A Multicenter, Community-Based Chart Review of the Evaluation and Management of Lung Nodules by Pulmonologists

Abstract

PURPOSE: Lung nodules are a common reason for referral to a pulmonologist. Much of what is known about pulmonary nodules is derived from lung cancer screening studies. Little is known about patient demographics, nodule characteristics, the prevalence of malignancy, or the management strategies of lung nodules among practicing pulmonologists. METHODS: 195 charts were reviewed at 10 geographically diverse community pulmonary practices. Consecutive charts from patients with newly identified indeterminate lung nodules between 8 to 20 mm in size with either a histopathologic diagnosis or minimum two-years of follow-up were included. Patient demographics, nodule characteristics, follow-up imaging, invasive procedures and histopathologic results were abstracted. Statistical analyses with chi-squared testing were performed to determine factors influencing follow-up. RESULTS: Demographics of the 195 patients included an average age of 64.7 (±10.8) years, with 46% male and 87% Caucasian, and a smoking status distribution of 28% never, 41% former, and 31% current smokers. The average nodule size was 12.4 mm (±3.4) with a lobar distribution of 58.5% upper or middle and 41.5% lower. Clinical follow-up for 34.4% of patients was performed exclusively by CT/CXR, with an additional 10.8% undergoing PET scan. 54.9% of patients underwent an invasive diagnostic procedure, distributed between 31.3% minor (bronchoscopy and/or CT-guided needle biopsy) and 23.6% major (mediastinoscopy, video-assisted thorascopic surgery, thoracotomy, and thoracoscopy) procedures. Patients undergoing invasive diagnostic procedures had larger nodules than those who received monitoring alone (13.3±3.7 mm vs. 11.4±2.8 mm; p<0.01). 21.2% of the patients had a histopathologically confirmed malignancy. 15% of surgeries yielded a cancer diagnosis; the remaining cancers were diagnosed with minor invasive procedures (6%). CONCLUSIONS: Although the vast majority of pulmonary nodules presenting to community pulmonologists are benign, a significant number of patients undergo invasive procedures. Larger nodules were more likely to undergo invasive procedures, though the majority of those were benign.