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Follow-up Recommendations for Chest CT Scan Reports of Incidental Pulmonary NodulesPulmonary Nodules in CT Scans FREE TO VIEW

Douglas B. Johnson, MD; Mark A. Powers, MD; Shiying Wu, PhD; Yuh-Chin T. Huang, MD, MHS, FCCP
Author and Funding Information

From the Department of Medicine (Drs Johnson, Powers, and Huang), Duke University Medical Center; and the Research Triangle Institute (Dr Wu).

Correspondence to: Yuh-Chin T. Huang, MD, MHS, FCCP, 330 Trent Dr, Hanes House, Room 105-B, Duke University Medical Center, Durham, NC 27705; e-mail: huang002@mc.duke.edu


Portions of this correspondence were presented at the International Conference of the American Thoracic Society in Denver, Colorado, May 18, 2011 (Am J Respir Crit Care Med. 2011;183:A6101).

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(1):280-281. doi:10.1378/chest.11-2157
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To the Editor:

Pulmonary nodules (PNs) are common incidental findings on CT scans. Despite the published guidelines,1 follow-up recommendations for CT scan reports remain variable.2,3 To determine factors that may influence these recommendations, we analyzed chest CT scan reports from patients with PNs (International Classification of Diseases, Ninth Edition code 518.89) between January 1, 2006, and June 30, 2009, after approval by the Institutional Review Board of Duke University Medical Center (Pro00019510). We excluded CT scans done within 5 years of a cancer diagnosis. We categorized follow-up recommendations into level 1 (≤3 months with interventions, eg, PET scan or invasive procedures), level 2 (≤3 months without interventions, or “worrisome or suspicious for malignancy”), level 3 (3-6 months), level 4 (>6 months), and level 5 (no follow-up recommendations).

We enrolled 283 patients (Table 1). The size distribution of the nodules was 24.0%, ≤4 mm; 21.6%, 4-6 mm; 14.8%, 6-8 mm; and 39.2%, >8 mm. The follow-up recommendations were 13.4%, level 1; 21.9%, level 2; 19.1%, level 3; 23.0%, level 4; and 22.6%, level 5. Logistic regression analysis using age (<40, 40-65, >65 years), sex (male or female), largest size of the nodule (<4 mm, 4-6 mm, 6-8 mm, >8 mm), solitary or multiple nodules, availability of previous CT images, study site (university vs community hospital), and time of the CT scan study (January 1, 2006, to December 31, 2007, or January 1, 2008, to June 30, 2009) as independent variables and levels of recommendations as dependent variables showed larger size was associated with more aggressive follow-up recommendations (P < .0001). Smoking status was not included in the analysis since it was not readily available to the radiologists. We then asked two physicians to independently provide follow-up recommendations based on the same clinical information plus smoking status and the Fleischner Society guidelines. The physicians made fewer aggressive follow-up recommendations for nodules ≤8 mm (Fig 1).

Table Graphic Jump Location
Table 1 —Clinical Characteristics of Patients With Pulmonary Nodules

Data given as No. (%) unless otherwise indicated.

Figure Jump LinkFigure 1. Charts show the percentage of patients who received the most aggressive follow-up recommendations (<3 months with and without interventions). Physicians who were blinded for the radiologic recommendations were asked to give follow-up recommendations according to the Fleischner Society guidelines. Radiologic recommendations included levels 1 and 2. P = .0069 for solitary pulmonary nodules and P < .0001 for multiple pulmonary nodules. *P < .05 vs radiologists by contingency table analysis. F/U = follow-up.Grahic Jump Location

The probability of malignancy for small incidental PNs is quite low (only one patient with nodules ≤8 mm had malignancy in our study), but follow-up imaging studies or procedures are frequently recommended, increasing the cost, exposure to radiation, and morbidity.4 Causes for making aggressive recommendations may include varying degrees of conformance with the existing guidelines,3 the lack of clear follow-up recommendations in the guidelines,4 the interpreting radiologist’s lack of knowledge about risk factors (eg, smoking) (Fig 1), and different weight placed on some nonspecific characteristics of the nodules, including shape, spiculation, calcification, and location.5-7 Our results underscore the need to standardize radiologic recommendations for small incidental PNs and the importance for physicians to formulate independent follow-up plans based on the patients’ risk factors and current guidelines.

MacMahon H, Austin JH, Gamsu G, et al. Fleischner Society Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;2372:395-400 [PubMed] [CrossRef]
 
Singh S, Pinsky P, Fineberg NS, et al. Evaluation of reader variability in the interpretation of follow-up CT scans at lung cancer screening. Radiology. 2011;2591:263-270 [PubMed]
 
Eisenberg RL, Bankier AA, Boiselle PM. Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology. 2010;2551:218-224 [PubMed]
 
Alpert JB, Naidich DP. Imaging of incidental findings on thoracic computed tomography. Radiol Clin North Am. 2011;492:267-289 [PubMed]
 
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;1578:849-855 [PubMed]
 
Takashima S, Sone S, Li F, Maruyama Y, Hasegawa M, Kadoya M. Indeterminate solitary pulmonary nodules revealed at population-based CT screening of the lung: using first follow-up diagnostic CT to differentiate benign and malignant lesions. AJR Am J Roentgenol. 2003;1805:1255-1263 [PubMed]
 
Takashima S, Sone S, Li F, et al. Small solitary pulmonary nodules ( < or =1 cm) detected at population-based CT screening for lung cancer: reliable high-resolution CT features of benign lesions. AJR Am J Roentgenol. 2003;1804:955-964 [PubMed]
 

Figures

Figure Jump LinkFigure 1. Charts show the percentage of patients who received the most aggressive follow-up recommendations (<3 months with and without interventions). Physicians who were blinded for the radiologic recommendations were asked to give follow-up recommendations according to the Fleischner Society guidelines. Radiologic recommendations included levels 1 and 2. P = .0069 for solitary pulmonary nodules and P < .0001 for multiple pulmonary nodules. *P < .05 vs radiologists by contingency table analysis. F/U = follow-up.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Clinical Characteristics of Patients With Pulmonary Nodules

Data given as No. (%) unless otherwise indicated.

References

MacMahon H, Austin JH, Gamsu G, et al. Fleischner Society Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;2372:395-400 [PubMed] [CrossRef]
 
Singh S, Pinsky P, Fineberg NS, et al. Evaluation of reader variability in the interpretation of follow-up CT scans at lung cancer screening. Radiology. 2011;2591:263-270 [PubMed]
 
Eisenberg RL, Bankier AA, Boiselle PM. Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology. 2010;2551:218-224 [PubMed]
 
Alpert JB, Naidich DP. Imaging of incidental findings on thoracic computed tomography. Radiol Clin North Am. 2011;492:267-289 [PubMed]
 
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;1578:849-855 [PubMed]
 
Takashima S, Sone S, Li F, Maruyama Y, Hasegawa M, Kadoya M. Indeterminate solitary pulmonary nodules revealed at population-based CT screening of the lung: using first follow-up diagnostic CT to differentiate benign and malignant lesions. AJR Am J Roentgenol. 2003;1805:1255-1263 [PubMed]
 
Takashima S, Sone S, Li F, et al. Small solitary pulmonary nodules ( < or =1 cm) detected at population-based CT screening for lung cancer: reliable high-resolution CT features of benign lesions. AJR Am J Roentgenol. 2003;1804:955-964 [PubMed]
 
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