How should we evaluate a solitary pulmonary nodule found on chest x-ray?

Journal of Family Practice, June, 2004 by Keith B. Holten

* When is a CT scan indicated to examine a solitary pulmonary nodule found on a chest x-ray film?

* Is there an indication for positron-emission tomography scanning?

* When should a biopsy be performed?

* What is the best biopsy method?

In January 2003 the American College of Chest Physicians Expert Panel on Lung Cancer Guidelines released its guideline on evaluating a solitary pulmonary nodule (SPN), an intraparenchymal lung lesion <3 cm in diameter unassociated with atelectasis or adenopathy. The objectives of this guideline were to define appropriate evidence-based practices for imaging and diagnostic tests, as well as indications for obtaining a tissue evaluation for the patient with a SPN. This expert panel included physicians from nuclear medicine, oncology, pulmonary medicine, radiology, and thoracic surgery. The major recommendations were summarized in the National Guideline Clearinghouse (available at www.guideline.gov).

The evidence categories for this guideline are diagnosis and management. Outcomes considered were sensitivity and specificity of diagnostic tests and diagnostic yield. No cost analysis was performed.

The committee used a complex recommendation rating scheme (A, B, C, D, I) after comparing levels of evidence (good, fair, or poor) compared with net benefits (substantial, moderate, small/weak, or none). The scheme was then revised to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine.

* GUIDELINE RELEVANCE AND LIMITATIONS

Solitary pulmonary nodules are discovered in 150,000 patients per year, and a delay in performing diagnostic studies can have dire consequences for those whose nodule proves malignant.

The guideline is weakened by the lack of a cost-effectiveness analysis.

A lengthy bibliography accompanies the guideline, but the support document does not provide evidence tables.

* GUIDELINE DEVELOPMENT AND EVIDENCE REVIEW

Computerized bibliographic databases including Medline, Cancerlit, CINAHL, HealthStar, the

Cochrane Collaboration Database of Abstracts of Reviews of Effectiveness, the National Guideline Clearinghouse, and the National Cancer Institute Physician Data Query database were searched for existing evidence. Priority was given to secondary sources including guidelines, systematic reviews, and meta-analyses. Search terms were lung neoplasms or bronchial neoplasms. Reference lists of review articles were also studied for additional evidence. There were 55 references.

* SOURCE FOR THIS GUIDELINE

Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest 2003; 123 (1 suppl):89S-96S.

* OTHER GUIDELINES ON SOLITARY PULMONARY NODULES

ACR Appropriateness Criteria [TM] for work-up of the solitary pulmonary nodule (SPN). 1995 (revised 2000). This guideline is one in a series of guidelines developed by the American College of Radiology. It ranks the utility of various diagnostic testing modalities based on evidence. This guideline is complex, because there are several "variants" based on the size of the lesion (>1 cm or <1 cm) and the clinical suspicion of cancer (low, moderate to high). The clinical utility for primary care physicians is limited.

Source: Henschke CI, Yankelevitz D, Westcott J, et al. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215 (Suppl):607-609. (19 references)

PRACTICE RECOMMENDATIONS

Diagnosis

* A solitary pulmonary nodule (SPN) with benign central calcification does not require further diagnostic testing (A).

* Spiral chest computed tomography (CT) scan with contrast should be performed for new SPNs (B).

* Review all previous chest x-rays when a SPN is found (C).

* Magnetic resonance imaging (MRI) is not indicated (D).

* Positron-emission tomography (PET) scan is not recommended for SPN <1 cm in size (D).

Management and follow-up evaluations

* Lymph node dissection should be performed for all pulmonary resections (A).

* If a wedge resection is not possible, a diagnostic lobectomy is an acceptable alternative (A).

* SPN that does not change on chest x-ray after 2 years of follow-up requires no further evaluation (B).

* PET scan of the chest with 18-fluorode-oxyglucose, might be considered preoperatively for SPN patients who are surgical candidates and have a negative mediastinal chest CT (B).

* Chest x-ray and chest CT scanning at 3, 6, 12, and 24 months should be performed for patients who are not good surgical candidates (B).

* An alternative to surgical intervention is percutaneous transthoracic needle aspiration (TTNA) or transbronchial needle biopsy for patients who refuse surgery (B).

* High surgical risk patients may be candidates for TTNA (B).

* Wedge resection followed by lobectomy is appropriate for pathology positive for cancer (B).

* Wedge resection or segmentectomy may be appropriate for marginal surgical candidates (B).

* Without a definitive tissue diagnosis, follow-up for 2 years is recommended with chest x-ray and chest CT (at 3, 6, 12, and 24 months) (C).

* Marginal surgical candidates who have a negative PET scan should have a CT scan at least in 3 months (C).

* For patients who are surgical candidates, TTNA is not indicated (D).

Keith B. Holten, MD, Editor

University of Cincinnati College of Medicine, Cincinnati, Ohio

Correspondence: Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: keholtenmd@cmhregional.com