Lung nodule and Lung cancer service

Lung cancer is the most common cause of cancer. It is also the most common cause of death from cancer worldwide. This is because lung cancer is often diagnosed in the later stages after the disease has progressed and symptoms become more apparent. Thus, there is a great need to increase awareness of lung cancer risk factors and establish an early assessment and diagnosis pathway for such patients.

National Lung Cancer Screening Program

Australia now has a Lung Cancer Screening Program for people at highest risk of lung cancer.

. To be eligible, a person needs to be between 50 and 70 years old, have smoked the equivalent of 30 packet-years (e.g. 20 cigarettes a day for 30 years, or 30 cigarettes a day for 20 years) and either still smokes cigarettes or gave up smoking in the last 10 years. A free low-dose CT scan is performed every two years.

For patients who have been diagnosed with a lung nodule:

If a CT scan or Coronary CT score scan finds a growth in the lung (lung nodule), then you may be referred to doctors at East Melbourne Heart & Lung. Here we offer a service with an established pathway for patients with a newly diagnosed lung nodule needing urgent investigation and management.

We work closely in a multidisciplinary manner with radiologists, pathologists, oncologists and radiotherapy specialists. All you will need is a referral from your provider and bring your scans to your clinic appointment. After a review of your scans we will organise any further relevant testing. Many scans can be accessed by our doctors on line if you tell our secretaries where the scan was performed.

What are pulmonary nodules?

A pulmonary nodule is a small round or oval-shaped growth in the lung. It may also be called a “spot on the lung” or a “coin lesion.” Pulmonary nodules are smaller than 3cm in diameter. If the growth is larger than that, it is called a pulmonary mass and is more likely to represent a cancer than a nodule.

What causes pulmonary nodules?

There are two main types of pulmonary nodules: malignant (cancerous) and benign (noncancerous). The majority (>90%) of pulmonary nodules that are smaller than 2cm in diameter are benign.
There are a number of causes for benign nodules. Many are due to inflammation in the lungs as a result of an infection or more widespread inflammation. The nodule may represent an active problem or it may be due scar tissue from a previous inflammation. Causes of benign lesions include:

• Infections
• Non-infectious causes eg. Sarcoidosis, rheumatoid arthritis
• Neoplasms (benign or malignant)

What are the symptoms of pulmonary nodules?

Usually there are no symptoms but if present, symptoms would be related to the condition that caused the nodule to develop. If the nodule is due to lung cancer, the patient is often without symptoms or may have developed a new cough, or coughed up blood. Most of the time, a patient is unaware of the presence of a lung nodule until a CT scan of the lungs is performed and the nodule is picked up incidentally or as part of the National Lung Cancer Screening Program.

How common are pulmonary nodules?

Countless pulmonary nodules are found each year on CT scans. Most nodules are non-cancerous (benign). A solitary pulmonary nodule is found on up to 0.2% of all chest X-ray films. Lung nodules are more commonly found on more sensitive scans such as lung CT scans, where they are discovered upto 50% of the time. Risk factors for malignant pulmonary nodules include a history of smoking and older age.

How is the cause of pulmonary nodules diagnosed?

Though most lung nodules are not malignant, it is very important that nodules that could be cancerous are identified early on so that they can be removed at an early and curable stage.

What are the initial tests involved in investigating a lung nodule?

• CT Scans — Usually, the first sign that a pulmonary nodule is present is a spot on the lung that shows up on a chest X-ray or a CT scan. These tests are usually done when a person sees the doctor for a respiratory illness, or may be found as part of the National Lung Cancer Screening Program.

If the CT scan shows a spot on the lungs, your doctor will ask you about your medical history, including whether you have had cancer in the past. He or she will want to know whether you are a smoker or former smoker and about any exposure to environmental chemicals that may be toxic.

The doctor will look at the scan to evaluate the size and shape of the nodule, its location, and its general appearance. Nodules can be seen on a CT scan as small as 2-3 mm. Smaller nodules will be difficult to see. Other factors that make a nodule look more cancerous are: the larger the nodule is, the more irregularly shaped it is, and those located in the upper portions of the lung. Usually doctors are not concerned about nodules of less than 6mm, but they may need to be observed over several years to be sure.

You should bring in an old chest CT scans so that your doctor can look at them to determine the growth rate of the nodule. In general, malignant nodules double in size every one to six months. Nodules with a slower or faster growth rate are less likely to be cancerous.

