This patient is a 73 year-old female who came in the other day with chest pain. Her Chest XR shows:
Two calcified nodules can be seen in the lateral R mid lung field. These are not the cause of the patient’s ED presentation and referred to as “incidental” findings on her Chest XR.
Incidental findings of nodules on Chest XR are a very common ED problem. What do we do with these? It turns out this is a very complicated question. Here is a quick summary of solitary pulmonary nodules (SPN):
The incidence of SPN detected by Chest XR in the United States is estimated at 150,000 times per year (1). Malignancy is the highest concern in these patients, many of which are amenable to discharge. Lung cancer is the number one cause of cancer-related deaths worldwide, estimated at 1.38 million per year (2). It is often silent and only discovered when it is extensive and has a poor prognosis of survival. Nodule-forming cancer is likely to be metastatic or non-small cell lung cancer (NSCLC). If you’ve discovered a primary lung cancer (NSCLC) and it is stage I, the 5-year survival rate is very high if treated. However not all of these nodules are malignant. Herein lies the problem: who do we work up for these nodules and what is the follow-up we should recommend from the ED?
I did some searching for help and found two evidence-based guidelines discussing SPN management:
American College of Radiology (ACR)
What do the radiologists recommend? Here is a link to the ACR recommendations on further imaging in SPN:
ACR SPN Guidelines
American College of Chest Physicians (ACCP)
The ACCP also weighs in on SPN management with open access guidelines from 2007:
ACCP SPN Guidelines
Reading these guidelines can help formulate a plan for your patient based on risk profiles, nodule characteristics, and suspicion of malignancy. I would encourage you to read these so that a plan can be made if you are discharging anyone with an incidental finding of SPN. My advice:
1. Show them the nodule and mention the word “cancer.” I prefer the statement “we need to make sure this isn’t cancer.” In my experience this causes a brief state of shock followed by motivation to listen to your follow up plan. Be prepared to explain to them why you aren’t admitting them to the hospital.
2. Explicitly discuss and write down a follow up plan with the patient and/or patient representative. Make sure this plan is documented in your record. Missed follow-up of these nodules could cause a early malignancy with a good prognosis to progress to a large malignancy with a poor prognosis. This is not only bad for the patient but is a significant source of litigation for ED providers. I usually refer them to primary care and tell them to take my discharge instructions to the provider. On the discharge papers I provide a description of the nodule and any radiologist’s impression and recommendations.
3. If you need further information on differential, timing and choice of further studies, etc. call your in-house radiologist and have them give you some recommendations and/or follow the guidelines above.
Author: Russell Jones, MD
1. Kanne JP, Jensen LE, Mohammed TH, et. al. ACR Appropriateness Criteria® radiographically detected solitary pulmonary nodule. [online publication]. Reston (VA): American College of Radiology (ACR); 2012.
2. Ferlay J; Shin HR, Bray F et al. Estimates of worldwide burden of cancer 2008: GLOBOCAN 2008. International Journal of Cancer 127 (12): 2893–2917.
3. Weinberger SE. Diagnostic evaluation and management of solitary pulmonary nodules. www.uptodate.com. Sept. 14, 2012.
4. Gould MK, Fletcher J, Iannettoni MD et al. Evaluation of Patients with Pulmonary Nodules: When is it Lung Cancer?: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest. Sept. 2007; 132(Supplement 3): 108S-130S.