Managing the Small Pulmonary Nodule Discovered by CT

doi:10.1378/chest.125.4.1522

Chest

Volume 125, Issue 4, April 2004, Pages 1522-1529

https://doi.org/10.1378/chest.125.4.1522 Get rights and content

Objectives

To review the Early Lung Cancer Action Project experience and the medical literature from 1993 to 2003 on detection of the small, noncalcified pulmonary nodule by CT in order to formulate a management algorithm for these nodules.

Design

Prospective noncomparative study of smokers without prior malignancy and a review of the medical literature of CT screening of lung cancer.

Interventions

Chest CT and, where appropriate, CT observation for nodule growth, antibiotics, CT-guided fine-needle aspiration (FNA) biopsy, fiberoptic bronchoscopy, and video-assisted thoracoscopic surgery (VATS).

Results

The following factors influence the probability of malignancy in a CT-detected, small, noncalcified pulmonary nodule: size, change in size, age, smoking history, density, number of nodules, gender, circumstance of the CT, spirometry, occupational history, and endemic granulomatous disease. The two diagnostic techniques most useful in evaluating the CT-detected, small, noncalcified nodule are short-term observation of nodule growth by CT and CT-guided FNA. Due to small nodule size and the frequent finding of nonsolid or part-solid nodules, positron emission tomography, fiberoptic bronchoscopy, and VATS were less useful.

Conclusions

Pulmonologists are frequently asked to evaluate the CT-detected, small, noncalcified nodule invisible on standard chest radiography. Immediate biopsy is justified if the likelihood of cancer is high, but if that likelihood is low or intermediate, a period of observation by CT is appropriate. VATS or thoracotomy are rarely necessary for a diagnosis of lung cancer in the CT-detected small pulmonary nodule.

Section snippets

Materials and Methods

We reviewed our experience with lung cancer screening by CT in patients without prior malignancy at the Weill Medical College of Cornell University ELCAP from 1993 to the present, and performed a review of the literature using MEDLINE to evaluate all published studies of CT screening for lung cancer to determine the best approach to the diagnosis and management of the small pulmonary nodule. A small pulmonary nodule was defined as an opacity in the pulmonary parenchyma < 3 cm in greatest

Size

Since CXR studies have shown the likelihood of cancer in solitary pulmonary nodules, it has been recognized that nodule size correlates with the risk of cancer,¹⁷ but until CT there were little data on nodules < 1.5 to 2.0 cm in diameter (Table 1).¹⁸ It is difficult to recognize lung cancer by CT in nodules < 5 mm in diameter among the many nodules of this size. Lung cancer appears to be rare in nodules < 5 mm in size, and it is safe to repeat the CT at 1 year in these patients (Fig 1, top).⁷⁸

Discussion

Lung cancer is common and, under present “routine care,” commonly fatal. In CXR screening, less than one third of lung cancers were discovered in stage I. While this represents a great improvement over no screening, it is not sufficient. CT finds lung cancer in stage I 85% of the time, a fact documented in many thousands of patients in the United States, Europe, and Japan.⁷⁸⁹¹⁰¹¹¹²¹³¹⁴

Faced with a small, CT-detected pulmonary nodule, the physician must first assess the likelihood of lung

References (37)

BJ Flehinger et al.
The effect of surgical treatment on survival from early lung cancer: implications for screening
Chest
(1992)
MR Melamed et al.
Screening for early lung cancer: results of the Memorial Sloan-Kettering study in New York
Chest
(1984)
CI Henschke et al.
Early Lung Cancer Action Project: overall design and findings from baseline screening
Lancet
(1999)
S Sone et al.
Mass screening for lung cancer with mobile spiral computed tomography scanner
Lancet
(1998)
GA Lillington et al.
Evaluation and management of solitary multiple pulmonary nodules
Clin Chest Med
(1993)
CI Henschke et al.
Screening for lung cancer: the Early Lung Cancer Action Project approach
Lung Cancer
(2002)
DF Yankelevitz et al.
CT-guided transthoracic needle biopsy of small solitary pulmonary nodules
Clin Imaging
(1997)
S Goldsmith et al.
Nuclear medicine imaging of lung cancer
Radiol Clin North Am
(2000)
KG Torrington et al.
The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule
Chest
(1993)
F Reichenberger et al.
The value of transbronchial needle aspiration in the diagnosis of peripheral pulmonary lesions
Chest
(1999)

A Jemal et al.