If the nodule is too small to be sampled or if its features suggest a very low likelihood that it represents a cancer, your doctor may recommend to follow the nodule over time with repeated chest imaging. If the nodule size remains stable over a certain period of time, then it is confirmed to be benign. If a concerning pace of growth is noted, then additional evaluation would be suggested. The interval between scans and the length of follow-up depends on the size of the nodule and the risk of malignancy.

Other tests that may be required to further investigate your lung nodule:

• Positron emission tomography (PET) — A PET scan can also help to find out if a nodule is malignant or benign. A PET scan uses a radiolabeled substance such as glucose that is absorbed by the nodule, and provides a picture of the nodule’s metabolic activity level. Malignant cells have faster metabolic rates than normal cells, so they require more energy and thus absorb more of the radiolabeled substance. Nodules can light up on PET imaging if they are malignant or if there is active inflammation. We have to be careful with the PET scan interpretation when someone has nodules smaller than 8-10 mm because they are not seen well by PET imaging.
• Biopsy — A biopsy is a procedure in which a small tissue sample is removed from the nodule so it can be examined under a microscope. It may be performed when other tests are inconclusive to rule out the chance that a growth is malignant.

There are a few ways to obtain a sample of the lesion, short of going to surgery. The method used depends on the size and location of the nodule, as well as the comfort of the medical team with these procedures. Our expert respiratory physicians or thoracic surgeons perform the first two procedures, whilst a needle biopsy with CT guidance is undertaken by experienced radiologists.

• Bronchoscopy: This procedure is used if it appears the nodule can be reached through the breathing tubes. It uses a bronchoscope, which is a thin, lighted flexible tube that can be inserted into the mouth or nose and through the windpipe (trachea) into the bronchus (airway) of the lung. The bronchoscope has a very small camera at its end. Biopsy tools can be passed through the camera to reach the nodule. It is an outpatient procedure with a low risk profile generally.
• Linear or Radial EBUS (Endobronchial Ultrasound): This procedure is used when the nodule lies a bit deeper in the lung. It is similar to a bronchoscopy but a slightly thicker flexible tube is inserted into the mouth or nose and then through to the lungs. The nodule (or sometimes a lymph node) is identified using ultrasound and a sample is obtained specifically from the site of the nodule. This increases the likelihood of obtaining a result.
• Needle biopsy (also known as transthoracic needle aspiration): This test is most successful when the nodule is towards the edge of the lung, near the chest wall. A needle is inserted through the chest wall and into the nodule, usually under the guidance of a CT scan.

Surgical removal is reserved if the nodule has a very concerning appearance or growth pattern, or it is somewhat concerning and its nature is not able to be clarified by the above tests. This will diagnose the nature of the nodule while treating it at the same time. However, this requires the patient be fit enough to undergo the surgery.

How are pulmonary nodules treated?

If the pulmonary nodule is benign, it usually does not require treatment. If an active infection or a disease of inflammation in the body is found, then treatment would be based on the condition identified and the symptoms that are present.

If the nodule is malignant, there seems to be no spread of the cancer, and the patient is fit, then the cancer should be removed with surgery. If a non-surgical biopsy of a nodule with high concern for malignancy is done and the results are inconclusive, it is recommended that the nodule be taken out.

Surgical techniques to take out pulmonary nodules include:

Video-Assisted Thoracoscopy (VATS) — This procedure uses a flexible tube with a small camera on its end. This scope is inserted through a small cut into the chest wall. The camera allows the surgeon to view an image of the nodule on a screen. This technique needs a smaller cut and a shorter recovery time than a thoracotomy procedure.

Robotic Thoracic Surgery (RTS) – This procedure involves the creation of small cuts, called ports, on the chest. The da Vinci robot is docked to these ports and samll robotic instruments are inserted into the chest. Your surgeon then controls these instruments from a console so that complex surgery can be performed with much less pain and much quicker recovery. Many thoracic surgical procedures can now be performed with the da Vinci dV5, da Vinci Xi or da Vinci SP robots.

Thoracotomy – This is the original method for performing lung surgery, however, it is now rarely performed. It is reserved for cases where the tumour to be removed is too big to be removed by keyhole surgery such as VATS or RTS, or if there is major bleeding or other difficulty during VATS or RTS.