SUMMARY

Pulmonary Nodule Programs are being developed to identify and follow abnormalities in persons that may or may not be cancerous at the time of diagnosis. However, some may lead to cancer as time progresses. The goal of this program is to catch lung cancer earlier in its transition (stage I-II) vs. the current timeline (usually stage III or IV).

Utilizing an oncology nurse as navigator gives credence to the program that we are being proactive about early detection of lung cancer. In addition, oncology knowledge can be applied to review of imaging studies and set up of necessary patient appointments. As oncology nurses, all of us know of cases in which a lung nodule looks benign but the patient’s previous medical history indicates that may not be the case. An appointment with a pulmonologist may be more of a priority for these patients than for other patients.

Beyond what NCI and CDC believe to be important, quality patient care requires all of us to maintain routine screening and observation with appropriate intervention for any person in whom cancer is more than a normal-risk possibility. High-risk persons with pulmonary nodules will need follow-up scans for a minimum of 2 years to determine whether those nodules are benign or transitioning to cancer. A program in which nurse navigators with an oncology background work with a multidisciplinary pulmonary team is the best approach to providing our patients with the new standards of care.


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Rosemarie Tucci is program coordinator for the MLH Lung Nodule Program at Main Line Health, in Lankenau, Pennsylvania. Lynne Quinn is the oncology director at Bryn Mawr Hospital, Main Lain Health, in Bryn Mawr, Pennsylvania, and administrator of the Lung Cancer System Working Group for MLH.


REFERENCES

1. MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the Fleischner Society. Radiology. 2005;237(2):395-400.

2. Boise State University. Performance Management – Creating Smart Objectives: Participant Guide. April 24, 2007. http://www.falmouthinstitute.com/files/GV018/SMARTgoals.pdf. Accessed January 19, 2016.

SUPPLEMENTAL MATERIAL

TABLE 2. Major Recommendations for Lung Nodule Follow-up

Recommendation Grade of Recommendation
Patients with a solitary pulmonary nodule (SPN): We recommend clinicians estimate the pretest probability of malignancy either qualitatively by using their clinical judgment or quantitatively by using a validated model. 1C
Patients with an SPN that is visible on chest radiography (CXR): We recommend a review of previous CXRs and other relevant imaging tests. 1C
Patients who have an SPN that shows clear evidence of growth on imaging tests: We recommend tissue diagnosis should be obtained unless specifically contraindicated. 1C
Patients with an SPN that is stable on imaging tests for at least 2 years: We suggest no additional diagnostic evaluation be performed, except for patients with pure ground-glass opacities on computed tomography (CT) for whom a longer duration of annual follow-up should be considered. 2C
Patients with an SPN that is calcified in a clearly benign pattern: We recommend no additional diagnostic evaluation. 1C
Patients with an indeterminate SPN that is visible on CXR: We recommend CT of the chest should be performed, preferably with thin sections through the nodule. 1C
Patients with an indeterminate SPN that is visible on chest CT: We recommend a review of previous imaging tests. 1C
Patients with normal renal function and an indeterminate SPN on CXR or chest CT: We recommend CT with dynamic contrast enhancement be considered in centers with experience performing this technique. 1B
Patients with low-to-moderate pretest probability of malignancy (5% to 60%) and an indeterminate SPN that measures at least 8 to 10 mm in diameter: We recommend F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging to characterize the nodule. 1B
Patients with an SPN that has a high pretest probability of malignancy (>60%) or patients with a subcentimeter nodule that measures <8 to 10 mm in diameter: We suggest FDG-PET not be performed to characterize the nodule. 2C
Patients with an SPN: We recommend clinicians discuss the risks and benefits of alternative management strategies and elicit patient preferences. 1C
Patients with an indeterminate SPN that measures at least 8 to 10 mm in diameter and who are candidates for curative treatment: Observation with serial CT scans is an acceptable management strategy in the following circumstances:
• Clinical probability of malignancy is very low (<5%);
• Clinical probability of malignancy is low (<30% to 40%) and the lesion is not hypermetabolic on FDG-PET or does not enhance >15 Hounsfield units (HU) on dynamic contrast CT;  
• Needle biopsy is nondiagnostic, and the lesion is not hypermetabolic on FDG-PET;  
• A fully informed patient prefers this nonaggressive management approach.
2C
Patients who have an indeterminate SPN that measures at least 8 to 10 mm in diameter and undergo observation: We suggest repeating serial CT scans no less than at 3, 6, 12, and 24 months. 2C
Patients who have an indeterminate SPN that measures at least 8 to 10 mm in diameter and are candidates for curative treatment: A transthoracic needle biopsy or bronchoscopy is appropriate in the following circumstances:  
• Clinical pretest probability and findings on imaging tests are discordant (eg, pretest probability of malignancy is high and the lesion is not hypermetabolic on FDG-PET);  
• A benign diagnosis requiring specific medical treatment is suspected;  
• A fully informed patient desires proof of a malignant diagnosis before surgery, especially when the risk of surgical complications is high.

