Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?

Abstract

we suggest that no additional diagnostic evaluation need be performed (Grade 2C) .Remark : This recommendation applies only to solid nodules. For guidance about follow-up of subsolid nodules, see Recommendations 6.5.1 to 6.5.4 . 2.3.3.In the individual with an indeterminate nodule that is identifi ed by chest radiography, we recommend that CT of the chest should be performed (preferably with thin sections Objectives: The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules. Methods: We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed. Results: We formulated recommendations for evaluating solid pulmonary nodules that measure . 8 mm in diameter, solid nodules that measure Յ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefi ts and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences. Conclusions: Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management. CHEST 2013; 143(5)(Suppl):e93S-e120SAbbreviations: AAH 5 atypical adenomatous hyperplasia; ACCP 5 American College of Chest Physicians; AIS 5 adenocarcinoma in situ; EBUS 5 endobronchial ultrasound; ENB 5 electromagnetic navigation bronchoscopy; FDG 5 fl uorodeoxyglucose; HU 5 Hounsfi eld unit; LR 5 likelihood ratio; SPECT 5 single-photon emission CT; TBB 5 transbronchial biopsy; TTNB 5 transthoracic needle biopsy; VATS 5 video-assisted thoracic surgery; VBN 5 virtual bronchoscopy navigation; VDT 5 volume doubling time

A Novel Method for In Vivo Imaging of Solitary Lung Nodules Using Navigational Bronchoscopy and Confocal Laser Microendoscopy

“…3f for comparison. The diagnosis of subcentimetric nodules is challenging even with standard guidelines [3,13,14]. In the first case, we demonstrated that subcentimetric nodules could be reached with this technique.…”

Using Clinical Risk Models for Lung Nodule Classification

“…The Mayo Clinic model is an older model that does not incorporate FDG-PET scan results or patient symptoms, but it is the only validated model to receive recommendation by the American College of Chest Physicians (ACCP). 4,12 The VA model has limited input for radiographic characteristics of the lesion but was specifically developed in a VA population.…”

“…The ACCP and the National Cancer Comprehensive Network practice guidelines detail an evidence-based algorithm for the diagnosis of lung cancer 4,23 Upon discovery of a nodule, lesion or lung mass, non-invasive diagnosis and staging of the patient is conducted using chest CT. The guidelines recommend that in patients who are operative candidates, clinicians estimate the probability of lung cancer using their clinical expertise or by use of a validated diagnostic prediction model.…”

“…Previously, most lung cancer was diagnosed symptomatically (estimated 75%), but incidental discovery has increased recently with the proliferation of imaging modalities like Computed Tomographic (CT) scans. 4 Once a national screening program is fully initiated in the US, a dramatic increase in asymptomatic lung nodules requiring diagnosis will occur. Irrespective of the source of a lung nodule, clinical risk models have been developed and employed to determine who should be screened, who should receive continued radiographic surveillance and who should be referred to a surgeon.…”

The impact of radiologists’ expertise on screen results decisions in a CT lung cancer screening trial

“…Nodules were classified as benign or malignant on the basis of histology, or benign on the basis of stable volume for at least 2 years after the baseline CT [17,18]. In addition, nodules were classified on the basis of distance to costal pleura (peripheral or non-peripheral), shape (spherical or non-spherical) and margin (smooth, lobulated, spiculated or irregular) [8,16,19].…”