Management of Pulmonary Nodules by Community Pulmonologists

Abstract

BACKGROUND:Pulmonary nodules (PNs) are a common reason for referral to pulmonologists. The majority of data for the evaluation and management of PNs is derived from studies performed in academic medical centers. Little is known about the prevalence and diagnosis of PNs, the use of diagnostic testing, or the management of PNs by community pulmonologists.METHODS:This multicenter observational record review evaluated 377 patients aged 40 to 89 years referred to 18 geographically diverse community pulmonary practices for intermediate PNs (8-20 mm). Study measures included the prevalence of malignancy, procedure/test use, and nodule pretest probability of malignancy as calculated by two previously validated models. The relationship between calculated pretest probability and management decisions was evaluated.RESULTS:The prevalence of malignancy was 25% (n = 94). Nearly one-half of the patients (46%, n = 175) had surveillance alone. Biopsy was performed on 125 patients (33.2%). A total of 77 patients (20.4%) underwent surgery, of whom 35% (n = 27) had benign disease. PET scan was used in 141 patients (37%). The false-positive rate for PET scan was 39% (95% CI, 27.1%-52.1%). Pretest probability of malignancy calculations showed that 9.5% (n = 36) were at a low risk, 79.6% (n = 300) were at a moderate risk, and 10.8% (n = 41) were at a high risk of malignancy. The rate of surgical resection was similar among the three groups (17%, 21%, 17%, respectively; P = .69).CONCLUSIONS:A substantial fraction of intermediate-sized nodules referred to pulmonologists ultimately prove to be lung cancer. Despite advances in imaging and nonsurgical biopsy techniques, invasive sampling of low-risk nodules and surgical resection of benign nodules remain common, suggesting a lack of adherence to guidelines for the management of PNs.

AJRCCM: 100-Year Anniversary.The Shifting Landscape for Lung Cancer: Past, Present, and Future

“…Although this has improved the ability to assess the likelihood of malignancy, particularly in patients with intermediate risk of disease, PET is still hampered by a high rate of false-negative and -positive findings. This, coupled with both patient and physician anxiety, results in an excessively high rate of invasive evaluation, including surgical lung biopsy, for many patients with indeterminate lung nodules in whom the likelihood of malignancy does not support such an aggressive approach (41)(42)(43).…”

The many facets of diagnostic bronchoscopy for pulmonary ground glass nodules

“…Several investigators have demonstrated the use of three basic approaches for the diagnosis of peripheral pulmonary lesions: surgical, transbronchial, and transthoracic (2). The recent use of image guidance has particularly improved the yield of transbronchial biopsy (TBB) for pulmonary lesions, including those in the peripheral subsegments (3)(4)(5).…”

Development of Guidelines for the Management of Pulmonary Nodules Toward Better Implementation

“…2 -4 In this issue of CHEST there are three articles that further contribute to the subject of adherence to guidelines for the management of pulmonary nodules. Tanner and colleagues 5 (see page 1405 ) report a retrospective observational study of the management of pulmonary nodules by physicians at 18 geographically spread pulmonary practices. Th ey found that the surgical resection rate was similar for pulmonary nodules whether the probability of malignancy was low, intermediate, or high and that invasive sampling of low-risk nodules was undertaken in 28% of individuals.…”

“…Th is clinical-serologic presentation has been referred to as either lung-dominant CTD (LD-CTD), undiff erentiated CTD, or autoimmunefeatured interstitial lung disease. 2 -4 In the current issue of CHEST (see page 1438 ), Omote et al 5 summarized the clinical, radiographic, and histologic features in 44 subjects collected from a single center in Japan over a 4-year period. Th ese were considered to have LD-CTD if, in addition to lung disease, at least one serum autoantibody was present.…”