James G. Ravenel MD, Presenter: Nothing to Disclose

Nichole Tanner, Abstract Co-Author: Research support, Integrated Diagnostics

Anil Vachani, Abstract Co-Author: Research support, Integrated Diagnostics

Gregory B. Diette, Abstract Co-Author: Research support, Integrated Diagnostics

Jyoti Aggarwal, Abstract Co-Author: Nothing to Disclose

Charles Mathews, Abstract Co-Author: Nothing to Disclose

Paul Kearney, Abstract Co-Author: Nothing to Disclose

Kenneth Fang, Abstract Co-Author: Nothing to Disclose

Gerard Silvestri MD, Abstract Co-Author: Nothing to Disclose

Increased utilization of CT along with a growth in lung cancer screening will result in the detection of many new small nodules. While there are defined algorithms for the management of small nodules in screening trials, little is known as to how small nodules are managed in the private practice setting.  The purpose of this chart abstraction is to understand what diagnostic pathways are utilized to diagnose small pulmonary nodules in community practice.

A chart review was conducted of ten community practice pulmonology clinics across the United States. This study was approved with a waiver of consent from the IRB and charts were reviewed and findings documented in a HIPAA compliant manner.  Consecutive charts from patients with newly detected pulmonary nodules between 8 and 20 mm with either a confirmed diagnosis or two-years follow-up were included. Nodules >8 and <15 mm were further reviewed for procedures performed and divided into major (medistinoscopy, thoracoscopy or thoracotomy), minor (bronchoscopy or image guided biopsy) or surveillance (PET, CT).

One hundred ninety-five charts from 10 practices were abstracted. The average age was 64.7 years. 46% were male and 87% were white. Never smokers, former smokers, and current smokers accounted for 28%, 41%, 31%, respectively. A total of 159 nodules 8-15 mm in size were reviewed. A final diagnosis of malignancy was made in 30 (18.8%) by 24 major and 6 minor procedures. There were 129 (82.1%) benign nodules. This was confirmed by histopathology in 48 cases (30.3%) (14 major and 34 minor procedures). The remaining 81 (50.9%) were followed radiographically and considered indeterminate or benign at the end of two years. Of those monitored, 4 underwent non diagnostic minor procedures, 74 had a least one CT follow-up (range 0-7) and 20 had a FDG PET scan. 

Over one third of benign nodules between 8 and 15 mm in our chart review underwent an invasive procedure for diagnosis. Education and improved pathways are needed in the community to limit costs and potential morbidity related to small nodule management.

Over 1/3 of benign nodules referred to community pulmonologists undergo an invasive procedure for diagnosis.  Better pathways are needed to avoid invasive diagnosis of benign lesions.

Ravenel, J, Tanner, N, Vachani, A, Diette, G, Aggarwal, J, Mathews, C, Kearney, P, Fang, K, Silvestri, G, A Multicenter, Community Based Chart Review of the Management of Small (8-15 mm) Nodules by Pulmonologists.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13024604.html