What is the management plan for a patient with an incidentally discovered lung nodule on chest X-ray, currently undergoing therapy and scheduled for a computed tomography (CT) scan, while also recovering from a road traffic accident (RTA) with physical therapy three times a week and orthopedic (ortho) follow-up?

From the Guidelines

The patient should continue with the established treatment plan, attending all scheduled appointments with both the pulmonologist and orthopedic specialists, and completing the recommended therapy sessions to ensure optimal recovery from the RTA while appropriately monitoring the lung nodule. The patient has an incidentally discovered lung nodule that is currently being managed by pulmonologist Dr. Ben Batson. The patient has an upcoming CT scan scheduled for the end of this month to further evaluate the nodule, which is the modality of choice to evaluate pulmonary nodules, as it is 10 to 20 times more sensitive than standard radiography and allows better nodule characterization 1. The patient is also recovering from a road traffic accident (RTA) and is attending therapy three times weekly with orthopedic follow-up. The VA has coordinated these medical services. At this time, the patient reports no additional medical needs or concerns beyond the ongoing monitoring of the lung nodule and rehabilitation from the RTA.

Key Considerations

• Incidental lung nodules often require serial imaging to monitor for any changes in size or characteristics, which explains the scheduled CT scan.
• The use of CT scans for lung nodule evaluation is supported by guidelines from the Fleischner Society and American College of Chest Physicians (ACCP) 1.
• The current plan appears appropriate, with pulmonary follow-up for the nodule and continued therapy for RTA recovery.
• It is essential to consider the patient's risk factors and preferences in management, as recommended by the updated guidelines 1.

Next Steps

• The patient should attend the scheduled CT scan to further evaluate the lung nodule.
• The patient should continue attending therapy sessions three times weekly and orthopedic follow-up to ensure optimal recovery from the RTA.
• The patient should follow up with Dr. Ben Batson for ongoing monitoring of the lung nodule and to discuss any changes in the treatment plan, as needed.

From the Research

Lung Nodule Management

The patient's lung nodule was incidentally discovered on chest X-ray during pre-operative evaluation, and Dr. Ben Batson is managing and monitoring the patient. An upcoming CT scan is scheduled for the end of the month.

• The patient is currently recovering from a road traffic accident (RTA) with therapy three times a week and orthopedic follow-up.
• The patient denies any other needs at this time.

Pulmonary Nodule Evaluation

According to 2, pulmonary nodules are identified in approximately 1.6 million patients per year in the US and are detected on approximately 30% of computed tomographic (CT) images of the chest.

• Optimal treatment of an individual with a pulmonary nodule can lead to early detection of cancer while minimizing testing for a benign nodule.
• At least 95% of all pulmonary nodules identified are benign, most often granulomas or intrapulmonary lymph nodes.
• Smaller nodules are more likely to be benign.

Nodule Categorization and Management

Pulmonary nodules are categorized as small solid (<8 mm), larger solid (≥8 mm), and subsolid 2.

• Subsolid nodules are divided into ground-glass nodules (no solid component) and part-solid (both ground-glass and solid components).
• The probability of malignancy is less than 1% for all nodules smaller than 6 mm and 1% to 2% for nodules 6 mm to 8 mm.
• Nodules that are 6 mm to 8 mm can be followed with a repeat chest CT in 6 to 12 months, depending on the presence of patient risk factors and imaging characteristics associated with lung malignancy, clinical judgment about the probability of malignancy, and patient preferences.

Diagnostic Procedures

The treatment of an individual with a solid pulmonary nodule 8 mm or larger is based on the estimated probability of malignancy; the presence of patient comorbidities, such as chronic obstructive pulmonary disease and coronary artery disease; and patient preferences 2.

• Management options include surveillance imaging, defined as monitoring for nodule growth with chest CT imaging, positron emission tomography-CT imaging, nonsurgical biopsy with bronchoscopy or transthoracic needle biopsy, and surgical resection.
• Part-solid pulmonary nodules are managed according to the size of the solid component.
• Larger solid components are associated with a higher risk of malignancy.

Biopsy Recommendations

According to 3, the recommended biopsy procedures for screen-detected suspicious pulmonary nodules resulted in a low intervention rate for benign nodules.

• This rate is minimal when following a research protocol that relies on shape and growth.
• A total of 128 diagnostic biopsies were recommended for suspicious nodules, and 127 biopsies were performed, including 110 percutaneous CT-guided fine-needle aspiration biopsies (FNABs), nine video-assisted thoracoscopic surgery (VATS) resections, seven bronchoscopies, and one ultrasound-guided biopsy of a lymph node.

Current Approach and Management

In daily clinical practice, radiologists and pulmonologists are faced with incidental radiographic findings of pulmonary nodules 4.

• Deciding how to manage these findings is very important as many of them may be benign and require no further action, but others may represent early disease and importantly early-stage lung cancer and require prompt diagnosis and definitive treatment.
• Clear algorithms for the imaging protocols and the management of positive findings should exist in lung cancer screening programs.

Low-Dose CT-Guided Biopsy

Low-dose CT-guided cutting needle biopsy (CNB) of lung nodules significantly decreased radiation dose compared with standard-dose CT 5.

• The low-dose protocol could provide similar diagnostic accuracy and safety as standard-dose CT-guided CNB for lung nodules.
• The mean dose-length product was 38.2 ± 17.2 mGy-cm and 375.3 ± 115.7 mGy-cm in the low-dose and standard-dose groups, respectively (P < .001).