What is the next step in managing a 71-year-old female non-smoker with chronic cough and shortness of breath, and a computed tomography (CT) scan of the chest showing bilateral pulmonary nodules, largest 7 mm in the left upper lobe, without fever or chills?

Management of Bilateral Pulmonary Nodules in a 71-Year-Old Female with Chronic Cough

The next step in managing this 71-year-old female non-smoker with bilateral pulmonary nodules (largest 7mm) should be a follow-up CT scan in 6-12 months to assess for nodule stability.

Patient Assessment and Risk Stratification

This patient presents with several important features:

• 71-year-old female (age is a risk factor)
• Non-smoker (lower risk for malignancy)
• Chronic cough with shortness of breath
• No fever or chills (less suggestive of infection)
• History of pneumonia
• CT showing bilateral pulmonary nodules with largest being 7mm in left upper lobe

Risk Assessment for Malignancy

The risk of malignancy in this case appears low to intermediate based on:

• Nodule size (7mm) - nodules <8mm have lower malignancy risk (1-2%) 1
• Non-smoker status - significantly reduces malignancy risk
• History of pneumonia - suggests possible post-inflammatory etiology
• Multiple bilateral nodules - often suggests benign etiology

Management Approach

Recommended Next Step

Based on the Fleischner Society guidelines and American College of Radiology (ACR) Appropriateness Criteria, the appropriate next step is:

1. Follow-up CT scan in 6-12 months 1, 2
   • This timing is appropriate for nodules 6-8mm in size
   • Allows assessment of nodule stability or growth
   • No immediate invasive testing is warranted given the low-intermediate risk profile

Rationale for Recommendation

The ACR Appropriateness Criteria states that "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" 3. This patient's nodules fall within this size range.

The probability of malignancy is approximately 1-2% for nodules 6-8mm in size 3, which does not warrant immediate invasive testing in a non-smoker with possible post-inflammatory etiology.

Important Considerations

When to Consider More Aggressive Evaluation

More aggressive evaluation would be warranted if:

• Nodules show growth on follow-up imaging
• Patient develops concerning symptoms (hemoptysis, significant weight loss)
• Nodule characteristics change (development of spiculation, irregular margins)

Pitfalls to Avoid

1. Overaggressive management - Immediate biopsy or PET/CT is not indicated for nodules <8mm in a non-smoker with possible post-inflammatory etiology 1, 3

2. Underestimating risk - Despite low risk, follow-up is essential as cough is present in >65% of patients at the time lung cancer is diagnosed 1

3. Ignoring clinical context - The history of pneumonia supports a post-inflammatory etiology, but doesn't eliminate the need for follow-up

Follow-up Plan

1. CT chest in 6-12 months to assess for stability
2. If nodules remain stable, consider one additional follow-up CT in 12 months
3. If nodules grow or develop concerning features, proceed to:
   • PET/CT if nodule becomes ≥8mm 1
   • Consider non-surgical biopsy if risk factors change or nodule characteristics become concerning

Patient Education

The patient should be informed about:

• The low risk of malignancy (1-2%) for nodules of this size
• The importance of follow-up adherence
• Reporting any new symptoms (hemoptysis, weight loss, worsening cough)

This approach balances the need for appropriate surveillance while avoiding unnecessary invasive procedures in a patient with low-intermediate risk nodules that are likely post-inflammatory in nature.