Recent trends in lung cancer mortality in the United States

J Natl Cancer Inst

(2001)

RS Fontana et al.

Lung cancer screening: the Mayo program

J Occup Med

(1986)

MS Tockman

Survival and mortality from lung cancer in a screened population: the Johns Hopkins study

Chest

(1986)

A Kubik et al.

Lack of benefit from semi-annual screening for cancer of the lung: follow-up report of a randomized controlled trial on a population of high-risk males in Czechoslovakia

Int J Cancer

(1990)

CI Henschke et al.

Early Lung Cancer Action Project: initial findings on repeat screenings

Cancer

(2001)

S Sone et al.

Results of three-year mass screening programme for lung cancer using mobile low-dose spiral computed tomography scanner

Br J Cancer

(2001)

SJ Swensen et al.

Screening for lung cancer with low-dose spiral computed tomography

Am J Respir Crit Care Med

(2002)

T Sobue et al.

Screening for lung cancer with low-dose helical computed tomography: anti-lung cancer association project

J Clin Oncol

(2002)

Cited by (178)

Comparison of cyanoacrylate and hookwire for localizing small pulmonary nodules: A propensity-matched cohort study
2019, International Journal of Surgery
Citation Excerpt :
Due to the widespread use of low-dose CT, small pulmonary nodules (SPNs) were increasingly identified in the screened population, and some suspected to be malignant may require further investigation [2]. Unfortunately, benign-malignant SPN differentiation is sometimes thorny just based on CT or positron emission tomography/CT [3,4]. Video-assisted thoracoscopic surgery (VATS), which allows complete removal of the entire nodule at one setting, provides a minimally invasive method for simultaneously diagnosing and treating SPNs.
Localizing small pulmonary nodules (SPNs) is a challenge during thoracoscopic resection, but preoperative computed tomography (CT)-guided localization using either cyanoacrylate or hookwire can be helpful. This study compared the safety, efficiency, and operability of the two techniques.
From September 2013 to November 2018, 269 patients (269 SPNs) who underwent preoperative CT-guided SPN localization were enrolled. A propensity-matched analysis, incorporating 13 variables, was performed to control potential selection bias.
All the patients were divided into two groups: CT-guided cyanoacrylate localization group (Group C, n = 149) and CT-guided hookwire localization group (Group H, n = 120). Eighty-six patients were propensity-matched in each group. All SPNs were successfully removed thoracoscopically, and no conversion was required. Localization-related complications in the two groups were similar, including intrapulmonary focal hemorrhage (p = 0.823), pneumothorax (p = 1.000), or hemoptysis (p = 0.121). For pain assessment and management, the cyanoacrylate localization saw a lower pain score (p < 0.001) and less morphine use (p < 0.001). In Group H, the localization took a significantly longer time (p < 0.001). Covering only the patients in Group C, the sub-analysis found that cyanoacrylate localization on the day before surgery did not compromise the accuracy of intraoperative targeting or increase the incidence of complications, compared with the localization on the day of surgery (all p > 0.05).
Compared to hookwire localization, CT-guided cyanoacrylate localization decreased pain and morphine use and allowed flexible surgical schedules, suggestive of its preferability for the resection of SPNs.
Risk factors for pulmonary nodules in north China: A prospective cohort study
2018, Lung Cancer
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.
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.
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.
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.
Safety and Efficacy of Endovascular Fiducial Marker Insertion for CyberKnife Stereotactic Radiation Therapy Planning in Early-Stage Lung Cancer
2017, Journal of Vascular and Interventional Radiology
To evaluate the safety and efficacy of endovascular fiducial markers (EVFMs) for CyberKnife stereotactic radiation therapy (RT) of malignant lung neoplasms in patients with contraindications to percutaneous fiducial marker (PTFM) placement.
