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Digby GC, Lam S, Tammemägi MC, Finley C, Dennie C, Snow S, Habert J, Taylor J, Gonzalez AV, Spicer J, Sahota J, Guy D, Marino P, Manos D. Recommendations to Improve Management of Incidental Pulmonary Nodules in Canada: Expert Panel Consensus. Can Assoc Radiol J 2024:8465371241257910. [PMID: 38869196 DOI: 10.1177/08465371241257910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
Introduction: Incidental pulmonary nodules (IPN) are common radiologic findings, yet management of IPNs is inconsistent across Canada. This study aims to improve IPN management based on multidisciplinary expert consensus and provides recommendations to overcome patient and system-level barriers. Methods: A modified Delphi consensus technique was conducted. Multidisciplinary experts with extensive experience in lung nodule management in Canada were recruited to participate in the panel. A survey was administered in 3 rounds, using a 5-point Likert scale to determine the level of agreement (1 = extremely agree, 5 = extremely disagree). Results: Eleven experts agreed to participate in the panel; 10 completed all 3 rounds. Consensus was achieved for 183/217 (84.3%) statements. Panellists agreed that radiology reports should include a standardized summary of findings and follow-up recommendations for all nodule sizes (ie, <6, 6-8, and >8 mm). There was strong consensus regarding the importance of an automated system for patient follow-up and that leadership support for organizational change at the administrative level is of utmost importance in improving IPN management. There was no consensus on the need for standardized national referral pathways, development of new guidelines, or establishing a uniform picture archiving and communication system. Conclusion: Canadian IPN experts agree that improved IPN management should include standardized radiology reporting of IPNs, standardized and automated follow-up of patients with IPNs, guideline adherence and implementation, and leadership support for organizational change. Future research should focus on the implementation and long-term effectiveness of these recommendations in clinical practice.
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Affiliation(s)
- Geneviève C Digby
- Department of Medicine, Division of Respirology, Queen's University, Kingston, ON, Canada
| | - Stephen Lam
- Department of Integrative Oncology, BC Cancer and the University of British Columbia, Vancouver, BC, Canada
| | - Martin C Tammemägi
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Christian Finley
- Department of Surgery, Division of Thoracic Surgery, McMaster University, Hamilton, ON, Canada
| | - Carole Dennie
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Stephanie Snow
- Department of Medicine, Division of Medical Oncology, Dalhousie University, Halifax, NS, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jana Taylor
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, QC, Canada
| | - Anne V Gonzalez
- Department of Medicine, Division of Respiratory Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Spicer
- Department of Surgery, Division of Thoracic Surgery, McGill University, Montreal, QC, Canada
| | - Jyoti Sahota
- Health Economics and Market Access, Amaris Consulting, Toronto, ON, Canada
| | - Danielle Guy
- Health Economics and Market Access, Amaris Consulting, Barcelona, Spain
| | - Paola Marino
- Health Economics and Market Access, Amaris Consulting, Montreal, QC, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada
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Loftus JR, Kadom N, Baran TM, Hans K, Waldman D, Wandtke B. Impact of Early Direct Patient Notification on Follow-Up Completion for Nonurgent Actionable Incidental Radiologic Findings. J Am Coll Radiol 2024; 21:558-566. [PMID: 37820835 DOI: 10.1016/j.jacr.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE The aim of this study was to evaluate whether early direct patient notification in addition to an existing multistage recommendation-tracking system (Backstop) increases follow-up completion rates for actionable incidental findings (AIFs). Patient attitudes toward early notification were also assessed. METHODS This prospective, randomized controlled trial recruited patients with AIFs requiring follow-up being enrolled into the Backstop system. Patients were randomized into four groups: those receiving additional early direct notification in a mailed letter (group 1, similar to Pennsylvania Act 112), by phone (group 2), or in an electronic portal message (group 3) and a control group (group 4) without additional notifications added to the existing Backstop system. Differences in follow-up completion rates among these groups were determined using χ2 tests. Patients were surveyed on binary yes/no and Likert-type scale questions, and descriptive statistics are reported. RESULTS Data from 2,548 randomized patients were analyzed for the study, including 593 patients notified by letter, 637 notified by phone, 701 notified by portal, and 617 control patients. Group 3 demonstrated the lowest rate of follow-up completion within 1 month of the follow-up due date at 36.4%, compared with 58.7% for group 1, 60.4% for group 2, and 53.2% for group 4 (P < .0001 for all). Group 2 was the only group to have a significantly higher completion rate than group 4 (P = .014). Patients responded positively regarding early notification and preferred electronic portal communication. CONCLUSIONS Early direct notification had a mixed impact on follow-up completion rates on the basis of communication modality but was positively received by patients and may have health care benefits when implemented within a recommendation-tracking system.
