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Background
Lung cancer is the leading cause of cancer-related deaths worldwide and the second most prevalent malignancy. Over 28 million adults in the United States still smoke cigarettes accounting for 136,000 deaths annually. Several landmark research trials such as The National Lung Screening Trial (NLST) and the Dutch-Belgian Randomized Lung Cancer Screening Trial (NELSON) have helped define screening guidelines. In 2022, the American College of Radiology (ACR) updated their own lung imaging guidelines, the Lung CT Screening Reporting and Data System (Lung-RADS v2022). In this exhibit, we aim to discuss the historical basis of lung cancer screening and Lung-RADS lexicon, review the recent key updates to the lexicon, and discuss the potential future updates to these guidelines.

Educational Goals / Teaching Points
Our goal with this educational exhibit is two-fold. First, to summarize the foundational literature on lung cancer screening initiation to gain a comprehensive understanding of the lung-RADS lexicon with its latest updates (November 2022). Second, to identify challenges in lung cancer screening programs in the U.S. and anticipate how lung cancer screening guidelines may evolve.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
We aim to provide a succinct overview of the evolution of lung cancer screening, emphasizing its current state, and the integration of artificial intelligence (AI) tools illustrated by clinical imaging examples from our institution. We delve into the history and present state of lung cancer screening, examining the need for screening and the literature that supports it, such as the NLST, NELSON, and recommendations from the United States Preventive Services Task Force (USPSTF). We will also explore imaging protocols of low-dose chest CT and Lung-RADS lexicon, discussing its various versions and their impact on radiologists, illustrated with clinical examples. Further, we will highlight the barriers and challenges to lung cancer screening at the patient, provider, and healthcare system levels, including disparities based on race, sex, and ethnicity, and suggest potential solutions. Finally, we will look to the future, identifying gaps in the latest Lung-RADS version, discuss upcoming updates, newer techniques like liquid biopsy, and the role and limitations of AI in lung cancer screening.

Conclusion
Several societies provide their own interpretation of lung cancer screening guidelines. The 2022 revisions to the ACR Lung-RADS guidelines have aimed to bolster the grading of imaging characteristics and clarify prior versions, enhancing the detection of potentially malignant lesions and refining follow-up recommendations. Just as this current rendition has been revised, we envision ongoing literature incorporation into future versions as we learn more each year. Knowledge of these changes is necessary for the reading radiologist to stay up to speed with the changing guidelines and to suggest appropriate follow up recommendations.