Evaluation of the Solitary Pulmonary Nodule

 


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Am Fam Physician. 2015 Dec 15;92(12):1084-1091A.

  Patient information: A handout on lung nodules, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

A solitary pulmonary nodule is a common radiologic finding that is often discovered incidentally and may require significant workup to establish a definitive diagnosis. A solitary pulmonary nodule is a well-circumscribed round lesion measuring up to 3 cm in diameter and surrounded by aerated lung. Once a nodule is discovered, clinical and radiologic features and quantitative models can be used to determine the likelihood of malignancy. Evaluation is guided by nodule size and assessment of probability of malignancy. Surgical resection or nonsurgical biopsy should be performed in patients with solid or subsolid solitary pulmonary nodules that show clear growth on serial imaging. Solid solitary pulmonary nodules that have been stable for at least two years typically do not need further evaluation. The workup for patients with solid solitary pulmonary nodules measuring 8 mm or greater in diameter, nodules measuring less than 8 mm in diameter, and subsolid nodules should be guided by the probability of malignancy, imaging results, and the risks and benefits of different management strategies. Management should be individualized according to patient values and preferences. Medicare now covers lung cancer screening with low-dose computed tomography for high-risk patients 55 to 77 years of age at institutions that can provide a comprehensive approach to the management of solitary pulmonary nodules.

The identification of solitary pulmonary nodules has become more common in the United States because of the increased use of computed tomography (CT). The incidence of cancer in patients with solitary pulmonary nodules ranges from 10% to 70%.1 Recent U.S. Preventive Services Task Force recommendations for lung cancer screening with CT will likely further increase the detection of solitary pulmonary nodules.2 Therefore, it is important that clinicians become familiar with evaluating and managing these nodules.

WHAT IS NEW ON THIS TOPIC: EVALUATION OF THE SOLITARY PULMONARY NODULE

In 2014, the American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS) was released to standardize lung cancer screening computed tomography reporting and management recommendations.

Lung cancer screening should preferably be performed at institutions that can provide a comprehensive approach to the management of solitary pulmonary nodules.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Computed tomography is the imaging modality of choice for reevaluating solitary pulmonary nodules visible on chest radiography and for subsequently monitoring nodules for change in size.

C

6

Patients with a solid or subsolid pulmonary nodule showing clear evidence of growth on serial imaging should undergo biopsy, unless it is specifically contraindicated.

C

6

Physicians should discuss the risks and benefits of annual screening for lung cancer with low-dose computed tomography in adults 55 to 77 years of age who have a 30-pack-year smoking history and who currently smoke or have quit within the previous 15 years.

B

2, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Computed tomography is the imaging modality of choice for reevaluating solitary pulmonary nodules visible on chest radiography and for subsequently monitoring nodules for change in size.

C

6

Patients with a solid or subsolid pulmonary nodule showing clear evidence of growth on serial imaging should undergo biopsy, unless it is specifically contraindicated.

C

6

Physicians should discuss the risks and benefits of annual screening for lung cancer with low-dose computed tomography in adults 55 to 77 years of age who have a 30-pack-year smoking history and who currently smoke or have quit within the previous 15 years.

B

2, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN PULMONARY MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.

American College of Chest Physicians/American Thoracic Society

Do not perform CT screening for lung cancer among patients at low risk for lung cancer.

American College of Chest Physicians/American Thoracic Society


CT = computed tomography.

Source: For more information on the Choosing Wisely Campaign, see

The Authors

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GEORGE E. KIKANO, MD, is dean of the Central Michigan University College of Medicine in Mount Pleasant....

ANDRE FABIEN, MD, is chief fellow in the Division of Pulmonary, Critical Care, and Sleep Medicine at Case Western Reserve University School of Medicine in Cleveland, Ohio.

ROBERT SCHILZ, DO, PhD, is an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at Case Western Reserve University School of Medicine.

Address correspondence to George E. Kikano, MD, Central Michigan University College of Medicine, 2520 S. University Park, Mt. Pleasant, MI 48859 (e-mail: kikan1ge@cmich.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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