From the Guidelines
The chest X-ray finding of volume loss in the left base of an 88-year-old male with a 30-year smoking history requires follow-up imaging to ensure complete resolution, and I recommend scheduling a low-dose computed tomography (LDCT) scan instead of a repeat chest X-ray to better characterize the abnormality, as LDCT is the recommended screening method for lung cancer in high-risk patients, according to the NCCN guidelines 1. Given the patient's significant smoking history, which is a major risk factor for lung cancer, it is crucial to use the most effective screening method available. The NCCN guidelines recommend LDCT for lung cancer screening in patients at high risk, such as those with a 30-year smoking history 1. The patient should be assessed for symptoms such as cough, shortness of breath, chest pain, or fever, which might indicate an underlying condition like pneumonia, atelectasis, or potentially a malignancy. If symptoms are present, earlier follow-up with both imaging and clinical evaluation would be appropriate. The patient should be encouraged to stay well-hydrated, perform deep breathing exercises several times daily, and maintain mobility as tolerated to help expand the lungs and prevent further atelectasis. It is also essential to consider the patient's overall health status and ability to tolerate potential treatments, as well as their preferences and values, when deciding on the best course of action. As noted in the NCCN guidelines, lung cancer screening should not be considered a substitute for smoking cessation, and all individuals who currently smoke should be advised to quit smoking 1. In terms of follow-up, the NCCN guidelines recommend a systematic process for appropriate follow-up, and all screening and follow-up chest CT scans should use a CT dose index volume (CTDIvol) threshold of 3 mGy or less for a patient of average size, unless evaluating mediastinal abnormalities or lymph nodes, where standard-dose CT with IV contrast might be appropriate 1. Key points to consider in the management of this patient include:
- The use of LDCT for lung cancer screening in high-risk patients
- The importance of symptom assessment and early follow-up if symptoms are present
- The need for patient education on smoking cessation and the risks of lung cancer
- The consideration of the patient's overall health status and ability to tolerate potential treatments
- The use of a systematic process for follow-up and the optimization of CT scan parameters to minimize radiation exposure.
From the Research
Chest X-Ray Findings and Recommendations
- The patient's chest X-ray shows volume loss at the left base, which may indicate a potential issue that requires follow-up.
- Given the patient's 30-year smoking history, it is essential to consider the risk of lung cancer and chronic obstructive pulmonary disease (COPD) 2, 3, 4.
Lung Cancer Screening and COPD
- Studies have shown that annual screening using low-dose computed tomography (LDCT) of the chest can significantly reduce mortality due to lung cancer in high-risk populations, including those with COPD 2, 3, 4.
- The presence of radiographic emphysema has been associated with an increased risk of lung cancer, even in never smokers 2.
- Specific lung cancer risk scores, such as the COPD lung cancer screening score (LUCSS), have been developed to identify patients at high risk 2.
Follow-up and Treatment
- Follow-up to complete radiographic resolution is recommended for the patient's volume loss at the left base.
- Considering the patient's smoking history and potential risk of COPD, treatment with bronchodilators, such as tiotropium, may be beneficial in improving lung function and reducing symptoms 5, 6.
- Preoperative use of inhaled tiotropium in lung cancer patients with untreated COPD has been shown to improve respiratory symptoms and pulmonary function 6.