The efficacy of computed tomography (CT) screening for early lung cancer detection in heavy smokers is currently being tested by a number of randomized trials. Critical issues remain the frequency of unnecessary treatments and impact on mortality, indicating the need for biomarkers of aggressive disease. We explored microRNA (miRNA) expression profiles of lung tumors, normal lung tissues and plasma samples from cases with variable prognosis identified in a completed spiral-CT screening trial with extensive follow-up. miRNA expression patterns significantly distinguished: (i) tumors from normal lung tissues, (ii) tumor histology and growth rate, (iii) clinical outcome, and (iv) year of lung cancer CT detection. Interestingly, miRNA profiles in normal lung tissues also displayed remarkable associations with clinical features, suggesting the influence of a permissive microenvironment for tumor development. miRNA expression analyses in plasma samples collected 1-2 y before the onset of disease, at the time of CT detection and in disease-free smokers enrolled in the screening trial, resulted in the generation of miRNA signatures with strong predictive, diagnostic, and prognostic potential (area under the ROC curve ≥ 0.85). These signatures were validated in an independent cohort from a second randomized spiral-CT trial. These results indicate a role for miRNAs in lung tissues and plasma as molecular predictors of lung cancer development and aggressiveness and have theoretical and clinical implication for lung cancer management.circulating biomarkers | risk prediction | miRNA ratios D espite recent advances in the management of resected lung cancer and the use of molecular targeted agents in specific clinical settings, the cure rate of non-small-cell lung cancer (NSCLC) remains low due to drug-refractory recurrent and metastatic disease.Early detection studies using chest X-rays (1) and, more recently, spiral-computed tomography (CT; refs. 2 and 3), have reported a significant increase in the number of lung cancer diagnoses, without apparent major decrease in advanced cancers or reduction of mortality in smokers (4). A recent press release (http://www.cancer.gov) reporting the findings of the largest randomized trial comparing spiral-CT to chest X-rays showed a 6.9% reduction in all-cause mortality (−20.3% lung cancer mortality), but a full report of the results of this trial is not yet available. A likely explanation of the limited impact of CT screening on mortality is that perhaps not all aggressive lung tumors arise from identifiable slow-growing precursors, suggesting a possible paradigm shift in our understanding of the natural history of lung cancer (5, 6). In this respect, the identification of biologic and molecular features of indolent and aggressive disease would be critical to define clinically useful predictors of high-risk lesions. microRNAs (miRNAs) are small RNA molecules with regulatory function and marked tissue specificity that can modulate multiple targets belonging to several pathways. They are fr...