An Official American Thoracic Society Research Statement: A Research Framework for Pulmonary Nodule Evaluation and Management

Development of a Pulmonary Nodule Service and Clinical Pathway: A Pragmatic Approach Addressing an Unmet Need

Background/Objectives: The surveillance of patients with incidental pulmonary nodules overloads existing respiratory and lung cancer clinics, as well as multidisciplinary team meetings. In our clinical setting, until 2018, we had numerous patients with incidental pulmonary nodules inundating our outpatient clinics; therefore, the need to develop a novel service and dedicated clinical pathway arose. The aims of this study are to 1. provide (a) a model of setting up a novel pulmonary nodule service, and (b) a pragmatic clinical pathway to address the increasing need for surveillance of patients with incidental pulmonary nodules. 2. share real-world data from a dedicated pulmonary nodule service running in a tertiary setting with existing resources. Methods: A retrospective review of established processes and referral mechanisms to our tertiary pulmonary nodule service was conducted. We have also performed a retrospective collection and review of data for patients reviewed and discussed in our tertiary pulmonary nodule service between April 2018 and April 2024. Results: Our tertiary pulmonary nodule service (PNS) comprises a dedicated pulmonary nodule clinic, a nodule multidisciplinary team (MDT) meeting and a dedicated proforma referral system. Due to the current national health system legislation and relevant processes, patients are required to physically attend clinic appointments. There are various sources of referral, including other departments within the hospital, other hospitals, various specialties in primary care and self-referrals. Between 15 April 2018 and 15 April 2024, 2203 patients were reviewed in the pulmonary nodule clinic (903 females, 1300 males, mean age 64 ± 19 years). Of those patients, 65% (1432/2203) were current smokers. A total of 1365 new patients and 838 follow-up patients were reviewed in total. Emphysema was radiologically present in 72% of patients, and 75% of those (1189/1586) already had a confirmed diagnosis of chronic obstructive pulmonary disease (COPD). Coronary calcification was identified in 32% (705/2203), and 78% of those (550/705) were already known to cardiology services. Interestingly, 27% (368/1365) of the new patients were discharged following their first MDT meeting discussion, and 67% of these were discharged as the reason for their referral was an intrapulmonary lymph node which did not warrant any further action. Among all patients, 11% (246/2203) were referred to the multidisciplinary thoracic oncology service (MTOS) due to suspicious appearances/changes in their nodules that warranted further investigation, and from those, 37% were discharged (92/246) from the MTOS. The lung cancer diagnosis rate was 7% (154/2203). Conclusions: The applied pathway offers a pragmatic approach in setting up a service that addresses an increasing patient need. Its application is feasible in a tertiary care setting, and admin support is of vital importance to ensure patients are appropriately tracked and not lost to follow-up. Real-world data from pulmonary nodules services provide a clear overview and contribute to understanding patients' characteristics and improving service provision.

Indeterminate pulmonary nodules and prior malignancy: survival and recurrence after surgery in newly diagnosed stage I non-small cell lung cancer

Background

Surgical excision biopsy remains the only reliable option in most cases of indeterminate pulmonary nodules, particularly in cancer survivors for whom surgery provides local control of pulmonary metastasis and the best chance of cure for early-stage lung cancer. Nevertheless, unnecessary surgeries remain a concern and the prognosis of newly diagnosed lung cancer might be influenced by the history of previous malignancy. We aimed to analyze the outcomes of resected indeterminate pulmonary nodules in patients with and without previous malignancy, and the impact of prior cancer history on survival and recurrence in stage I non-small cell lung cancer (NSCLC) patients.

Methods

We retrospectively studied 176 resected indeterminate pulmonary nodules from 169 patients (58% with and 42% without previous cancer). Recurrence and overall survival (OS) were analyzed in newly diagnosed stage I NSCLC using the Kaplan-Meier method and Cox proportional hazard models.

Results

The rate of benign lesions was 15.3% (9.6% in the previous cancer group and 23.6% in the no previous cancer group). In stage I NSCLC patients (n=86), previous malignancy was associated with recurrence (P<0.001) but not OS (P=0.23). Chronic obstructive pulmonary disease and visceral pleural invasion were associated with impaired OS and recurrence. Mediastinal lymph node removal was associated with better OS.

Conclusions

The rate of benign resections among indeterminate pulmonary nodules in the no-previous cancer group more than doubled that of the previous cancer group and, in newly diagnosed stage I NSCLC patients, recurrence was independently associated with prior cancer. Therefore, in this setting, a history of previous malignancy should be taken into consideration when identifying patients at risk of tumor recurrence.

Radiomics and artificial intelligence for risk stratification of pulmonary nodules: Ready for primetime?

