Pulmonary Nodule: So, you got a nodule, now what?

If the nodule was seen on a previous scan, this is remarkably helpful. Regardless of size, nodules that do not change size over time are less concerning. Nodules that enlarge, are more concerning. 

The presence of symptoms helps your doctor develop a management plan. Symptoms that suggest pneumonia (e.g. fevers, cough, sputum production) may need antibiotics and a repeat Chest CT in 8 weeks. Why 8 weeks? Because infections can take up to 6 weeks to clear, especially if the patient has a problem with their immune system. Waiting two more weeks usually allows complete resolution of the findings from the infection. If the follow up Chest CT is done too soon, it may require a third scan to make sure the lungs have gone back to normal. 

If the patient with a nodule is at an age where screening for other cancers is recommended, then it is a necessity to complete these screenings. These screenings currently look for breast, colon, cervical and prostate cancer and are performed through primary care physicians. 

It is important to properly evaluate a patient’s lung cancer risk. A history of exposure to substances that can cause lung cancer i.e. asbestos, radon, uranium and cigarette smoke, increase a person’s risk. A previous history of cancer may increase lung cancer risk but also increases the chance that a nodule is a reoccurrence of the previous cancer. Family history of lung cancer contributes a 2-5% risk to other family members regardless of smoking. And certain inflammatory lung conditions such as Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Diseases like Idiopathic Pulmonary Fibrosis (IPF) also increase lung cancer risk. 

If the nodule is detected by a CT scan done for lung cancer screening, we use the Lung-RADS system (https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads). If the nodule is detected incidentally on a scan for a different reason, we usually follow the Fleischner Society Guidelines (https://pubs.rsna.org/doi/full/10.1148/rg.2018180017). Both systems require that the patients does not have concerning symptoms.

The Lung-RADS algorithm is only applied to patients at high risk for lung cancer whereas the Fleischner Society guidelines algorithm differentiates between people at high and low risk for lung cancer. Based on all of these assessments, the physician can recommend the best course of action. 

These treatment algorithms have been designed to both expedite evaluation of nodules that are at increased risk of cancer AND avoid over evaluation of nodules that are unlikely to be cancer. This strives to both prevent a cancer from being missed until its too late and prevent a patient from undergoing unnecessary tests that could cause complications.