Tuesday, July 12, 2005
tiny nodules
Let me ask you a question. I come across these patients all the time. You get a patient with a few tiny nodules on CT, picked up incidentally. Even though you know deep down they are benign, are you obligated to follow them out to 2 years? I have a CT from 12/04 and a CT from 6/05 with no change in these little nodules. She is a nonsmoker so I thik I'm done... BUT even if she is a smoker, do we HAVE to follow these things out to 2 years? I mean what do you *actually* do, now that you are an attending/in real world and it's your neck on the line.
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4 comments - CLICK HERE to read & add your own!:
We've picked up a few of these in the "screening" CT trial that is ongoing (actually, I think the recruitment phase is done). There's no good answer--but I think that it's reasonable to get periodic imaging. I wouldn't get the 3,6,12,24 month CT scans, but I'd consider 6,12, and then maybe yearly or every other year. We all know that the "2 year" rule is based on a small, poorly done study.
I'd love to not follow these, but I'd also love to not get sued for the 1 in 100 or 1 in 1000 that actually has a cancer develop (that may or may not be related to any of the nodules...)
But if you have a bunch of tiny nodules that don't change in a whole year, how could that possibly be cancer? The 2 year rule is based on studies with CXR's that would not have picked up these little lung specks.
I'm more inclined to follow them if they are clustered in one area, than if there are, say, 4 diffent 2mm nodules scattered in 3 different lobes. Also, I may approach it differently if there is one more "dominant" nodule. Again, until the studies are done, there is no definitive answer.
The standrad of care issue seems to be pushing us to follow them. I frequently use an algorithm based SPN calculator for the risk of Ca. If the risk is very low (particularly in a non-smoker) and if you have an enlightened Pt who understands odds you can follow them at longer intervals than 3 months. In your case, the nodules seem to be so small you may repeat a CT in 6 months and and then at the 2 year mark and call it a day.
The more frustrating cases I've had is when on the third or fourth CT scan the nodules are finally resolving but you find a brand new 5mm nodule in a different location... do you then reset the follow-up clock or just keep an eye on all of them.
I have recently seen a guy in follow-up: his 6mm nodule had been stable for a year on q3month scans and now decided to increase to 10mm so he is going to surgery (he is a smoker though).
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