NETWORKS Pulmonary Physiology, Function, and Rehabilitation Disaster Response Pulmonary Vascular Disease Thoracic Oncology

BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.

Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.

Dr. Wassim H. Fares, FCCP, NetWork Member

Dr. William R. Auger, FCCP, Steering Committee Member

Pulmonary nodules: Are you seeing spots?

Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.

Dr. Lynn Tanoue, FCCP

NetWork Chair

Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.

Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.

Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. https://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.

MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.

McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.

Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.

Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.

Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.