A thoracic surgery clinic dedicated to solitary pulmonary nodules- too many scans and too little pathology?
Nirmal K. Veeramachaneni, Traves D. Crabtree, Daniel Kreisel, Jennifer B. Zoole, Joanne Musick, Nicole G. Taylor, Alexander S. Krupnick, G Alexander Patterson, Bryan F. Meyers; Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
Comment on this Abstract
Objective: Widespread application of CT has increased detection of asymptomatic pulmonary nodules. A dedicated clinic was established to encourage referral and manage large numbers of patients with such nodules.
Methods: Patients were evaluated periodically by a nurse practitioner with surgeon oversight, and follow-up CT was centralized. Patients were re-scanned at intervals based upon radiologist advice for at least two years.
Results: 414 patients, 189 male and 225 female with a median age of 60.3 (20.7 - 86.6) years, were seen since April 2000. Median follow-up was 1.51(0- 6.65) years. 40% (153/414) were older than 60 years with at least 10 pack-years of tobacco use, while 30% (123/414) had never smoked. 286 patients completed at least 2 years of follow-up evaluation. The median initial nodule size was 0.6cm (0.2- 4.3). After 2 years, 23.8% (68/286) were deemed radiographically stable and were discontinued from further follow-up. 30% (88/286) of patients were followed longer than two years due to the development of new nodules. 2.1% (6/286) were scanned longer than 2 years despite radiographic stability. At least 1111 CT scans were performed. 10.1% (42/414) underwent FDG-PET imaging which suggested malignancy in 8 patients. A pathological diagnosis was made by CT FNA in 3 patients and by operative procedure in 17 patients. Of the 20 patients undergoing an invasive procedure, 11 had preliminary FDG-PET imaging. Overall, 3% (13/414) of our patients have been shown to have a malignancy. Nine patients had non-small cell lung cancer, 1 patient had small cell lung cancer, 1 patient had lymphoma, and 2 patients had lung metastasis of a distant tumor. Of the 10 patients with lung cancer, the median age was 64 (58.0 - 78.0) years with a mean smoking history of 57.3 ± 30.8 pack-years. All patients with lung cancer underwent biopsy procedure due to change in the nodule on follow-up CT scan. An operative procedure was performed in 7 patients for a benign process.
Conclusion: In a population of patients with indeterminate nodules in routine clinical practice, few patients required intervention and few cancers were detected. Older patients with extensive smoking history were more likely to be diagnosed with lung cancer. Intensive follow-up CT evaluation may be reserved for patients with high probability for cancer, avoiding unnecessary follow-up and CT scans. Benefits of a “nodule clinic” are difficult to prove but may include patient reassurance and convenience to referring physicians.
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