Pulmonary nodules are ubiquitously found on computed tomography (CT) imaging either incidentally or via lung cancer screening and require careful diagnostic evaluation and management to both diagnose malignancy when present and avoid unnecessary biopsy of benign lesions. To engage in this complex decision-making, clinicians must first risk stratify pulmonary nodules to determine what the best course of action should be. Recent developments in imaging technology, computer processing power, and artificial intelligence algorithms have yielded radiomics-based computer-aided diagnosis tools that use CT imaging data including features invisible to the naked human eye to predict pulmonary nodule malignancy risk and are designed to be used as a supplement to routine clinical risk assessment. These tools vary widely in their algorithm construction, internal and external validation populations, intended-use populations, and commercial availability. While several clinical validation studies have been published, robust clinical utility and clinical effectiveness data are not yet currently available. However, there is reason for optimism as ongoing and future studies aim to target this knowledge gap, in the hopes of improving the diagnostic process for patients with pulmonary nodules.

Factors influencing surgical choice and anxiety in patients with pulmonary nodules smaller than 8 mm

Background

The detection of pulmonary nodules significantly impacts the lives and mental health of patients. Although the 2020 National Comprehensive Cancer Network (NCCN) guidelines recommend scheduled surveillance for nodules ≤8 mm, patients often opt to have their nodules surgically removed.

Methods

A cross-sectional questionnaire was administered to patients with small pulmonary nodules who presented to a local grade 3 hospital with small pulmonary nodules and decided to receive surgery versus prescribed monitoring. The questionnaire included four aspects: (I) patient characteristics; (II) nodule-specific knowledge; (III) doctor-patient communication; and (IV) nodular-specific distress. Nodular-specific distress was measured by the Impact of Event Scale-Revised (IES-R).

Results

A total of 234 (69%) patients responded to the survey and were included in the final analysis. Poor performance in activities of daily living (ADLs), the presence of solid nodules, multifocal disease, and a family history of lung cancer were significantly associated with reported anxiety. Most notably, facilitating patient choice for surgery was the computed tomography (CT) scan results, with reference to lung nodule size and number of nodules, where concerns related to lung nodule, cancer risk, and fear of surgery or death had a significant psychological impact on patients.

Conclusions

In this cohort of patients who elected to have their small pulmonary nodules surgically removed, we identified key factors underlying their anxiety toward guideline recommended surveillance. Our findings will be useful for clinicians when discussing treatment options with their patients.

Systemic Profiles of microRNAs, Redox Balance, and Inflammation in Lung Cancer Patients: Influence of COPD

Lung cancer (LC) risk increases in patients with chronic respiratory diseases (COPD). MicroRNAs and redox imbalance are involved in lung tumorigenesis in COPD patients. Whether systemic alterations of those events may also take place in LC patients remains unknown. Our objectives were to assess the plasma levels of microRNAs, redox balance, and cytokines in LC patients with/without COPD. MicroRNAs (RT-PCR) involved in LC, oxidized DNA, MDA-protein adducts, GSH, TEAC, VEGF, and TGF-beta (ELISA) were quantified in plasma samples from non-LC controls (n = 45), LC-only patients (n = 32), and LC-COPD patients (n = 91). In LC-COPD patients compared to controls and LC-only, MDA-protein adduct levels increased, while those of GSH decreased, and two patterns of plasma microRNA were detected. In both LC patient groups, miR-451 expression was downregulated, while those of microRNA-let7c were upregulated, and levels of TEAC and TGF-beta increased compared to the controls. Correlations were found between clinical and biological variables. A differential expression profile of microRNAs was detected in patients with LC. Moreover, in LC patients with COPD, plasma oxidative stress levels increased, whereas those of GSH declined. Systemic oxidative and antioxidant markers are differentially expressed in LC patients with respiratory diseases, thus implying its contribution to the pathogenesis of tumorigenesis in these patients.

The LungVision navigational platform for peripheral lung nodule biopsy and the added value of cryobiopsy

BACKGROUND

The LungVision system is a novel augmented-fluoroscopy-based real-time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real-time visualization and localization of pulmonary nodules.

OBJECTIVES

To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system.

METHODS

This prospective, single-center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy.

RESULTS

Sixty-three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18-28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported.

CONCLUSIONS

The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield.

Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules

IMPORTANCE

Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown.

OBJECTIVE

To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020.

EXPOSURES

With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended.

MAIN OUTCOMES AND MEASURES

The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection.

RESULTS

Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], -5.9%; 95% CI, -7.2% to -4.6%), lower mean radiation exposure (-9.5 milliSieverts [mSv]; 95% CI, -10.3 mSv to -8.7 mSv), and lower mean health expenditures (-$10 916; 95% CI, -$16 112 to -$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, -22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, -0.5%; 95% CI, -28% to +27%).

CONCLUSIONS AND RELEVANCE

This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.

Improvement in Follow-up Imaging With a Patient Tracking System and Computerized Registry for Lung Nodule Management

PURPOSE

Despite established guidelines, radiologists' recommendations and timely follow-up of incidental lung nodules remain variable. To improve follow-up of nodules, a system using standardized language (tracker phrases) recommending time-based follow-up in chest CT reports, coupled with a computerized registry, was created.

MATERIALS AND METHODS

Data were obtained from the electronic health record and a facility-built electronic lung nodule registry. We evaluated two randomly selected patient cohorts with incidental nodules on chest CT reports: before intervention (September 2008 to March 2011) and after intervention (August 2011 to December 2016). Multivariable logistic regression was used to compare the cohorts for the main outcome of timely follow-up, defined as a subsequent report within 13 months of the initial report.

RESULTS

In all, 410 patients were included in the pretracker cohort versus 626 in the tracker cohort. Before system inception, 30% of CT reports lacked an explicit time-based recommendation for nodule follow-up. The proportion of patients with timely follow-up increased from 46% to 55%, and the proportion of those with no documented follow-up or follow-up beyond 24 months decreased from 48% to 31%. The likelihood of timely follow-up increased 41%, adjusted for high risk for lung cancer and age 65 years or older. After system inception, reports missing a tracker phrase for nodule recommendation averaged 6%, without significant interyear variation.

CONCLUSIONS

Standardized language added to CT reports combined with a computerized registry designed to identify and track patients with incidental lung nodules was associated with improved likelihood of follow-up imaging.

Increased PARP Activity and DNA Damage in NSCLC Patients: The Influence of COPD

(1) Background: Lung cancer (LC) is a major leading cause of death worldwide. Poly (ADP-ribose) polymerase (PARP)-1 and PARP-2 are key players in cancer. We aimed to assess PARP-1 and PARP-2 expression and activity and DNA damage in tumors and non-tumor lungs from patients with/without chronic obstructive pulmonary disease (COPD). (2) Methods: Lung tumor and non-tumor specimens were obtained through video-assisted thoracoscopic surgery (VATS) in LC patients with/without underlying COPD (two groups of patients, n = 15/group). PARP-1 and PARP-2 expression (ELISA), PARP activity (PARP colorimetric assay kit) and DNA damage (immunohistochemistry) levels were identified in all samples. (3) Results: Both PARP-1 and PARP-2 expression levels were significantly lower in lung tumors (irrespective of COPD)compared to non-tumor specimens, while DNA damage and PARP activity levels significantly increased in lung tumors compared to non-tumor specimens only in LC-COPD patients. PARP-2 expression was positively correlated with smoking burden in LC-COPD patients. (4) Conclusions: In lung tumors of COPD patients, an overactivation of PARP enzyme was observed. A decline in PARP-1 and PARP-2 protein expression was seen in lung tumors irrespective of COPD. Other phenotypic features (airway obstruction) beyond cancer may account for the increase in PARP activity seen in the tumors of patients with underlying COPD.

Markers of Stroma in Lung Cancer: Influence of COPD

BACKGROUND

Stroma, mainly composed by fibroblasts, extracellular matrix (ECM) and vessels, may play a role in tumorigenesis and cancer progression. Chronic Obstructive Pulmonary Disease (COPD) is an independent risk factor for LC. We hypothesized that markers of fibroblasts, ECM and endothelial cells may differ in tumors of LC patients with/without COPD.

METHODS

Markers of cultured cancer-associated fibroblasts and normal fibroblasts [CAFs and NFs, respectively, vimentin and alpha-smooth muscle actin (SMA) markers, immunofluorescence in cultured lung fibroblasts], ECM, and endothelial cells (type I collagen and CD31 markers, respectively, immunohistochemistry) were identified in lung tumor and non-tumor specimens (thoracotomy for lung tumor resection) from 15 LC-COPD patients and 15 LC-only patients.

RESULTS

Numbers of CAFs significantly increased, while those of NFs significantly decreased in tumor samples compared to non-tumor specimens of both LC and LC-COPD patients. Endothelial cells (CD31) significantly decreased in tumor samples compared to non-tumor specimens only in LC patients. No significant differences were seen in levels of type I collagen in any samples or study groups.

CONCLUSIONS

Vascular endothelial marker CD31 expression was reduced in tumors of non-COPD patients, while type I collagen levels did not differ between groups. A rise in CAFs levels was detected in lung tumors of patients irrespective of airway obstruction. Low levels of CD31 may have implications in the overall survival of LC patients, especially in those without underlying airway obstruction. Identification of CD31 role as a prognostic and therapeutic biomarker in lung tumors of patients with underlying respiratory diseases warrants attention.

B Cells and Tertiary Lymphoid Structures Influence Survival in Lung Cancer Patients with Resectable Tumors

Simple Summary

Nowadays, humans still die of lung cancer (LC), a disease mainly related to cigarette smoking (CS). Smokers also develop chronic bronchitis, namely chronic obstructive pulmonary disease (COPD). Environmental factors and a natural predisposition from the patients’ sides may render them more prone to develop tumors derived from CS. Thus, a great number of patients may suffer from chronic bronchitis and LC simultaneously. Chronic respiratory diseases are also important risks factors for LC. The immune system, among other biological mechanisms, protect our cells from infections and cancer development. Several immune structures and cells may be altered in the tumors of patients with COPD as opposed to lung tumors of patients with no underlying respiratory disease. A total of 133 patients with LC participated in the study: 93 with underlying COPD. Several structures (tertiary lymphoid structures, TLS) and T and B lymphocytes were analyzed in the lung tumor and non-tumor areas (specimens obtained during surgical extirpation of the tumors). We found that in LC patients with COPD, compared to those without it, fewer numbers of TLSs and B cells were detected, and those patients died significantly earlier. These results have implications in the diagnosis and treatment options of lung tumors in patients with underlying respiratory diseases.

Abstract

Immune profile of B and T cells and tertiary lymphoid structures (TLSs) may differ in tumors of lung cancer (LC) patients with/without chronic obstructive pulmonary disease (COPD), and may also influence patient survival. We sought to analyze: (1) TLSs, germinal centers (GCs), B and T cells, and (2) associations of the immune biomarkers with the patients’ 10-year overall survival (OS). TLSs (numbers and area), B [cluster of differentiation (CD) 20], and T (CD3), and GCs cells were identified in both tumor and non-tumor specimens (thoracotomy) from 90 LC-COPD patients and 43 LC-only patients. Ten-year OS was analyzed in the patients. Immune profile in tumors of LC-COPD versus LC: TLS numbers and areas significantly decreased in tumors of LC-COPD compared to LC patients. No significant differences were observed in tumors between LC-COPD and LC patients for B or T cells. Immune profile in tumors versus non-tumor specimens: TLS areas and B cells significantly increased, T cells significantly decreased in tumors of both LC and LC-COPD patients. Survival: in LC-COPD patients: greater area of TLSs and proportion of B cells were associated with longer survival rates. The immune tumor microenvironment differs in patients with underlying COPD and these different phenotypes may eventually impact the response to immunotherapy in patients with LC.

Preoperative Body Weight and Albumin Predict Survival in Patients With Resectable Lung Neoplasms: Role of COPD

INTRODUCTION

The impact of preoperative nutritional status on survival in lung cancer (LC) patients with underlying chronic obstructive pulmonary disease (COPD) is still unclear. We hypothesized that presurgical nutritional assessment may differentially predict mortality in patients with resectable LC with moderate COPD and relatively well-preserved nutritional status.

METHODS

Nutritional assessment [body mass index (BMI), blood parameters including albumin and protein levels, and body weight loss], and other clinical parameters [cigarette smoking (CS) history, LC staging and histological subtypes, COPD severity, lung function, and adjuvant therapy] were evaluated in 125 patients from the LC Mar Prospective Cohort: 87 LC-COPD patients and 38 LC patients without COPD before thoracotomy. Ten-year overall survival (OS) was analyzed in all patients.

RESULTS

Prior to thoracotomy, in LC-COPD patients compared to LC, BMI and albumin declined relatively, low levels of the parameters BMI, albumin, and total proteins were associated with poorer 10-year survival, especially in the LC-COPD. CS burden also correlated with impaired survival. COPD per se worsened the prognosis in LC patients.

CONCLUSIONS

In the present cohort of LC patients with resectable tumors and relatively well-preserved nutritional status, the parameters BMI and blood albumin and protein levels measured prior to thoracotomy predicted OS, especially in those with COPD. These are clinically relevant findings, since values of those nutritional parameters were within the normal ranges in the majority of the analyzed patients. A thorough nutritional preoperative assessment should be included in the study of patients with resectable LC, particularly in those with chronic airway obstruction.

Standardized Reporting and Management of Suspicious Findings on Chest CT Imaging Is Associated With Improved Lung Cancer Diagnosis in an Observational Study

BACKGROUND

Follow-up of chest CT scan findings suspicious for lung cancer may be delayed because of inadequate documentation. Standardized reporting and follow-up may reduce time to diagnosis and care for lung cancer.

STUDY DESIGN AND METHODS

We implemented a reporting system that standardizes tagging of chest CT scan reports by classifying pulmonary findings. The system also automates referral of patients with findings suspicious for lung cancer to a multidisciplinary care team for rapid review and follow-up. The system was designed to reduce the time to diagnosis, particularly for early-stage lung cancer. We evaluated the effectiveness of this system, using a quasi-experimental stepped wedge cluster design, examining 99,148 patients who underwent diagnostic (nonscreening) chest CT imaging from 2015 to 2017 and who had not received a chest CT scan in the preceding 24 months. We evaluated the association of the intervention with the incidence of diagnosis and surgical treatment of early-stage (I, II) and late-stage (III, IV) lung cancer within 120 days of chest CT imaging.

RESULTS

Forty percent of patients received the intervention. Among 2,856 patients (2.9%) who received diagnoses of lung cancer, 28% had early-stage disease. In multivariable analyses, the intervention was associated with 24% greater odds of early-stage diagnosis (OR, 1.24; 95% CI, 1.09-1.41) and no change in the odds of late-stage diagnosis (OR, 1.04; 95% CI, 0.95-1.14). The intervention was not associated with the rate of surgical treatment within 120 days.

INTERPRETATION

In this large quasi-experimental community-based observational study, implementation of a system that combines standardized tagging of chest CT scan reports with clinical navigation was effective for increasing the diagnosis of early-stage lung cancer.

Immune Cell Subtypes and Cytokines in Lung Tumor Microenvironment: Influence of COPD

Background: The immune microenvironment plays a role in tumorigenesis. Chronic Obstructive Pulmonary Disease (COPD) is an independent risk factor for lung cancer (LC). We hypothesized that immune profile characterized by T regulatory (Treg), natural killer (NK), and plasma cells, as well as interleukin (IL)-10 and interferon-gamma, may differ within tumors of LC patients with/without COPD. Methods: Treg (anti-CD3 and anti-forkhead boxP3 antibodies), NK (anti-NCR1 antibody), IgG (anti-CD138-IgG antibody), IgA (anti-CD138-IgA antibody) using immunohistochemistry, and both IL-10 and interferon-gamma (ELISA) were quantified in tumor and non-tumor specimens (thoracotomy for lung tumor resection) from 33 LC–COPD patients and 20 LC-only patients. Results: Immune profile in tumor versus non-tumor specimens: Treg cell counts significantly increased in tumors of both LC and LC–COPD patients, while in tumors of the latter group, IgG-secreting plasma cells significantly decreased and IL-10 increased. No significant differences were seen in levels of NK cells, IgA-secreting cells, IgA/IgG, or interferon-gamma. Immune profile in tumors of LC–COPD versus LC: No significant differences were observed in tumors between LC–COPD and LC patients for any study marker. Conclusions: Immune cell subtypes and cytokines are differentially expressed in lung tumors, and the presence of COPD elicited a decline in IgG-secreting plasma cell levels but not in other cell types.

Follow-up of incidental pulmonary nodules and association with mortality in a safety-net cohort

Background Though incidental pulmonary nodules are common, rates of guideline-recommended surveillance and associations between surveillance and mortality are unclear. In this study, we describe adherence (categorized as complete, partial, late and none) to guideline-recommended surveillance among patients with incidental 5-8 mm pulmonary nodules and assess associations between adherence and mortality. Methods This was a retrospective cohort study of 551 patients (≥35 years) with incidental pulmonary nodules conducted from September 1, 2008 to December 31, 2016, in an integrated safety-net health network. Results Of the 551 patients, 156 (28%) had complete, 87 (16%) had partial, 93 (17%) had late and 215 (39%) had no documented surveillance. Patients were followed for a median of 5.2 years [interquartile range (IQR), 3.6-6.7 years] and 82 (15%) died during follow-up. Adjusted all-cause mortality rates ranged from 2.24 [95% confidence interval (CI), 1.24-3.25] deaths per 100 person-years for complete follow-up to 3.30 (95% CI, 2.36-4.23) for no follow-up. In multivariable models, there were no statistically significant associations between the levels of surveillance and mortality (p > 0.16 for each comparison with complete surveillance). Compared with complete surveillance, adjusted mortality rates were non-significantly increased by 0.45 deaths per 100 person-years (95% CI, -1.10 to 2.01) for partial, 0.55 (95% CI, -1.08 to 2.17) for late and 1.05 (95% CI, -0.35 to 2.45) for no surveillance. Conclusions Although guideline-recommended surveillance of small incidental pulmonary nodules was incomplete or absent in most patients, gaps in surveillance were not associated with statistically significant increases in mortality in a safety-net population.

Implementation of a Standardized Template for Reporting of Incidental Pulmonary Nodules: Feasibility, Acceptability, and Outcomes

OBJECTIVE

Incidental pulmonary nodules (IPNs) are common. Up to 70% are not followed up according to current guidelines. Follow-up recommendations are based on the characteristics of the patient and the IPN. However, many IPNs are incompletely characterized in CT reports. Structured radiology reports have been shown to reduce missing information. We sought to improve IPN reporting by assessing the feasibility, acceptability, and effectiveness of a structured dictation template to increase the presence of six key nodule descriptors.

METHODS

We performed a mixed methods, pre- and postimplementation assessment. A template was developed with a multidisciplinary group based on Fleischner Society guidelines. A standardized checklist was used to determine the presence of documented descriptors pre- and postimplementation for sequential radiology reports of patients with an IPN present (n = 400 pre-implementation and n = 400 postimplementation) on a CT performed at the Minneapolis Veterans Affairs Health Care System. We conducted qualitative interviews with radiologists (n = 4) and members of the lung nodule tracking team (n = 2) to elicit their experiences of the template implementation process.

RESULTS

The proportion of radiology reports including all six elements increased from 12% to 47% (P < .001). Postimplementation, the template was used in 40% of interpretations involving lung nodules, 67% of follow-up scans, and 8% of initial identifications. Response to the template was overall positive.

DISCUSSION

Use of a dictation template seems to be effective in increasing compliance with full IPN documentation, streamlining the follow-up process. Low utilization rates of the template for initial nodule identification is a limitation, which may be combated through clearer communication and advances in technology.

Pulmonary Nodules: A Small Problem for Many, Severe Distress for Some, and How to Communicate About It

Every year, millions of patients are diagnosed with pulmonary nodules, and as increasing numbers of people undergo lung cancer screening, even more patients will be found to have a nodule. The vast majority of patients cannot benefit from the detection of a pulmonary nodule because most are benign. Accordingly, it is important to develop strategies to minimize harm, in particular the distress of a "near-cancer" diagnosis. In other settings, communication strategies are critical mediators of patient-centered outcomes for those with cancer and those at-risk of cancer. We conducted multiple studies to characterize the experience of patients with the diagnosis and evaluation of incidental pulmonary nodules, measure patient-centered outcomes for patients with pulmonary nodules, and determine the association of patient-clinician communication practices with those outcomes. We learned that a substantial proportion of patients experience distress and inadequate communication about pulmonary nodules and their evaluation, and yet many clinicians are unaware of the degree to which some patients are affected by the finding of a pulmonary nodule. The present review provides a comprehensive summary of our results and offers suggestions for how clinicians can best provide high-quality communication for their patients.

Longitudinal Assessment of Distress among Veterans with Incidental Pulmonary Nodules

RATIONALE

Millions of patients are diagnosed with pulmonary nodules every year. Increased distress may be a common harm, but methods of mitigating this distress are unclear.

OBJECTIVES

We aimed to determine whether high-quality communication regarding the discovery of a pulmonary nodule is associated with a lower level of patient distress.

METHODS

We conducted a prospective, repeated-measures cohort study of 121 patients with newly reported, incidentally detected pulmonary nodules. The primary exposure was participant-reported quality of communication regarding the nodule. Secondary exposures included communication measures regarding participants' values, preferences, and decision making. The main outcome was nodule-related distress measured using the Impact of Event Scale. We used adjusted generalized estimating equations to measure the association between nodule communication quality and at least mild distress.

MEASUREMENTS AND MAIN RESULTS

Most participants (57%) reported at least mild distress at least once. While average distress scores decreased over time, one-fourth still had elevated distress after 2 years of surveillance for a nodule. The average calculated risk of cancer at baseline was 10% (SD, 13%), but 52.4% believed they had a greater than 30% risk of lung cancer at baseline, and this percentage remained fairly constant at all visits. High-quality nodule communication was associated with decreased odds of distress (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.73). Lower-quality communication processes regarding participants' values and preferences were also associated with increased odds of distress, but concordance between the actual and preferred decision-making roles was not.

CONCLUSIONS

Among patients with incidentally discovered pulmonary nodules, distress is common and persistent for about 25%. Many participants substantially overestimate their risk of lung cancer. Incorporating patients' values and preferences into communication about a pulmonary nodule and its evaluation may mitigate distress.

Patient and Clinician Characteristics Associated with Adherence. A Cohort Study of Veterans with Incidental Pulmonary Nodules

RATIONALE

Many patients are diagnosed with small pulmonary nodules for which professional societies recommend subsequent imaging surveillance. Adherence to these guidelines involves many steps from both clinicians and patients but has not been well studied.

OBJECTIVES

In a health care setting with a nodule tracking system, we evaluated the association of communication processes and distress with patient and clinician adherence to recommended follow up and Fleischner Society guidelines, respectively.

METHODS

We conducted a prospective, longitudinally assessed, cohort study of patients with incidentally detected nodules who received care at one Veterans Affairs Medical Center. We measured patient-centered communication with the Consultation Care Measure and distress with the Impact of Event Scale. We abstracted data regarding participant adherence to clinician recommendations (defined as receiving the follow-up scan within 30 d of the recommended date) and clinician adherence to Fleischner guidelines (defined as planning the follow-up scan within 30 d of the recommended interval) from the electronic medical record. We measured associations of communication and distress with adherence using multivariable-adjusted generalized estimating equations.

MEASUREMENTS AND MAIN RESULTS

Among 138 veterans, 39% were nonadherent at least once during follow up. Clinicians were nonadherent to Fleischner guidelines for 27% of follow-up scans. High-quality communication (adjusted odds ratio, 3.65; P = 0.02) and distress (adjusted odds ratio, 0.38; P = 0.02) were associated with increased and decreased participant adherence, respectively. Neither was associated with clinician adherence.

CONCLUSIONS

Patients and clinicians often do not adhere to nodule follow-up recommendations. Interventions designed to improve communication quality and decrease distress may also improve patient adherence to nodule follow-up recommendations.

State-of-the-Art Modalities for Peripheral Lung Nodule Biopsy

Lung nodules are being increasingly detected, particularly with lung cancer screening with low-dose computed tomography. Although the vast majority of lung nodules are benign, many often require tissue diagnosis. Several modalities to obtain diagnostic tissue from peripheral lung nodules are available. Bronchoscopic modalities such as radial ultrasound and electromagnetic navigational bronchoscopy are becoming increasingly used because of their superior safety profile and improving diagnostic yield. Although these modalities continue to become more advanced, newer and complementary technologies appear promising.

Napsin A levels in epithelial lining fluid as a diagnostic biomarker of primary lung adenocarcinoma

BACKGROUND

It is crucial to develop novel diagnostic approaches for determining if peripheral lung nodules are malignant, as such nodules are frequently detected due to the increased use of chest computed tomography scans. To this end, we evaluated levels of napsin A in epithelial lining fluid (ELF), since napsin A has been reported to be an immunohistochemical biomarker for histological diagnosis of primary lung adenocarcinoma.

METHODS

In consecutive patients with indeterminate peripheral lung nodules, ELF samples were obtained using a bronchoscopic microsampling (BMS) technique. The levels of napsin A and carcinoembryonic antigen (CEA) in ELF at the nodule site were compared with those at the contralateral site. A final diagnosis of primary lung adenocarcinoma was established by surgical resection.

RESULTS

We performed BMS in 43 consecutive patients. Among patients with primary lung adenocarcinoma, the napsin A levels in ELF at the nodule site were markedly higher than those at the contralateral site, while there were no significant differences in CEA levels. Furthermore, in 18 patients who were undiagnosed by bronchoscopy and finally diagnosed by surgery, the napsin A levels in ELF at the nodule site were identically significantly higher than those at the contralateral site. In patients with non-adenocarcinoma, there were no differences in napsin A levels in ELF. The area under the receiver operator characteristic curve for identifying primary lung adenocarcinoma was 0.840 for napsin A and 0.542 for CEA.

CONCLUSION

Evaluation of napsin A levels in ELF may be useful for distinguishing primary lung adenocarcinoma.

Lung Cancer Screening Update

Since the release of the US Preventive Services Task Force and Centers for Medicare and Medicaid Services recommendations for lung cancer screening, low-dose chest computed tomography screening has moved from the research arena to clinical practice. Lung cancer screening programs must reach beyond image acquisition and interpretation and engage in a multidisciplinary effort of clinical shared decision-making, standardization of imaging and nodule management, smoking cessation, and patient follow-up. Standardization of radiologic reports and nodule management will systematize patient care, provide quality assurance, further reduce harm, and contain health care costs. Although the National Lung Screening Trial results and eligibility criteria of a heavy smoking history are the foundation for the standard guidelines for low-dose chest computed tomography screening in the United States, currently only 27% of patients diagnosed with lung cancer would meet US lung cancer screening recommendations. Current and future efforts must be directed to better delineate those patients who would most benefit from screening and to ensure that the benefits of screening reach all socioeconomic strata and racial and ethnic minorities. Further optimization of lung cancer screening program design and patient eligibility will assure that lung cancer screening benefits will outweigh the potential risks to our patients.

The pulmonary nodule "discovered" by pneumonia: a case report

The number of patients diagnosed with pulmonary nodules increased as more patients with high risk of lung cancer choose low-dose computed tomography (CT) scans for the screening of cancer. Clinicians might get two questions from the patients: what is the definite diagnosis of the nodule? What should we do? We have already got many guidelines trying to solve these problems. There are also several prediction models for pulmonary nodules. However, guidelines are not suitable for all types of patients, and the reality of patients is more complicated. Here we reported a 58-year-old man with a lung nodule in the right upper lobe, which was occasionally found during a period of pneumonia. We suggested two periods of follow-up, and the patient was also admitted to a clinical trial about circulating tumor cells (CTCs). He finally accepted surgical excision with a pathologic diagnosis of adenocarcinoma. This case suggests that: we might suggest CT surveillance for patients with solid nodules about 8 mm maximum diameter; three-dimensional reconstruction of CT scans could provide more information about the details of nodules; CTCs counts of peripheral blood could be considered as a potential clue for malignancy.

Evaluations of Implementation at Early-Adopting Lung Cancer Screening Programs: Lessons Learned

BACKGROUND

Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation.

METHODS

We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory.

RESULTS

Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication.

CONCLUSIONS

Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.

An Automated Method for Identifying Individuals with a Lung Nodule Can Be Feasibly Implemented Across Health Systems

INTRODUCTION

The incidence of incidentally detected lung nodules is rapidly rising, but little is known about their management or associated patient outcomes. One barrier to studying lung nodule care is the inability to efficiently and reliably identify the cohort of interest (i.e. cases). Investigators at Kaiser Permanente Southern California (KPSC) recently developed an automated method to identify individuals with an incidentally discovered lung nodule, but the feasibility of implementing this method across other health systems is unknown.

METHODS

A random sample of Group Health (GH) members who had a computed tomography in 2012 underwent chart review to determine if a lung nodule was documented in the radiology report. A previously developed natural language processing (NLP) algorithm was implemented at our site using only knowledge of the key words, qualifiers, excluding terms, and the logic linking these parameters.

RESULTS

Among 499 subjects, 156 (31%, 95% confidence interval [CI] 27-36%) had an incidentally detected lung nodule. NLP identified 189 (38%, 95% CI 33-42%) individuals with a nodule. The accuracy of NLP at GH was similar to its accuracy at KPSC: sensitivity 90% (95% CI 85-95%) and specificity 86% (95% CI 82-89%) versus sensitivity 96% (95% CI 88-100%) and specificity 86% (95% CI 75-94%).

CONCLUSION

Automated methods designed to identify individuals with an incidentally detected lung nodule can feasibly and independently be implemented across health systems. Use of these methods will likely facilitate the efficient conduct of multi-site studies evaluating practice patterns and associated outcomes.

The neutrophil to lymphocyte and platelet to lymphocyte ratios as biomarkers for lung cancer development

OBJECTIVES

Elevated neutrophil-to-lymphocyte ratios (NLR) and platelet-to-lymphocyte ratios (PLR) at time of cancer diagnosis have been associated to poor prognosis in various cancers. There is no data on their natural progression before the cancer diagnosis has been established. We aim to evaluate whether or not the annual changes in these ratios could be early indicators of lung cancer development.

MATERIALS AND METHODS

Participants recruited into the Pamplona International Early Lung Cancer Action Program (P-IELCAP, n=3061) between 2001 and 2015 were considered. Complete blood counts (CBC) were registered at annual intervals between enrolment and time of diagnosis. Linear regression was used to calculate the mean annual change in NLR and PLR in participants with ≥3CBCs. Changes were expressed relative to baseline values. Lung cancer incidence density and lung cancer risk (Cox regression analysis) were calculated for different NLR and PLR annual thresholds (<0%, ≥0%, ≥1%, ≥2%, ≥4%). Results were compared to a matched group of participants who did not develop lung cancer.

RESULTS

After a median follow-up of 80 months and a median of 4 (IQR 3-6) CBCs, subjects who developed lung cancer (n=32) showed greater NLR and PLR annual changes than matched controls (n=103) (2.56% vs. 0.27% [p=0.25] per year; and 3.75% vs. 0.33% [p=0.053] per year, respectively). Lung cancer incidence density per 100 person-years increased with higher annual NLR and PLR thresholds. On multivariable analysis (adjusting for emphysema and baseline lung-function), NLR and PLR were not significant lung cancer predictors. However, among individuals with emphysema, for each relative unit increase in PLR, lung cancer risk increased 5% (p=0.03). There was a significant supra-additive risk effect between PLR increase and emphysema. Annual NLR change was not a significant lung cancer predictor.

CONCLUSION

In a lung cancer screening setting, the assessment of annual PLR change could help predict lung cancer development.

Patients' Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey

INTRODUCTION

Pulmonary nodules are detected in more than 1 million Americans each year. Prior qualitative work suggests that the detection of incidental pulmonary nodules can be burdensome for patients, but whether these findings generalize to a broader sample of patients is unknown. We categorized patients' knowledge, beliefs, and distress associated with detection and evaluation of a pulmonary nodule, as well as their impressions of clinician communication.

METHODS

We administered a cross-sectional survey to adults with an incidental pulmonary nodule who were recruited from a rural medical center, an urban safety net hospital, and a Veterans Affairs hospital.

RESULTS

Of the 490 individuals mailed surveys, 244 (50%) responded. Median nodule size was 7 mm, mean patient age was 67 years, 29% of respondents were female, and 86% were white. A quarter of the respondents (26%) reported clinically significant distress related to their nodule, our primary outcome, as measured by the Impact of Event Scale. Patients reported multiple concerns, including uncertainty about the nodule's cause (78%), the possibility of cancer (73%), and the possible need for surgery (64%). Only 25% of patients accurately estimated their lung cancer risk (within 15% of their actual risk); overall, there was no correlation between perceived and actual risk (r = -0.007, p = 0.93). The 23% of patients who did receive information on cancer risk from their provider were more likely to find this information reassuring (16%) than scary (7%).

CONCLUSION

A quarter of patients with incidental pulmonary nodules experienced clinically significant distress. Knowledge about cancer risk and evaluation was poor. Clinician communication may help bridge knowledge gaps and alleviate distress in some patients.