mortality rates were 6-fold higher for UILD participants and 3-fold higher for fibrotic and non-fibrotic ILA subtypes. On multivariable Cox regression analysis, ILA/UILD presence (HR=4.90, 95% CI =2.36 to 10.10, p<0.001) showed stronger independent associations with mortality than baseline FVC (HR=0.98, 95% CI =0.96 to 1.00, p=0.04). Conclusion: We demonstrate a new reproducible classification of clinically important ILA/UILDs in LCS populations. We highlight that FVC shows limited associations with mortality in ILA/UILD subjects. Increased multiorgan comorbidity in ILA/UILD subjects highlights a need for comprehensive early multisystem evaluation.

Objective Malignant oesophageal strictures can cause airway compromise and fistula formation. Combined oesophageal and airway stenting is a potential treatment, yet no guidelines exist. This study aims to describe the outcomes of same-session oesophageal and airway endoscopic stenting for malignant strictures and propose an algorithm for intervention. Method A retrospective cohort study on patients undergoing same-session gastrointestinal (GI) and respiratory endoscopy at University College London Hospital between 2019 and 2023. Data collected included malignancy type, degree of luminal narrowing (%), completed interventions, complications and mortality. The primary objective was to describe interventions performed during same-session procedures, with a focus on developing a decision-based algorithm. Results 26 patients were identified with a mean age of 63 years. Primary cancer type was oesophageal (81%) or lung (19%). The most common referral indication was dysphagia (42%), although radiological signs of airway compromise were frequently seen on imaging (65%). Stent insertion included oesophageal only (35%), airway only (19%) and dual (27%). After oesophageal stenting, repeat bronchoscopy showed increased airway stenosis in four patients (25%). There was only one intraoperative complication, an oesophageal perforation. New tracheo-oesophageal fistula was the most common post-intervention complication (15%). Median time from malignancy diagnosis to death was 7.9 weeks. Conclusion Malignant oesophageal strictures with airway involvement are a challenging condition to treat. Given the complexity of cases, joint upper GI and respiratory multidisciplinary discussion is suggested to plan any intervention including same-session endoscopy. To our knowledge, we present the first algorithm for endoscopic stenting in patients with malignant oesophageal stricture and airway involvement. Decision-making should be framed by patient-centred goals, as this group demonstrated poor prognosis.

A previously healthy woman in her 40s presented with a 6-month history of increasing cough and breathlessness following COVID-19 infection. She experienced vocal hoarseness and recurrent respiratory infections during this time, requiring several antibiotic courses. She was treated for gastro-oesophageal reflux and trialled on inhaled corticosteroids, without improvement. Further work up included CT scan, demonstrating tracheal thickening, endobronchial narrowing and mucosal abnormalities. Bronchoscopy with biopsies demonstrated amyloidosis. She was referred to a specialist centre with further work up including serum amyloid P component (SAP) scan, echo and bloodwork. She was diagnosed with localised tracheobronchial amyloidosis and referred to interventional respiratory for treatment. Bronchoscopy demonstrated severe narrowing in left main, left upper and lower lobes and to a lesser extent, the right main bronchus. Endobronchial treatment included diode laser therapy, electrocautery and cryorecanalisation. Significant improvement was seen on 3 months post surveillance bronchoscopy. Following this treatment, the patient experienced sustained improvement in breathlessness and cough.