Pulmonary nodules are spots that may be seen on chest imaging studies. Those can be found incidentally or through lung cancer screening studies.
 

Screening:
The US Preventive Taskforce (USPTF) recommends annual lung cancer screening in individuals who do not have symptoms. Symptoms include coughing blood, interactable cough, abnormal weight loss, and meet the following criteria.

• Age 50-80 and
• 20 pack year smoking (cigarette) history and
• Current Smoker or quit within 15 years and
• Healthy enough to undergo curative treatment (surgery/radiation)

When small nodules are detected, your provider would need to determine high risk ones based on their appearance and your individual risks.

High risk nodules:

• Irregular margins
• displace the pulmonary fissure
• Associated with enlarged hilar or mediastinal lymph nodes
• Size >8mm

Once high risk nodules are identified, an outpatient consultation is processed by the pulmonary team.

• The initial evaluation team includes a pulmonologist, a dedicated Pulmonary Nodule Nurse Practitioner, and an RN coordinator.
• A pulmonologist is an internist who has completed specialty training in diagnosing and treating lung conditions including procedures such as pulmonary endoscopy (Bronchoscopy).
• The provider dispositioning the consult would evaluate the clinical features, radiographic features, and occasionally utilize quantitative models to determine the likelihood of malignancy. The likelihood of malignancy then determines further management, usually evaluation in the Specialty Consult One Time (SCOT) clinic, PET/CT, and consideration for a biopsy or continuation of surveillance in pulmonary nodule clinic.

1. Specialty Consult One Time (SCOT) Clinic

• This clinic is a one-time, rapid evaluation clinic where patients with identified high risk pulmonary nodules or masses are seen.
• In collaboration with the Pulmonary RN coordinator, all required testing including radiology studies and pulmonary function testing are coordinated prior to or on the same day of the consult visit. Appointments are generally scheduled within 1-2 weeks of the creation date of consultation.

2. Pulmonary nodule clinic

• This clinic is dedicated for non-urgent initial nodule evaluations, routine monitoring of nodules and post treatment for early stage disease monitoring.

3. Radiology

• CT chest with and without
• PET/CT

4. Other Testing:

• Pulmonary function testing:
  • Pulmonary function tests (PFTs) are noninvasive tests that show how well the lungs are working. The test usually includes spirometry, lung volume measurements, and quantification of diffusing capacity. 
• Exercise testing:
  • Cardiopulmonary exercise testing (CPET), is used to assess patients with abnormal PFTs to determine the safety of planned lung resection surgery.

• Nuclear stress testing:
  • A stress test measures how well the heart works when it is pumping very fast.

• Perfusion study:
  • The test measures perfusion ratio into the different sections of your lungs to determine the safety of planned lung resection surgery.

5. Tissue Biopsy:

• Standard Bronchoscopy:
  • is an endoscopy procedure that visualizes the airway tree by placing an camera inside the airway to examine them to visualize and
• Endobronchial Ultrasound (EBUS):
  • This involved placing a flexible bronchoscopy with an ultrasound probe to visualize structures surrounding the airway (e.g. lymph nodes, blood vessels, or lung masses). It allows a visual of the tissue to facilitate endobronchial biopsies of enlarged nodes or masses
• Navigation bronchoscopy:
  • This special catheter allows your pulmonologist to insert a probe and steer it into the smaller airways to allow access to nodules or masses away from the mid-line of the chest.
• Trans-thoracic needle aspiration (TTNA):
  • Peripheral nodules may be amenable for biopsy with the guidance of a CT scan.
• Pathology
  • The sample of tissue (biopsy) taken from a patient and examined by a pathologist to determine if cancer is present.
  • A pathologist is a medical doctor who specializes in the diagnosis and anatomic staging of cancer by looking at tissues or single cells under a microscope, in the context of clinical history and any available imaging findings.
  • The pathologist will examine and diagnose both the biopsy sample and any larger specimens removed during surgery (“resections”), to determine whether a tumor is benign or cancerous, and if cancerous, the exact cell type, grade, and stage of the tumor.
  • In some cases, a pathologist will also perform testing for genetic alterations within the tumor that may guide targeted therapies for specific cancer subtypes.

If you have a biopsy performed at an outside facility, please ensure that the referring provider requests the pathology sample and results be mailed to the TVHS Pathology Department for a secondary review.

Tennessee Valley Healthcare System
Department of Pathology (113-Histology)
Nashville Campus
1310 24th Avenue South
Nashville, TN 37212

Pulmonary chest conference is a multidisciplinary team (MDT) for the discussion of collective decisions focused on the diagnosis and treatment of patients with lung cancer. Lung cancer MDTs involve combinations of the following sub-specialties: a pulmonologist, interventional pulmonologist, medical and radiation oncologists, thoracic surgeons, pathologists, radiologists, and specialist nurse practitioners. The MDT allows for ease of communication between specialists for discussions regarding selection of additional testing and treatment and individualizing the patient plan of care.

1. Thoracic Surgery – Surgical biopsies (Mediastinoscopy) and surgical treatments
Our thoracic surgical team is globally, regionally and locally recognized for their expertise in treating simple and complex thoracic and esophageal conditions. Our surgeons and providers offer medical knowledge, technical expertise, and compassion needed to manage thoracic surgical care. At the VA, our priority is treating Veterans with lung and esophageal cancer.