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Affiliation(s)
- James Ryan Loftus
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York.
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory Healthcare, Atlanta, Georgia; Chair, ACR Metrics Committee; Interim Medical Director for Radiology Quality, Emory Healthcare, Atlanta, Georgia
| | - Timothy M Baran
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - Kristen Hans
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - David Waldman
- Chief Medical IT Development Officer and Associate Vice President, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - Ben Wandtke
- Vice Chair of Quality and Safety, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
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Slatore CG, Hooker ER, Shull S, Golden SE, Melzer AC. Association of patient and health care organization factors with incidental nodule guidelines adherence: A multi-system observational study. Lung Cancer 2024; 190:107526. [PMID: 38452601 PMCID: PMC10999337 DOI: 10.1016/j.lungcan.2024.107526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/01/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Health care organizations are increasingly developing systems to ensure patients with pulmonary nodules receive guideline-adherent care. Our goal was to determine patient and organization factors that are associated with radiologist adherence as well as clinician and patient concordance to 2005 Fleischner Society guidelines for incidental pulmonary nodule follow-up. MATERIALS Trained researchers abstracted data from the electronic health record from two Veterans Affairs health care systems for patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. METHODS We classified radiology reports and patient follow-up into two categories. Radiologist-Fleischner Adherence was the agreement between the radiologist's recommendation in the computed tomography report and the 2005 Fleischner Society guidelines. Clinician/Patient-Fleischner Concordance was agreement between patient follow-up and the guidelines. We calculated multivariable-adjusted predicted probabilities for factors associated with Radiologist-Fleischner Adherence and Clinician/Patient-Fleischner Concordance. RESULTS Among 3150 patients, 69% of radiologist recommendations were adherent to 2005 Fleischner guidelines, 4% were more aggressive, and 27% recommended less aggressive follow-up. Overall, only 48% of patients underwent follow-up concordant with 2005 Fleischner Society guidelines, 37% had less aggressive follow-up, and 15% had more aggressive follow-up. Radiologist-Fleischner Adherence was associated with Clinician/Patient-Fleischner Concordance with evidence for effect modification by health care system. CONCLUSION Clinicians and patients seem to follow radiologists' recommendations but often do not obtain concordant follow-up, likely due to downstream differential processes in each health care system. Health care organizations need to develop comprehensive and rigorous tools to ensure high levels of appropriate follow-up for patients with pulmonary nodules.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Division of Pulmonary & Critical Care Medicine, Department of Medicine, and Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA
| | - Anne C Melzer
- Section of Pulmonary & Critical Care Medicine, VA Minneapolis Health Care System, 1 Veterans Dr, Minneapolis, MN 55417, USA
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Wang Z, Mortani Barbosa EJ. Socio-Economic Factors and Clinical Context Can Predict Adherence to Incidental Pulmonary Nodule Follow-up via Machine Learning Models. J Am Coll Radiol 2024:S1546-1440(24)00274-6. [PMID: 38461910 DOI: 10.1016/j.jacr.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/19/2024] [Accepted: 02/02/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To quantify the relative importance of demographic, contextual, socio-economic, and nodule-related factors that influence patient adherence to incidental pulmonary nodule (IPN) follow-up visits and evaluate the predictive performance of machine learning models utilizing these features. METHODS We curated a 1,610-subject patient data set from electronic medical records consisting of 13 clinical and socio-economic predictors and IPN follow-up adherence status (timely, delayed, or never) as the outcome. Univariate analysis and multivariate logistic regression were performed to quantify the predictors' contributions to follow-up adherence. Three additional machine learning models (random forests, neural network, and support vector machine) were fitted and cross-validated to examine prediction performance across different model architectures and evaluate intermodel concordance. RESULTS On univariate basis, all 13 predictors except comorbidity were found to have a significant association with follow-up. In multiple logistic regression, inpatient or emergency clinical context (odds ratio favoring never following up: 7.28 and 8.56 versus outpatient, respectively) and high nodule risk (odds ratio: 0.25 versus low risk) are the most significant predictors of follow-up, and sex, race, and marital status become additionally significant if clinical context is removed from the model. Clinical context itself is associated with sex, race, insurance, employment, marriage, income, nodule risk, and smoking status, suggesting its role in mediating socio-economic inequities. On cross-validation, all four machine learning models demonstrated comparable and good predictive performances, with mean area under the curve ranging from 0.759 to 0.802, with sensitivity 0.641 to 0.660 and specificity 0.768 to 0.840. CONCLUSION Socio-economic factors and clinical context are predictive of IPN follow-up adherence, with clinical context being the most significant contributor and likely representing uncaptured socio-economic determinants.