Between January 2011 and December 2013, 15 patients (7 men and 8 women) aged 59–87 years (mean, 73 y) underwent EVFM placement and 109 patients (54 men and 55 women) aged 55–92 years (mean, 73 y) underwent 114 PTFM placements. All patients who received EVFMs had contraindications to PTFM insertion. Complications were recorded for all 129 procedures. Proportions of markers used for CyberKnife stereotactic RT planning and distance between markers and tumor were assessed in all 15 patients in the EVFM group and in 15 randomly selected patients in the PTFM group.
Sixty-two EVFMs and 56 PTFMs were inserted in the groups of 15 patients. CyberKnife stereotactic RT was not performed in 2 EVFM recipients (8 EVFMs) and 1 PTFM recipient (4 PTFMs). CyberKnife stereotactic RT was planned with the use of 39 of 54 EVFMs (72%) in 13 patients and 37 of 52 PTFMs (71%) in 14 patients. Mean distances between the tumor and EVFMs and PTFMs were 5.5 mm and 2.7 mm, respectively (P = .0152). No complications occurred in the EVFM group. In the PTFM group, 60 of 114 patients (52.6%) had small or moderate pneumothoraxes, 13 (11.4%) had chest tubes inserted, and 5 (4.4%) had self-limiting hemoptysis.
EVFM is feasible and safe, and may therefore offer an alternative when patients are not candidates for percutaneous marker placement.
Predictive factors of complications during CT-guided transthoracic biopsy
2017, Revue de Pneumologie Clinique
La ponction transpariétale (PTP) scanoguidée est un acte fréquemment utilisé pour obtenir le diagnostic de lésions intrathoraciques, en particulier en oncologie. L’objectif de cette étude est de décrire les complications et leurs facteurs de risque au sein d’une large cohorte rétrospective multicentrique.
Les dossiers des PTP réalisées entre 2006 et 2012 dans 3 centres ont été revus. Une analyse statistique multivariée par régression logistique binaire a été utilisée pour rechercher les facteurs prédictifs de survenue de complication.
Neuf cents soixante-dix PTP ont été réalisées. Au moins une complication est survenue dans 34 % des cas (dont 6 % de complications sévères). Il s’agissait majoritairement de pneumothorax (29 % dont 4 % drainés) et d’hémoptysies (5 %). Le seul facteur prédictif significatif de complications était la petite taille de la lésion cible (adjusted odd ratio [AOR] [1 mm de lésion] = 0,984 ; IC 95 % [0,976–0,992] ; p < 0,001). Ce facteur prédictif était également retrouvé pour la survenue de complication sévère (AOR = 0,982 ; [0,965–0,999] ; p = 0,037), le risque de pneumothorax (AOR = 0,987 ; [0,978–0,995] ; p = 0,002) et le risque d’hémoptysies (AOR = 0,973 ; [0,951–0,997] ; p = 0,024).
Environ le tiers des PTP se compliquent mais les complications sévères ne concernent que 6 % des gestes. Une lésion de petite taille est un facteur de risque de complication.
CT-guided transthoracic core-needle biopsy (TTNB) is frequently used for the diagnosis of lung nodules. The aim of this study is to describe TTNBs’ complications and to investigate predictive factors of complications.
All consecutive TTNBs performed in three centers between 2006 and 2012 were included. Binary logistic regression was used for multivariate analysis.
Overall, 970 TTNBs were performed in 929 patients. The complication rate was 34% (life-threatening complication in 6%). The most frequent complications were pneumothorax (29% included 4% which required chest-tube) and hemoptysis (5%). The mortality rate was 0.1% (n = 1). In multivariate analysis, predictive factor for a complication was small target size (AOR = 0.984; 95% CI [0.976–0.992]; P < 0.001). This predictive factor was also found for occurrence of life-threatening complication (AOR = 0.982; [0.965–0.999]; P = 0.037), of pneumothorax (AOR = 0.987; [0.978–0.995]; P = 0.002) and of hemoptysis (AOR = 0.973; [0.951–0.997]; P = 0.024).
One complication occurred in one-third of TTNBs. The proportion of life-threatening complication was 6%. A small lesion size was predictive of complication occurrence.
Veterinary diagnostic imaging: Probability, accuracy and impact
2016, Veterinary Journal
