From the Guidelines
For a 70-year-old man with a 2.5 cm nodule in the right lower lobe on CT chest and a 40-year smoking history, the next step should be referral to a Multidisciplinary Team that includes Pulmonologists, Radiologists, Interventional Radiologists, and Thoracic Surgeons to discuss the appropriate management strategy, as recommended by the most recent guidelines 1. This approach is most appropriate because the patient has significant risk factors for lung cancer (advanced age and extensive smoking history) and the nodule is relatively large at 2.5 cm.
- The patient's history of smoking for 40 years increases the risk of lung cancer, and the size of the nodule creates a high pre-test probability for malignancy, making immediate tissue sampling or further evaluation more appropriate than watchful waiting with repeat imaging.
- Diagnostic strategies for establishing the diagnosis of lung cancer usually include transthoracic biopsies and or bronchoscopy, with a trend towards combining lung cancer diagnosis with lymph node endosonographic guided using endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) for mediastinal staging in an all-in-one procedure 1.
- The NCCN guidelines also recommend a multidisciplinary approach for nodule management, including the specialties of thoracic radiology, pulmonary medicine, and thoracic surgery, and considering the patient's functional status and comorbidity when deciding on curative intent therapy 1.
- Given the high suspicion for malignancy, delaying diagnosis with a repeat CT in 3 months would be inappropriate and could potentially allow disease progression if cancer is present.
- The patient should also be advised to quit smoking, as smoking cessation is essential for reducing the risk of lung cancer, and lung cancer screening should not be considered a substitute for smoking cessation 1.
From the Research
Diagnostic Approach
The next step in managing a 70-year-old man with a 2.5 cm nodule in the right lower lobe on computed tomography (CT) chest, with a history of smoking for 40 years, involves a thorough diagnostic approach. The following steps can be considered:
- Bronchoscopy with direct examination of the visible airways is most often the preferred invasive diagnostic procedure 2
- For peripheral nodules that are smaller than 3 cm, the diagnostic yield of transbronchial biopsy (TBBX) and transbronchial needle aspiration (TBNA) is lower 2
- Transthoracic needle aspiration (TTNA) has a high diagnostic sensitivity, especially for larger peripheral-based lung lesions, but its sensitivity falls for smaller or more central lesions 2
Considerations for Diagnostic Procedures
When selecting a diagnostic procedure, several factors should be considered:
- The size and location of the parenchymal lesion and the presence and location of enlarged lymph nodes can be determined by CT examination 3
- Central lesions are more easily approached by the bronchoscopic route, whereas a transthoracic route is preferred for peripheral lesions 3
- The diagnostic algorithm provided by the International Early Lung Cancer Action Program can be used to determine the indication for biopsy 4
Biopsy Recommendations
Biopsy recommendations should be based on the characteristics of the disease process, institutional availability of diagnostic procedures, and patient preferences:
- A research protocol that relies on shape and growth can result in a low intervention rate for benign nodules 4
- The overall false-positive recommendation rate for biopsy procedures can be minimal when following a research protocol 4
- A rating scale based on the degree of invasiveness and diagnostic yield can be used to compare different diagnostic techniques 5
Emerging Diagnostic Techniques
Emerging diagnostic techniques, such as transesophageal endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA), can be useful in certain cases: