Incidental nodule management-should there be a formal process?

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.

Associations of long-term exposure to air pollution with prevalence of pulmonary nodules: A cross-sectional study in Shijiazhuang, China

A complete understanding of the associations of ambient air pollution with prevalence of pulmonary nodule is lacking. We aimed to investigate the associations of ambient air pollutants with prevalence of pulmonary nodule. A total of 9991 health examination participants was enrolled and 3166 was elected in the final in Shijiazhuang between April 1st, 2018, and December 31st, 2018. 107 participants were diagnosed in pulmonary nodule while 3059 participants were diagnosed in non-pulmonary (named control). The individual exposure of participants was evaluation by Empirical Bayesian Kriging model according to their residential or work addresses. The pulmonary nodules were found and diagnosed by health examination through chest x-ray detection. Our results suggested that there were positive associations between prevalence of pulmonary nodules and PM2.5 (OR = 1.06, 95% CI: 1.02, 1.11) as well as O3 (OR = 1.49, 95% CI: 1.35, 1.66) levels. The platelet count (PLT) acted as the mediator of pulmonary nodules related with the PM2.5 exposure, while the neutrophil-to-lymphocyte ratio (NLR) as well as platelet-to-lymphocyte ratio (PLR) were the mediators of pulmonary nodules related with the O3 exposure. This study suggests that long-term exposure to PM2.5 and O3 may significantly associated with prevalence of pulmonary nodules, and the above associations are mediated by PLT, NLR and PLR.

Predicting lung nodules malignancy

BACKGROUND

It is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting.

METHODS

The authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy.

RESULTS

From a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573.

CONCLUSIONS

The prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.

Development and outcomes of a comprehensive multidisciplinary incidental lung nodule and lung cancer screening program

BACKGROUND

Appropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging.

METHODS

This single-center, retrospective report describes the development and outcomes of a comprehensive lung nodule program at a community practice in Tennessee. Computed tomography (CT) scans potentially revealing incidental lung nodules were identified by a computerized search. Incidental or screening-identified lung nodules that were enlarging or not seen in prior scans were entered into a nodule database and guideline-based review determined whether to conduct a diagnostic intervention or radiologic follow-up. Referral rates, diagnosis methods, stage distribution, treatment modalities, and days to treatment are reported.

RESULTS

The number of patients with lung nodules referred to the program increased over 2 years, from 665 patients in Year 1 to 745 patients in Year 2. Most nodules were incidental (62-65%). Nodules identified with symptoms (15.2% in Year 1) or through screening (12.6% in Year 1) were less common. In Year 1, 27% (182/665) of nodules required a diagnostic intervention and 18% (121/665) were malignant. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. In screening cases, 71% of patients completed follow-up scans within 18 months. Only 2% of Year 1 patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis.

CONCLUSIONS

The current study reports outcomes over the first 2 years of a lung cancer screening and incidental nodule program. The results show that the program was successful, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

Communication About the Probability of Cancer in Indeterminate Pulmonary Nodules

Importance

Clinical guidelines recommend that clinicians estimate the probability of malignancy for patients with indeterminate pulmonary nodules (IPNs) larger than 8 mm. Adherence to these guidelines is unknown.

Objectives

To determine whether clinicians document the probability of malignancy in high-risk IPNs and to compare these quantitative or qualitative predictions with the validated Mayo Clinic Model.

Design, Setting, and Participants

Single-institution, retrospective cohort study of patients from a tertiary care Department of Veterans Affairs hospital from January 1, 2003, through December 31, 2015. Cohort 1 included 291 veterans undergoing surgical resection of known or suspected lung cancer from January 1, 2003, through December 31, 2015. Cohort 2 included a random sample of 239 veterans undergoing inpatient or outpatient pulmonary evaluation of IPNs at the hospital from January 1, 2003, through December 31, 2012.

Exposures

Clinician documentation of the quantitative or qualitative probability of malignancy.

Main Outcomes and Measures

Documentation from pulmonary and/or thoracic surgery clinicians as well as information from multidisciplinary tumor board presentations was reviewed. Any documented quantitative or qualitative predictions of malignancy were extracted and summarized using descriptive statistics. Clinicians' predictions were compared with risk estimates from the Mayo Clinic Model.

Results

Of 291 patients in cohort 1, 282 (96.9%) were men; mean (SD) age was 64.6 (9.0) years. Of 239 patients in cohort 2, 233 (97.5%) were men; mean (SD) age was 65.5 (10.8) years. Cancer prevalence was 258 of 291 cases (88.7%) in cohort 1 and 110 of 225 patients with a definitive diagnosis (48.9%) in cohort 2. Only 13 patients (4.5%) in cohort 1 and 3 (1.3%) in cohort 2 had a documented quantitative prediction of malignancy prior to tissue diagnosis. Of the remaining patients, 217 of 278 (78.1%) in cohort 1 and 149 of 236 (63.1%) in cohort 2 had qualitative statements of cancer risk. In cohort 2, 23 of 79 patients (29.1%) without any documented malignancy risk statements had a final diagnosis of cancer. Qualitative risk statements were distributed among 32 broad categories. The most frequently used statements aligned well with Mayo Clinic Model predictions for cohort 1 compared with cohort 2. The median Mayo Clinic Model-predicted probability of cancer was 68.7% (range, 2.4%-100.0%). Qualitative risk statements roughly aligned with Mayo predictions.

Conclusions and Relevance

Clinicians rarely provide quantitative documentation of cancer probability for high-risk IPNs, even among patients drawn from a broad range of cancer probabilities. Qualitative statements of cancer risk in current practice are imprecise and highly variable. A standard scale that correlates with predicted cancer risk for IPNs should be used to communicate with patients and other clinicians.

No stone unturned: Nodule Net, an intervention to reduce loss to follow-up of lung nodules

OBJECTIVE

Inadequate lung nodule surveillance leads to diagnostic delays. We implemented a retrospective intervention program, Nodule Net, to improve surveillance in our hospital.

METHODS

9,224 Chest computed tomography (CT) scans between January 1, 2015 and December 31, 2016 were manually reviewed for lung nodules. For patients without follow-up, charts were reviewed to assess follow-up. If follow-up appeared indicated, the clinician or patient was contacted, and follow-up was tracked.

RESULTS

Lung nodules were identified on 5,101 (55%) of 9,224 scans. Follow-up was potentially indicated and not completed in 1,385 (27%). 183 (13%) were excluded after imaging review. 1,202 received outreach. Of the 801 (66%) with a provider in our system, 225 (27%) returned for follow-up. Nodules were stable in 199 (88%), new or growing in 23 (11%), resolved in 3 (1%), and stage 1 lung cancer in 2 (1%). 90 (11%) had follow-up outside our system and 431 (51%) had no follow-up due to a clinical contraindication. 55 (7%) have imaging pending and 14 (2%) are awaiting pulmonary evaluation. Of the 302 (25%) patients with providers outside our system, 121 (40%) had followed-up elsewhere. 146 (48%) had no follow-up due to a clinical reason. 35 (12%) providers did not respond to outreach.

CONCLUSIONS

We identified 1,202 patients with lung nodules who needed follow-up over a two-year period. Compliance was more successful with providers within our hospital system. We recommend robust surveillance for patients to ensure follow-up is completed and clinical contraindications are well documented.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

BACKGROUND

A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings.

OBJECTIVES

To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals.

METHODS

The primary source for this retrospective observational study was the MarketScan^® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated.

RESULTS

Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year.

CONCLUSIONS

The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

Risk factors for pulmonary nodules in north China: A prospective cohort study

OBJECTIVES

Pulmonary nodules have become common incidental findings with the widespread use of computed tomography (CT) technology. Such nodules have the potential to become early lung cancer lesions, so understanding more about factors that may be associated with them is important.

MATERIALS AND METHODS

The present work was based on a large prospective cohort comprising 32,438 participants in Hebei Province (China) between January 2014 and March 2016. Participants aged 40-75 years completed a questionnaire, underwent low-dose CT (LDCT), and were followed up to March 2017. Grouped by the results of LDCT, normal participants and those with pulmonary nodules were included in the data analysis.

RESULTS

In total 7752 subjects were included in this study, of whom 2040 (26.32%) were pulmonary nodule patients. Older age, current smoking status (hazard ratio (HR) = 1.43, 95% confidence interval (95%CI): 1.21, 1.68), exposure to second-hand smoke (SHS) at work (HR = 1.17, 95%CI: 1.01, 1.35), dust exposure (HR = 1.49, 95%CI: 1.06, 2.11), history of lung disease (HR = 1.44, 95%CI: 1.16, 1.77), and family history of cancer (HR = 1.28, 95%CI: 1.12, 1.48) were associated with pulmonary nodules. However, consumption of vegetables (HR = 0.82, 95%CI: 0.68, 0.99), tea (HR = 0.88, 95%CI: 0.78, 0.99) and legumes reduced the risk. Approximately 10.09% and 8.58% of pulmonary nodule incidences were attributed to tobacco smoking and low fruit intake, respectively. An estimated 6.36% and 3.88% of patients with pulmonary nodules attributable to family history of cancer and history of lung disease were detected.

CONCLUSION

The results of this study suggest that age, smoking, SHS, dietary factors, occupational exposures, history of disease and family history of cancer may affect the incidence of pulmonary nodules.

Single-stage nonintubated uniportal thoracoscopic resection of synchronous bilateral pulmonary nodules after coil labeling: A case report and literature review

RATIONALE

Preoperative localization of small pulmonary nodules is essential for precise resection, besides, the optimal treatment for pulmonary nodules is controversial and the prognosis without surgery is uncertain.

PATIENT CONCERNS

Herein we present a patient with compromised pulmonary function harboring synchronous triple ground-glass nodules located separately in different pulmonary lobes.

DIAGNOSES

The pathological diagnosis of the nodules were chronic inflammation, inflammatory pseudotumor and atypical adenomatous hyperplasia, respectively.

INTERVENTIONS

The patient underwent single-stage, non-intubated thoracoscopic pulmonary wedge resection after computed tomography-guided coil labeling of the nodules.

OUTCOMES

The postoperative recovery was encouragingly fast without obvious complications.

LESSONS

Non-intubated thoracoscopic pulmonary wedge resection is feasible for patients with compromised lung function, meanwhile, preoperative coil labeling of small nodules is reliable.