Diagnostic imaging is essential for diagnosis and management of many common problems in veterinary medicine, but imaging is not 100% accurate and does not always benefit the animal in the way intended. When assessing the need for imaging, the probability that the animal has a morphological lesion, the accuracy of the imaging and the likelihood of a beneficial impact on the animal must all be considered. Few imaging tests are sufficiently accurate that they enable a diagnosis to be ruled in or out; instead, the results of imaging only modify the probability of a diagnosis. Potential problems with excessive use of imaging include false positive diagnoses, detection of incidental findings and over-diagnosis, all of which may contribute to a negative benefit to the animal. Veterinary clinicians must be selective in their use of imaging, use existing clinical information when interpreting images and sensibly apply the results of imaging in the context of the needs of individual animals. There is a need for more clinical research to assess the impact of diagnostic imaging for animals with common conditions to help clinicians make decisions conducive to optimal patient care.
Negative predictive value of transthoracic core-needle biopsy: A multicenter study
2015, Chest
Specimens collected by CT scan-guided transthoracic core-needle biopsy (TTNB) are frequently used for the diagnosis of lung nodules, but the clinical value of negative results has not been sufficiently investigated. We sought to determine the negative predictive value (NPV) of TTNB specimens and investigate predictive factors of negative results.
All consecutive TTNBs performed in three centers between 2006 and 2012 were included. The medical charts of patients with nonmalignant TTNB specimens were reviewed and classified as true or false negatives. Binary logistic regression was used for multivariate analysis.
Overall, findings from 980 TTNB specimens were included. Malignant disease was found in 79% (n = 777) of the cases, nonmalignant disease in 6% (n = 54), and “negative” results in 15% (n = 149). For the diagnosis of malignant disease, NPV was 51%. Estimated sensitivity, specificity, and accuracy were 89%, 99%, and 90%, respectively. The complication rate was 34% (life-threatening complication in 6%). In multivariate analysis, predictive factors for a false-negative result were radiologist experience (adjusted OR [AOR], 0.996;95% CI, [0.994-0.998]), occurrence of a complication during the procedure (AOR, 1.958;95% CI, [1.202-3.187]), and moderate to high maximum standardized uptake value on PET scan (AOR, 7.657;95% CI, [1.737-33.763]). In 24 cases, a second TTNB was performed at the same target. The complication rate was 33%, and TTNB specimens provided diagnosis in 95% of cases with a 67% NPV.
One-half of all “negative” TTNB specimen results were falsely negative for malignant diagnosis. Findings in tissue collected from a second TTNB at the same target provided a final diagnosis in most cases without increasing complication rates.

View all citing articles on Scopus

View full text

Chest

Opinions/HypothesesManaging the Small Pulmonary Nodule Discovered by CT

Objectives

Design

Interventions

Results

Conclusions

Section snippets

Materials and Methods

Size

Discussion

Chest

Chest

Lancet

Lancet

Clin Chest Med

Lung Cancer

Clin Imaging

Radiol Clin North Am

Chest

Chest

Recent trends in lung cancer mortality in the United States

J Natl Cancer Inst

Lung cancer screening: the Mayo program

J Occup Med

Survival and mortality from lung cancer in a screened population: the Johns Hopkins study

Chest

Lack of benefit from semi-annual screening for cancer of the lung: follow-up report of a randomized controlled trial on a population of high-risk males in Czechoslovakia

Int J Cancer

Early Lung Cancer Action Project: initial findings on repeat screenings

Cancer

Results of three-year mass screening programme for lung cancer using mobile low-dose spiral computed tomography scanner

Br J Cancer

Screening for lung cancer with low-dose spiral computed tomography

Am J Respir Crit Care Med

Screening for lung cancer with low-dose helical computed tomography: anti-lung cancer association project

J Clin Oncol

Opinions/Hypotheses
Managing the Small Pulmonary Nodule Discovered by CT