inpatient / hematology and oncology

New Solitary Lung Nodule

Last Updated: 1/4/2023

# New Lung Nodule
(High Risk: >2cm, >60yo, current smoker, upper lobe, spiculated; Low Risk <0.8cm, <40yo, never smoker, lower/middle lobe, smooth contours)

-- History: *** h/o PNAs, smoking (pack years, types, quit), radon, asbestos
-- Clinical: *** SOB, cough, hemoptysis, hoarseness, dysphagia
-- Exam: *** decreased breath sounds, horner syndrome, SVC syndrome, clubbing, focal neuro deficits (CNS mets),
-- Data: *** prior chest imaging, CXR, CT Chest, biopsy
-- Etiology/DDx: *** NSCLC (adenocarcinoma, SCC), small cell carcinoma, metastasis (multiple nodules), hamartoma, TB, sarcoid

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- High risk gets surgical excision; If >0.8cm FDG-PET or biopsy then either monitoring via CT scan q2-3 year or surgical excision
-- Tissue: plan to biopsy *** (node, metastatic site, primary lung mass)
-- Imaging: *** (staging scans - CTAP and CT chest, MRI brain)
-- Other: Liquid Biopsy per institutional protocol - Guardant
-- Supportive Tx: dex for vasogenic edema
-- Outpatient follow-up: oncology, radiation oncology, PFTs if surgery possible

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If You Remember Nothing Else

Compare to old imaging. If concerning features, get a biopsy - start with metastatic deposit (liver, node, etc), or the primary either via bronchoscopy or via trans-thoracic biopsy. Staging scans include CTAP, CT chest, and MRI brain. Many institutions will send off liquid biopsies to increase the sensitivity for picking up targetable mutations (along with the samples from the primary biopsy). Ensure the patient has adequate oncology follow-up planned.

Clinical Pearls

  • High Risk Solitary Nodules: >2cm, >60yo, current smoker, upper lobe, spiculated; Low Risk: <0.8cm, <40yo, never smoker, lower/middle lobe, smooth contours
  • Most solitary pulmonary nodules (SPNs) are benign
  • Calcifications and lack of growth over time are best indicators of benign pathology
  • Screening via CXR does not reduce lung cancer mortality; Screening via low dose CT scan may reduce mortality in some populations (older men who smoke)
  • You should attempt to biopsy any concerning metastatic deposits first (nodes, liver, etc) - if they are positive, that not only tells you the diagnosis, but also confirms stage 4 advanced disease
  • Hilar masses can often be sampled via bronchoscopy, more peripheral via SubQ biopsy
  • MRI has a greater sensitivity than CT for detecting CNS metastases, and is performed before definitive treatment, especially curative surgery
  • PET-CT has sensitivity of ~97% for detecting malignancy, but not as specific - also will pick up endemic infectious lung diseases (TB, etc)
  • SCC has a dose-response to tobacco smoking, usually in proximal airways; Adenocarcinoma usually more peripheral
  • Paraneoplastic Syndromes include SIADH, actoptic ACTH, Lambert-Eaton syndrome, Hypercalcemia from PTHrP
  • Targetable mutations - EGFR, ALK, BRAF, RET, ROS1, NTRK, MET, KRAS, PD-L1
  • Screening via CXR does not reduce lung cancer mortality; Screening via low dose CT scan may reduce mortality in some populations (older men who smoke)

Trials and Literature

  • Current Landscape of Non-Small Cell Lung Cancer (Cancers, 2021)
  • Screening for Lung Cancer: USPSTF (JAMA, 2021)
  • Low Dose CT Screening for Lung Cancer: Time to Implement or Unresolved Questions? : "As of 2020, in the process of shared decision-making with patients, we would suggest the following counseling: If you elect to undergo lung cancer screening, there is 13.93% risk of death at 10 years with screening and 13.76% risk of death without, and those percentages are statistically indistinguishable. As for the risk of lung cancer death, it is decreased from 3.2 to 2.4% with screening, a difference of 0.74%. Communication of these facts is essential to informed decision-making." (J Gen Intern Med, 2021)

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