Solitary Pulmonary Nodules
DR. FLORES, MD THE CHANGING PRACTICE OF NODULE MANAGEMENT DR. MARSHALL: How has lung cancer screening changed your practice? DR. SWANSON: I think what has changed is we’re seeing smaller, more peripheral nodules, and we’re also seeing multiple nodules. Twenty years ago, you might see a 3-cm lesion solitary and now you’ll see a 1.2-cm lesion in the right lower lobe and then a 3or 4-mm lesion in the left upper lobe or something in the right upper lobe in addition. How do you triage different multiple lesion scenarios in addition to just ground glass vs solid. DR. BAUER: I think the number has definitely increased for 2 reasons. One, there’s lung cancer screening that’s being done in the high-risk patients, but then it seems as though the vast majority of people who come into the emergency room end up with a CT of something. DR. MARSHALL: I have found that just the thickness of the slices in CT, as they have become so fine, these scans are picking up 3-mm nodules, 4mm nodules, which at times are just intraparenchymal lymph nodes. These are usually in patients who are being followed with a previous malignancy. I don’t recall seeing these a decade ago. DR. SWANSON: Agree. The high-resolution CTs have shown us a lot of pathology. But I think if they’re small and new, it’s easy to say “let’s see what happens to this in 3 months or 4 months.” If you see a spiculated mass or a concerning mass and then maybe 1 or 2 others, do you just focus on the one you’re worried about and does it affect what kind of operation you’re going to do, how you’re going to work it up? I’m more aggressive with mediastinal evaluation if there are multiple nodules. DR. FLORES: I think the most important thing is to figure out what is real and what is not real. Are you sitting on something that’s going to develop into