Reevaluation of missed lung cancer with artificial intelligence

Abstract

Lung cancer is often missed on chest radiographs, despite chest radiography typically being the first imaging modality in the diagnosis pathway. We present a 46 year-old male with chest pain referred for chest X-ray, and initial interpretation reported no abnormality within the patient's lungs. The patient was discharged but returned 4 months later with persistent and worsening symptoms. At this time, chest X-ray was again performed and revealed an enlarging left perihilar mass with post-obstructive atelectasis in the left lower lobe. Follow-up chest computerized tomography scan confirmed lung cancer with post-obstructive atelectasis, and subsequent bronchoscopy-assisted biopsy confirmed squamous cell carcinoma. Retrospective analysis of the initial chest radiograph, which had reported normal findings, was performed with Chest-CAD, a Food and Drug Administration (FDA) cleared computer-assisted detection (CAD) software device that analyzes chest radiograph studies using artificial intelligence. The device highlighted the perihilar region of the left lung as suspicious. Additional information provided by artificial intelligence software holds promise to prevent missed detection of lung cancer on chest radiographs.

Keywords: Artificial intelligence; Chest radiograph; Lung cancer; Machine learning; Misdiagnosis.

Fig. 1

Posterior-anterior (A) and lateral chest X-ray (B) demonstrating a subtle left infrahilar nodular opacity with a region of atelectasis in the left lower lung, best seen on the frontal view.

Fig. 2

The radiology report for the initial chest X-ray, where the findings demonstrated in Fig. 1 are not described.

Fig. 3

Posterior-anterior (A) and lateral chest X-ray (B) demonstrating an enlarging left perihilar mass with post-obstructive atelectasis in the left lower lobe when compared to earlier chest X-ray taken 4 months prior.

Fig. 4

Two examples of the axial CT scan of the chest with differing window level and width to highlight soft tissue (A) and lungs (B) that reveal a left lower lobe mass with post-obstructive atelectasis.

Fig. 5

Posterior-Anterior (A) and lateral chest X-ray (B) demonstrating Chest-CAD output that identified suspicious ROIs in the lungs.

Fig. 6

Posterior-Anterior (A) and lateral chest X-ray (B) demonstrating why Chest-CAD identified the lungs as having suspicious ROIs. The heatmaps are focused on the known left infrahilar malignancy and post-obstructive left lower lung atelectasis.