Is a repeat computed tomography (CT) scan necessary for an 86-year-old patient with a stable lung nodule?

From the Guidelines

A repeat CT scan is not recommended for an 86-year-old patient with a stable lung nodule, as the risks of radiation exposure and anxiety may outweigh the benefits, especially considering the patient's advanced age and the low likelihood of malignancy in small nodules. The decision to discontinue surveillance for a stable lung nodule should be individualized, taking into account the patient's overall health status, life expectancy, and the characteristics of the nodule, as suggested by the Fleischner Society guidelines and the American College of Radiology 1. For nodules less than 6 mm, the likelihood of malignancy is less than 1%, and routine follow-up is not recommended unless there are suspicious imaging features that increase the malignancy risk to the 1% to 5% range, as outlined in the ACR Appropriateness Criteria for incidentally detected indeterminate pulmonary nodules 1. Key factors to consider in the decision-making process include:

• The patient's age and life expectancy
• The size and characteristics of the nodule
• The presence of any suspicious imaging features
• The patient's comorbidities and functional status
• The potential risks and benefits of continued surveillance, including radiation exposure and anxiety
• The patient's personal preferences and goals of care, as discussed between the healthcare provider, patient, and family 1. Given the low likelihood of malignancy in small, stable nodules and the potential risks of continued surveillance, discontinuing repeat CT scans is a reasonable approach for an 86-year-old patient with a stable lung nodule, as supported by the most recent guidelines and evidence 1.

From the Research

Recommendation for Repeat CT Scan

The patient has a stable lung nodule with no change in the last CT scan with contrast and is now 86 years old. Considering the age and stability of the nodule, the following points are relevant:

• The Fleischner Society guidelines 2 suggest that small pulmonary nodules detected on CT scans can be managed based on their size and the patient's risk factors.
• For nodules less than 6 mm, the probability of malignancy is less than 1%, and for nodules 6 mm to 8 mm, the probability is 1% to 2% 3.
• A study on CT screening for lung cancer 4 found that short-term follow-up CT within 2 months may circumvent the need for further evaluation in some individuals, particularly on annual repeat screening.
• The management of pulmonary nodules should be guided by the probability that the nodule is malignant, safety of testing, the likelihood that additional testing will be informative, and patient preferences 3.
• For nodules between 5 and 10mm, an annual repeat scan is recommended for solid, smooth or attached indeterminate nodules, whilst for purely intra-parenchymal nodules a 3-month repeat scan should be made to assess growth 5.

Key Considerations

• The patient's age and overall health should be taken into account when deciding on the frequency of repeat CT scans.
• The stability of the nodule and the lack of change in the last CT scan suggest that a less frequent follow-up schedule may be appropriate.
• The patient's preferences and values should be considered in the decision-making process.

Possible Follow-up Schedule

• Based on the guidelines and studies, a possible follow-up schedule for the patient could be:

• Annual repeat CT scan to monitor the nodule for growth or change.
• Consideration of the patient's overall health and preferences in determining the frequency of follow-up scans.

• It is essential to weigh the benefits of repeat CT scans against the risks of radiation exposure and the potential for false positives or unnecessary interventions 3, 2, 5.