Multidisciplinary selection of pulmonary nodules for surgical resection: diagnostic results and long-term outcomes

Abstract Objective Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported. Methods All patients evaluated at a PNLCSC from 2012-2018 following referral by primary care physicians, specialist physicians or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival and recurrence were compared. Results Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)—representing 3.3% (21/632) of all incidental nodules evaluated—than in the screening group (4%, 1/25) (p=0.038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathological stage Ia. Complete follow-up was available in 725/747 (97%) and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (p=0.48). Conclusions A unique multidisciplinary PNLCSC for incidental and lung cancer screening-detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure and cost control need further study.