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Lung Cancer/Solitary Pulmonary Nodule

Risk factors

United States. Surgeon General's Advisory Committee on Smoking and Health, and United States. Public Health Service. Office of the Surgeon General. Smoking and Health.United States. Public Health Service. Office of the Surgeon General, 1964. Official Report This landmark U.S. Surgeon General’s report added to the growing international recognition of the multiple hazards of cigarette smoking.

Staging Created by the American College of Chest Physicians with other partners, this interactive website includes a staging calculator, an interactive staging table with links to representative diagnostic images, and survival figures, all designed to help navigate the complexity of lung cancer staging.

Lababede O, Meziane M, Rice T. Seventh edition of the cancer staging manual and stage grouping of lung cancer: quick reference chart and diagrams. Chest 2011;139:183-9. This quick and comprehensive reference is invaluable for determining stage based on the updated TNM classification.
PMID: 21208878
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Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell 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):e211S-50S. ACCP evidence-based clinical practice guidelines (3rd Edition) reviewing the evidence for both invasive and non-invasive staging of non-small cell lung cancer with CT and PET scanning as well as TTNA, TBNA, EBUS, EUS, VATS, Chamberlain procedure, mediastinoscopy and extended cervical mediastinoscopy.
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Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010;304:2245-52. An RCT of EUS/EBUS/surgical staging vs. surgical staging alone in 241 patients with potentially resectable NSCLC found a sensitivity and NPV of 94% and 93% with the combined approach, a substantial improvement over surgical staging alone (79% and 86%). In the 123 patients assigned to the combined modality arm, endosonography identified mediastinal metastases in half, precluding the need for mediastinoscopy. In the 65 patients with negative EUS/EBUS-FNA, mediastinoscopy identified cancer in six patients. The study was performed at tertiary centers using conscious sedation for endosonography.
PMID: 21098770
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Surgical Risk Assessment

Donington J, Ferguson M, Mazzone P, et al. American College Of Chest Physicians And Society Of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest 2012; 142:1620-35. This summary is a useful resource for identifying and weighing treatment options for stage I patients unlikely to tolerate lobectomy, including the relative merits of wedge resection vs. segmentectomy, as well as use of adjuvant therapies, radiation therapy, and percutaneous ablative therapy.
PMID: 23208335

Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e166S-90S. These guidelines provide methods of identifying low-risk and high-risk patients for lung resection surgery, as well as appropriate further testing once identified.
PMID: 23649437


Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 142(5 Suppl):e437S-54S. Guideline recommends serial surveillance chest CT scans and measures of quality of life following resection while acknowledging the paucity of studies guiding care in this population.
PMID: 23649451

Screening for lung cancer

National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409. This large trial compared annual CT versus CXR over two years (baseline, one-year, and two-year screening). Analyzing only those who underwent at least one screening test, the absolute risk reduction for lung cancer-associated mortality was 0.3% (relative reduction of 20%), yielding a number needed to screen to prevent one death of approximately 320, with a CT false positive rate of 96.4%. Cost-effectiveness analyses and evaluation of the impact of invasive procedures related to false-positive results have not been clearly defined.
PMID: 21714641
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Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA 2011;306:1865-73. A large prospective trial of annual CXR versus usual care found no difference in the incidence of lung cancer or in mortality.
PMID: 22031728
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Wiener RS, Gould MK, Arenberg DA, et al. An Official American Thoracic Society/American College of Chest Physicians Policy Statement: Implementation of low-dose computed tomography lung cancer screening programs in clinical practice.  Am J Resp Crit Care Med; 2015; 192:881-891. A consensus guideline from ATS and ACCP regarding the planning, implementation, and maintenance of a safe, and effective low-dose CT lung cancer screening program.
PMID: 26426785

Solitary pulmonary nodule

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-120S. Guideline for how best to work up nodule(s) that nicely distills the large number of trials on this topic.
PMID: 23649456

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; 237:395-400. Influential guideline on follow-up of pulmonary nodules based on findings from recent lung cancer screening studies.
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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; 304-317. This statement guides the follow up of ground glass and subsolid nodules. Differences from solid nodule follow up include earlier follow up CT to determine persistence, as well as longer duration of follow up for persistent subsolid nodules.
PMID: 23070270

Last Reviewed: June 2017