Medium-sized lung nodules may prompt unnecessary surgery

By David Douglas

A substantial proportion of patients who undergo surgery because of moderately sized lung nodules have benign disease, according to a review of community pulmonary practices.

As Dr. Gerard Silvestri said in a statement, "Indeterminate lung nodules (between 8 and 20 mm) are difficult to diagnose." Typically, he added, "nodules smaller than those are treated conservatively, while larger ones are treated more aggressively. This is the first study of its kind to focus on this middle group."

As reported June 18 online in Chest, Dr. Silvestri of the Medical University of South Carolina in Charleston and colleagues conducted an observational record review involving 377 patients aged 40 to 89 referred to 18 geographically diverse community pulmonary practices because of such nodules.

The prevalence of malignancy was 25%, and almost half of all patients (46%) had observation alone. Of 77 patients (20.4%) who underwent surgery, 27 (35%) had benign disease.

Positive emission tomography (PET) scans used in 141 patients (37%) had a false positive rate of 39%.

Researchers used two validated models to estimate the pretest probability of malignancy in each patient. These showed 9.5% of patients to be low-risk, 79.6% to be of moderate risk and 10.8% to be high risk. However, surgery rates in the high and low risk groups were identical (17%) and similar to that in the moderate risk group (21%).

Lead author Dr. Nichole T. Tanner, also of the Medical University of South Carolina, told Reuters Health by email, "With (computed tomography) scans being ordered for a myriad of symptoms, the number of indeterminate lung nodules is on the rise, and in the coming years we are likely to see a further increase as screening for lung cancer with low-dose CT is implemented."

"My hope," she concluded, "is that this study will play a role in raising awareness of the importance of managing these patients in closer accordance with established guidelines to ensure that only the appropriate patient is subjected to the risks associated with invasive procedures."

Commenting by email, pulmonologist Dr. Renda Soylemez Wiener of Boston University School of Medicine told Reuters Health, "This study makes an important contribution to the field in examining care of patients with pulmonary nodules in the community setting."

Dr. Wiener, who has conducted research in the field, added, "The finding that the risk of cancer did not appear to drive the work-up received - in other words that patients with a low risk of a malignant nodule were just as likely to receive surgery as patients with a high risk of a malignant nodule - is particularly concerning."

"As has been shown previously in the VA (Veterans Affairs) setting," she concluded, "this study suggests that patients with pulmonary nodules who receive care in the community are at risk of receiving both inadequate as well as overly aggressive evaluation."

The study was funded by Indi (Integrated Diagnostics) the maker of Xpresys Lung, which provides noninvasive lung nodule assessment. Drs. Tanner and Silvestri are among authors who have received consulting fees from Indi and another author is an employee of the company.

SOURCE: http://bit.ly/1ft5RtO

Chest 2015.

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