Board Review

A 58-year-old woman is evaluated for a right pulmonary nodule that was discovered incidentally 3 weeks ago. She is currently asymptomatic and has not had shortness of breath, fever, chills, weight loss, or night sweats. Medical history is otherwise unremarkable, and she takes no medications. She is a life-long nonsmoker.

On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 126/82 mm Hg, pulse rate is 68/min, and respiration rate is 10/min; BMI is 30. There is no cervical or supraclavicular lymphadenopathy. The lungs are clear to auscultation. No clubbing is noted.

The 5-mm nodule seen on CT is shown.

Which of the following is the most appropriate next step in management?

A) Bronchoalveolar lavage

B) PET/CT scan

C) Review any previous chest imaging

D) Transthoracic needle biopsy

Answer: C - Review any previous chest imaging

Objective: Evaluate a subcentimeter pulmonary nodule.

Key Point

In patients with a subcentimeter pulmonary nodule, any previous imaging of the chest should be obtained to establish whether the nodule has remained stable or has grown over time.

The most appropriate next step in management is to review any previous chest imaging the patient may have had. This patient's chest CT shows an incidental finding of a subcentimeter pulmonary nodule. Appropriate evaluation of a subcentimeter pulmonary nodule depends on the patient's risk for lung cancer, which relates to the patient's past or present smoking status and history of other malignancy. Regardless of risk stratification, however, any previous imaging of the chest should be obtained as a comparison. If previous chest imaging confirms stability of the nodule for more than 24 months, further imaging may not be necessary. Previous imaging can also help in determining the best next step in management as well as when to repeat future imaging. For example, if the nodule has been increasing in size, short term follow-up may be indicated whereas documented stability would allow the clinician to extend the time until next imaging. If no previous imaging is available, the clinician should refer to the Fleischner criteria to establish the timing of the next imaging.

Bronchoalveolar lavage provides samples from small bronchi and alveoli and is typically used to diagnose infection or to obtain cell counts in the diagnosis of parenchymal lung disease. It is rarely helpful in determining the cause of a solitary subcentimeter pulmonary nodule. Given the absence of other symptoms to suggest an infection or parenchymal lung disease, bronchoalveolar lavage is not indicated at this time.

Even if previous imaging is not available, a PET/CT would not be indicated at this time. The CT shows a 5-mm nodule, and PET imaging is usually normal in a subcentimeter pulmonary nodule even if the nodule is malignant.

Biopsy of a solitary pulmonary nodule can be obtained by bronchoscopy, CT-guided needle aspiration, or surgical excision. An enlarging pulmonary nodule or a suspicious-appearing nodule warrants more aggressive evaluation with tissue diagnosis or excision depending on the pretest probability of malignancy. This patient, however, has a low pretest probability of cancer because she is a lifetime nonsmoker and has no history of active malignancy. Even if previous imaging is not available, this nodule should be monitored with repeat imaging based on the Fleischner criteria.

Murrmann GB, van Vollenhoven FH, Moodley L. Approach to a solid solitary pulmonary nodule in two different settings: “Common is common, rare is rare”. J Thorac Dis. 2014 Mar;6(3):237-48. Link Out