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Affiliation(s)
- Zhuoyang Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eduardo J Mortani Barbosa
- Director of CT Modality at the Thoracic Imaging Section, Division of Cardiothoracic Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Digby GC, Habert J, Sahota J, Zhu L, Manos D. Incidental pulmonary nodule management in Canada: exploring current state through a narrative literature review and expert interviews. J Thorac Dis 2024; 16:1537-1551. [PMID: 38505054 PMCID: PMC10944736 DOI: 10.21037/jtd-23-1453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/21/2023] [Indexed: 03/21/2024]
Abstract
Background and Objective Incidental pulmonary nodules (IPNs) are common and increasingly detected with the overall rise of radiologic imaging. Effective IPN management is necessary to ensure lung cancer is not missed. This study aims to describe the current landscape of IPN management in Canada, understand barriers to optimal IPN management, and identify opportunities for improvement. Methods We performed a narrative literature review by searching biomedical electronic databases for relevant articles published between January 1, 2010, and November 22, 2023. To validate and complement the identified literature, we conducted structured interviews with multidisciplinary experts involved in the pathway of patients with IPNs across Canada. Interviews between December 2021 and May 2022 were audiovisual recorded, transcribed, and thematically analyzed. Key Content and Findings A total of 1,299 records were identified, of which 37 studies were included for analysis. Most studies were conducted in Canada and the United States and highlighted variability in radiology reporting of IPNs and patient management, and limited adherence to recommended follow-up imaging. Twenty experts were interviewed, including radiologists, respirologists, thoracic surgeons, primary care physicians, medical oncologists, and an epidemiologist. Three themes emerged from the interviews, supported by the literature, including: variability in radiology reporting of IPNs, suboptimal communication, and variability in guideline adherence and patient management. Conclusions Despite general awareness of guidelines, there is inconsistency and lack of standardization in the management of patients with IPNs in Canada. Multidisciplinary expert consensus is recommended to help overcome the communication and operational barriers to a safe and cost-effective approach to this common clinical issue.
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Affiliation(s)
- Geneviève C. Digby
- Department of Medicine, Division of Respirology, Queen’s University, Kingston, ON, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jyoti Sahota
- Health Economics and Market Access, Amaris Consulting, Toronto, ON, Canada
| | - Lucía Zhu
- Health Economics and Market Access, Amaris Consulting, Barcelona, Spain
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada
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Thakore NL, Russo R, Hang T, Moore WH, Chen Y, Kang SK. Evaluation of Socioeconomic Disparities in Follow-Up Completion for Incidental Pulmonary Nodules. J Am Coll Radiol 2023; 20:1215-1224. [PMID: 37473854 DOI: 10.1016/j.jacr.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/08/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE The aim of this study was to evaluate the association between census tract-level measures of social vulnerability and residential segregation and incidental pulmonary nodule (IPN) follow-up. METHODS This retrospective cohort study included patients with IPNs ≥6 mm in size or multiple subsolid or ground-glass IPNs <6 mm (with nonoptional follow-up recommendations) diagnosed between January 1, 2018, and December 30, 2019, at a large urban tertiary center and followed for ≥2 years. Geographic sociodemographic context was characterized by the 2018 Centers for Disease Control and Prevention Social Vulnerability Index (SVI) and the index of concentration at the extremes (ICE), categorized in quartiles. Multivariable binomial regression models were used, with a primary outcome of inappropriate IPN follow-up (late or no follow-up). Models were also stratified by nodule risk. RESULTS The study consisted of 2,492 patients (mean age, 65.6 ± 12.6 years; 1,361 women). Top-quartile SVI patients were more likely to have inappropriate follow-up (risk ratio [RR], 1.24; 95% confidence interval [CI], 1.12-1.36) compared with the bottom quartile; risk was also elevated in top-quartile SVI subcategories of socioeconomic status (RR, 1.23; 95% CI, 1.13-1.34), Minority status and language (RR, 1.24; 95% CI, 1.03-1.48), housing and transportation (RR, 1.13; 95% CI, 1.02-1.26), and ICE (RR, 1.20; 95% CI, 1.11-1.30). Furthermore, top-quartile ICE was associated with greater risk for inappropriate follow-up among high-risk versus lower risk IPNs (RR, 1.33 [95% CI, 1.18-1.50] versus 1.13 [95% CI, 1.02-1.25]), respectively; P for interaction = .017). CONCLUSIONS Local social vulnerability and residential segregation are associated with inappropriate IPN follow-up and may inform policy or interventions tailored for neighborhoods.
