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.

6 comments - CLICK HERE to read & add your own!:

Jeff H said...

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...)

Mendez said...

To be on the safe side, I have actually been doing 3,6, 12, 24. When I say safe, I mean that someone could argue that that is the standard of care - regardless of the poor evidence it is based on.

Jennings said...

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.

Jeff H said...

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.

Mendez said...

This is just defensive medecine. If a lawyer argues to a judge and/or lay people that the standard of care was not followed then I think you might be in trouble.
But, baw, in theory, I definitely agree with you.

Baleeiro said...

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).