In general, we suggest transthoracic needle biopsy be the first choice for patients with peripheral nodules unless the procedure is contraindicated or the nodule is inaccessible. We suggest bronchoscopy be performed when an air bronchogram is present or in centers with expertise in newer guided techniques.

2C
Surgical candidates with an indeterminate SPN that measures at least 8 to 10 mm in diameter: Surgical diagnosis is preferred in most circumstances, including:
• Clinical probability of malignancy is moderate to high (>60%);  
• The nodule is hypermetabolic on FDG-PET;  
• A fully informed patient prefers undergoing a definitive diagnostic procedure.
1C
Patients with an indeterminate SPN in the peripheral third of the lung and have chosen surgery: We recommend thoracoscopy to obtain a diagnostic wedge resection. 1C
Patients who choose surgery with an indeterminate SPN that is not accessible by thoracoscopy, bronchoscopy, or transthoracic needle aspiration (TTNA): We recommend a diagnostic thoracotomy be performed. 1C
Patients who undergo thoracoscopic wedge resection for an SPN found to be cancer via frozen section: We recommend anatomic resection with systematic mediastinal lymph node sampling or dissection during the same anesthetic. 1C
Patients with an SPN who are judged to be marginal candidates for lobectomy: We recommend definitive treatment by wedge resection/segmentectomy (with systematic lymph node sampling or dissection). 1B
Patients with an SPN who are not surgical candidates and prefer treatment: We recommend confirming the diagnosis of lung cancer by biopsy, unless contraindicated.
1C
Patients with a malignant SPN who are not surgical candidates and prefer treatment: We recommend referral for external-beam radiation or to a clinical trial of an experimental treatment such as stereotactic radiosurgery or radiofrequency ablation. 2C
Surgical candidates who have subcentimeter nodules and no risk factors for lung cancer: The frequency and duration of follow-up (preferably with low-dose CT) should depend on the size of the nodule. We suggest the following: 
• Nodules that measure up to 4 mm in diameter not be followed up, but the patient must be fully informed of the risks and benefits of this approach;  
• Nodules that measure >4 to 6 mm be re-evaluated at 12 months without additional follow-up if unchanged;
• Nodules that measure >6 to 8 mm be followed up sometime between 6 and 12 months, and again between 18 and 24 months if unchanged.
2C
Surgical candidates who have subcentimeter nodules and one or more risk factors for lung cancer: The frequency and duration of follow-up (preferably with low-dose CT) should depend on the size of the nodule. We suggest the following:  
• Nodules that measure up to 4 mm in diameter be re-evaluated at 12 months without additional follow-up if unchanged;  
• Nodules that measure >4 to 6 mm should be followed up sometime between 6 and 12 months, and again between 18 and 24 months if unchanged;
• Nodules that measure >6 to 8 mm be followed up initially sometime between 3 months and 6 months, then subsequently between 9 and 12 months, and again at 24 months if unchanged.
2C
Surgical candidates with subcentimeter nodules that display unequivocal evidence of growth during follow-up: We recommend obtaining definitive tissue diagnosis by surgical resection, transthoracic needle biopsy, or bronchoscopy. 1C
Patients who have subcentimeter nodules and are not candidates for curative treatment: We recommend limited follow-up (in 12 months) or follow-up when symptoms develop. 1C
Patients with a dominant SPN and one or more additional small nodules who are candidates for curative treatment: We recommend that each nodule be evaluated individually as necessary, and curative treatment should not be denied unless there is histopathologic confirmation of metastasis. 1C
In surgical candidates with a solitary pulmonary metastasis, we recommend that pulmonary metastasectomy be performed if there is no evidence of extrapulmonary malignancy and there is no better available treatment. 1C
Surgical candidates with an SPN that has been diagnosed as small cell lung cancer (SCLC): We recommend surgical resection with adjuvant chemotherapy, provided that noninvasive and invasive staging exclude the presence of regional or distant metastasis. 1C
Patients with an SPN and in whom SCLC is diagnosed intraoperatively: We recommend anatomic resection with systematic mediastinal lymph node sampling or dissection under the same anesthesia when there is no evidence of nodal involvement and when the patient will tolerate resection. Surgery should be followed by adjuvant chemotherapy. 1C