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Affiliation(s)
| | - Rienna Russo
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Tianchu Hang
- Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - William H Moore
- Section Chief, Thoracic Imaging, and Vice Chair, Clinical informatics, Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - Yu Chen
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Stella K Kang
- Associate Chair, Population Health Imaging & Outcomes, Department of Radiology and Department of Population Health, NYU Grossman School of Medicine, New York, New York.
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Simargi Y, Mulia RO, Dewi AP, Lay SK, Puspasari AF, Ronny, Susilo F. An incidental finding of lung nodule in patient presenting with posterior chest wall trauma: A case report. Radiol Case Rep 2023; 18:4304-4308. [PMID: 37780816 PMCID: PMC10539645 DOI: 10.1016/j.radcr.2023.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Lung nodule is considered a common incidental finding in chest CT evaluation. Most cases are benign and derived from a previous infection. However, here we present a case where a patient presenting to the hospital with posterior chest wall trauma had a solitary pulmonary nodule that is consistent with non-small cell lung cancer (NSCLC). We would like to emphasize the importance of evaluation of incidental findings in chest CT evaluation, in this case, trauma cases by presenting this case. An 81-year-old male was referred to the emergency department with altered consciousness and a history of posterior chest trauma. He complained of a productive cough, but no other symptoms were reported. He had a medical history of Alzheimer's dementia, COVID-19, and hypertension. Physical examination revealed a hematoma on the right side of his back and reduced breath sound. Anteroposterior radiograph showed multiple right posterior rib fractures with right pleural effusion. Contrast-enhanced chest CT revealed a low-density solitary pulmonary nodule with multiple lymphadenopathies, with the presumptive diagnosis of incidentaloma. It was confirmed by pleural analysis with the increase of Cyfra 21-1 tumor marker and consistent with non-small cell lung cancer. In CT studies, incidental solitary pulmonary nodules are common, occurring in 8%-51%. Nodules are often discovered incidentally in trauma patients, but they are not always reported or followed up. It is important to note that each may indicate a clinical significance and represents the potential for malignancy which requires additional workup and further evaluation.
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Affiliation(s)
- Yopi Simargi
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Resley O. Mulia
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Apriliani P. Dewi
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Sugiarto K. Lay
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Anita F. Puspasari
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Ronny
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Fenny Susilo
- Department of Radiology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
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Jiang LG, Cahill M, Chansakul A, Steel PAD, Sullivan D, Pua BB. A Collaborative Emergency Medicine and Radiology Pulmonary Nodule Program: Identification of Associated Efficacy and Outcomes. J Am Coll Radiol 2023; 20:796-803. [PMID: 37422161 DOI: 10.1016/j.jacr.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE Incidental radiologic findings are commonplace, but the episodic nature of emergency department (ED) care makes it challenging to ensure that patients obtain appropriate follow-up. Rates of follow-up range from 30% to 77%, with some studies demonstrating that more than 30% have no follow-up at all. The aim of this study is to describe and analyze the outcomes of a collaborative emergency medicine and radiology initiative to establish a formal workflow for the follow-up of pulmonary nodules identified during ED care. METHODS A retrospective analysis was performed of patients referred to the pulmonary nodule program (PNP). Patients were divided into two categories: those with follow-up and those who do not have post-ED follow-up. The primary outcome was determining follow-up rates and outcomes, including patients referred for biopsy. The characteristics of patients who completed follow-up compared with those lost to follow-up were also examined. RESULTS A total of 574 patients were referred to the PNP. Initial follow-up was established in 390 (69.1%); 30.8% were considered lost to follow-up, and more than half of these patients did not respond to initial contact. There were minimal differences in characteristics between patients in these two categories. Of the 259 patients who completed PNP follow-up, 26 were referred for biopsy (13%). CONCLUSIONS The PNP provided effective transitions of care and potentially improved patient health care. Strategies to further enhance follow-up adherence will provide iterative improvement of the program. The PNP provides an implementation framework for post-ED pulmonary nodule follow-up in other health care systems and can be modified for use with other incidental diagnostic findings.
