CONTENTS:

2.5 The Outcome of A Positive Screening Finding
2.5.1 The LDCT Report and Clinical Decision-Making
2.5.2 The Abnormal LDCT: What Happens Next?
2.5.3 Clinical Management for Patients with Abnormal LDCT
2.6 The Solitary Pulmonary Nodule (SPN) (‘Coin Lesion’)

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To all writers, always remember the pen is mightier than the sword. Only if the sword is quite small and the pen is really, really sharp!

2.5 The Outcome of A Positive Screening Finding

 
Asymptomatic individuals who attend for lung cancer screening may have an abnormality on Low-Dose Computed Tomography (LDCT)  imaging that results in them being referred for further imaging and clinical tests.

For patients with symptoms that may indicate a primary or metastatic lung cancer, these patients usually undergo initial imaging with chest X-ray.

In both situations, an attempt should be made to obtain and review any previous chest imaging results as this will help to determine any associated lung abnormalities and the growth pattern of any identified lung abnormalities.

Benign (non-cancerous) imaging features include solid lesions that are stable in size for at least two years and ‘ground-glass,’ non-solid lesions that are stable in size for at least three years.

The finding of multiple nodules in a patient with a known or suspected extrathoracic malignancy strongly suggests pulmonary metastasis

Did you hear about the glass blower who accidentaly inhaled? He ended up with a pane in his stomach.

2.5.1 The LDCT Report and Clinical Decision-Making

 
Once lung cancer is suspected or diagnosed by examination of a cytology or tissue sample, staging systems will be done.

Initial patient clinical work-up can include chest CT and whole-body imaging (i.e., positron emission tomography [PET]) and can also include brain imaging.

The staging of lung cancer is based upon the TNM (Tumor Node Metastasis) staging system; primary tumor (T) and lymph nodes (N) and Metastases (M) (see Section 7).

Depending on individual patient preferences, an aggressive investigation approach may be taken, aimed at cure; or minimal, or no investigations may be preferred with symptom-directed treatment only. Establishing patient preferences early can facilitate shared decision-making for future diagnostic and treatment choices.

There’s quite a lot about staging on here. I think there’s a whole section later.

Staging is very important. It’s a measure of how much the tumor has grown and spread and how well it may respond to treatment.

Moose I quite like the ‘TNM’ I have my own understanding of that; T = Time, M = Moose and N = Nap. Zzzzzzz!

2.5.2 The Abnormal LDCT: What Happens Next?

 
Imaging will guide the approach to invasive biopsy that will confirm the histopathological diagnosis and the stage of the lung tumor.

Where possible, tissue diagnosis and tumor staging should be established concurrently. However, some patients will require multiple imaging studies and / or invasive procedures for tissue sampling.  Although imaging and sampling procedures are usually described separately, it is often the case that the pathways to diagnosis and staging occur together.

There is no single, simple diagnostic algorithm to summarize the complexity and variation in the disease patterns of lung cancer. Local resources and clinical expertise and health system factors may influence the approach taken.

2.5.3 Clinical Management of Patients with Abnormal LDCT

 
Every patient with suspected non-small-cell lung cancer (NSCLC) should have a thorough history and physical examination. The presence of signs or symptoms usually indicates advanced or metastatic disease and is associated with a poor prognosis.

The following laboratory tests may be requested if lung cancer is suspected or diagnosed:-

• Complete blood count
• Electrolytes
• Calcium
• Alkaline phosphatase
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
• Total bilirubin
• Creatinine
• Albumin and lactate dehydrogenase

I was born to be a pessimist. My blood type is B negative.

2.6 The Solitary Pulmonary Nodule (SPN) (‘Coin Lesion’)

A solitary pulmonary nodule (SPN) or ‘coin lesion’ is defined as a round lung lesion < 3 cm in diameter, without any other abnormality.

Lung lesions > 3 cm are called ‘masses’ and are more likely to be cancer.

In 2003, Ost and colleagues reported that a solitary lung nodule was found to be present in up to 0.2 % of all chest X-rays. These researchers estimated that approximately 150,000 solitary lung nodules are identified in the U.S. each year.

The incidence of cancer in these solitary nodules has been reported to be between 10 % to 20 %. Approximately 80 % of benign solitary nodules are granulomas due to infection, with benign hamartomas making up 10 % (see Section 3)

In any patient found to have a solitary lung nodule, features suggestive of malignancy include the following:

• a large nodule size,
• a nodule with ‘spiculated‘ or irregular borders,
• a nodule with an upper lobe location,
• a nodule with thick-walled cavitation,
• the presence of a solid component within a ‘ground glass’ lesion, and
• detection of nodule ‘growth‘ by follow-up imaging.

The finding of multiple nodules in a patient with a known or suspected extrathoracic malignancy, strongly suggests pulmonary metastasis.

There you go girls, I knew it was all about size.

Oh Hector. Stop!

What? I’m talking about lung lesions. If they’re less than 3 cms they’re called a ‘nodule’ and if they’re bigger than 3 cms they’re called ‘masses’.

Figure 2.3 The Solitary Pulmonary
Nodule (SPN) or ‘Coin Lesion.’
LDCT image of a central lung nodule. 

A drunk goes to court. The judge says, ‘you’ve been brought here for drinking.’ The drunk says, ‘great, let’s get started.’

REFERENCES:

Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP, Wiener RS. (2013). Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143(5 Suppl), e93S-120S. (Retrieved 29th Jan 2015): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749714/

Ost DE, Yeung SC, Tanoue LT, Gould MK. (2013). Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143(5 Suppl), e121S-41S. (Retrieved 29th Jan 2015): http://journal.publications.chestnet.org/article.aspx?articleid=1685288

More references for this section are on this page..

PATIENT INFORMATION:

Lung Cancer Org. Types and Staging of Lung Cancer. (Retrieved 23^rd March 2015): staging systems

Mayo Clinic Lung Cancer: Can lung nodules be cancerous? (Retrieved 8^th March 2015):http://www.mayoclinic.org/diseases-conditions/lung-cancer/expert-answers/lung-nodules/faq-20058445

More patient information for this section is on this page.

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