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Affiliation(s)
- Lynn G Jiang
- Department of Emergency Medicine, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York.
| | - Meghan Cahill
- Department of Radiology, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Aisara Chansakul
- Department of Emergency Medicine, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Peter A D Steel
- Department of Emergency Medicine, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Deirdre Sullivan
- Department of Radiology, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Bradley B Pua
- Department of Radiology, Weill Cornell Medical Center, NewYork-Presbyterian Hospital, New York, New York
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The Chain of Adherence for Incidentally Detected Pulmonary Nodules after an Initial Radiologic Imaging Study: A Multisystem Observational Study. Ann Am Thorac Soc 2022; 19:1379-1389. [PMID: 35167780 DOI: 10.1513/annalsats.202111-1220oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist-Fleischner adherence was the agreement between the radiologist's recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/patient-Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient-radiologist adherence was agreement between the radiologist's recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist-Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient-Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient-radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient-Fleischner concordance: 52.0% concordance among radiologist-Fleischner adherent versus 11.6% concordance among radiologist-Fleischner nonadherent. Conclusions: In this multi-health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.
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Boukhiar S, Tiffet O, Bayle-Bleuez S, Picot T, Yvorel V, Forest F. [Multiple synchronous lung adenocarcinoma: Interest of molecular biology for staging]. Rev Mal Respir 2021; 38:942-945. [PMID: 34565641 DOI: 10.1016/j.rmr.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The presence of multiple synchronous lung tumors is not a rare event. Distinguishing intra-pulmonary metastases from multiple synchronous lung adenocarcinoma is a challenge for pathologists and physicians. We present observation of a patient with three lung tumors corresponding to three adenocarcinomas for which molecular analysis had a significant impact on tumor staging. OBSERVATION Three suspect lesions were discovered in a 61-year-old patient, a smoker, in each lobe of the right lung. Right pneumonectomy with lymph node dissection was performed. Pathological examination showed that each tumor was in fact an adenocarcinoma. In order to more precisely indicate tumor staging, molecular analysis was performed with next generation sequencing showing a different point mutation in a driver gene on each tumor. The final diagnosis is that the three tumors are distinct synchronous tumors, which must be staged separately. CONCLUSIONS In modern-day practice of thoracic oncology and of surgical pathology, molecular biology represents a complement for tumor staging in the event of multiple lung tumors.
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Affiliation(s)
- S Boukhiar
- Centre Hospitalier Universitaire de Saint Étienne, Hôpital Nord. Laboratoire d'Anatomie et Cytologie Pathologiques, avenue Albert-Raimond, 42055 Saint Étienne cedex 2, France
| | - O Tiffet
- Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, Service de Chirurgie Thoracique, avenue Albert-Raimond, 42055 Saint-Étienne cedex 2, France
| | - S Bayle-Bleuez
- Service de Pneumologie, Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, avenue Albert-Raimond, 42055 Saint-Étienne cedex 2, France
| | - T Picot
- Centre Hospitalier Universitaire de Saint Étienne, Hôpital Nord. Laboratoire d'Anatomie et Cytologie Pathologiques, avenue Albert-Raimond, 42055 Saint Étienne cedex 2, France; Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, Plateforme de biologie moléculaire des tumeurs solides, avenue Albert-Raimond, 42055 Saint-Étienne cedex 2, France
| | - V Yvorel
- Centre Hospitalier Universitaire de Saint Étienne, Hôpital Nord. Laboratoire d'Anatomie et Cytologie Pathologiques, avenue Albert-Raimond, 42055 Saint Étienne cedex 2, France; Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, Plateforme de biologie moléculaire des tumeurs solides, avenue Albert-Raimond, 42055 Saint-Étienne cedex 2, France
| | - F Forest
- Centre Hospitalier Universitaire de Saint Étienne, Hôpital Nord. Laboratoire d'Anatomie et Cytologie Pathologiques, avenue Albert-Raimond, 42055 Saint Étienne cedex 2, France; Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, Plateforme de biologie moléculaire des tumeurs solides, avenue Albert-Raimond, 42055 Saint-Étienne cedex 2, France.
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Kang SK, Doshi AM, Recht MP, Lover AC, Kim DC, Moore W. Process Improvement for Communication and Follow-up of Incidental Lung Nodules. J Am Coll Radiol 2020; 17:224-230. [DOI: 10.1016/j.jacr.2019.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
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