Clinical imaging for PLAB 1

A 58 year old smoker has a CT pulmonary angiogram for suspected pulmonary embolism, which is negative. The report notes an incidental 9 mm solid nodule in the right upper lobe with no previous imaging for comparison. He is asymptomatic from a respiratory point of view. What is the SINGLE most likely diagnosis?

1. Lung cancer A spiky-edged or growing lung nodule with risk factors, needing the fast-track cancer pathway. It does not fit a 9 mm solid nodule with no prior imaging.
2. Adrenal insufficiency Tiredness, weight loss and darkened skin with low sodium, a question of how the gland is working rather than what it looks like. That does not match a 9 mm solid nodule with no prior imaging.
3. Abdominal aortic aneurysm A widened main artery in the abdomen found by chance, watched over time and repaired at 5.5 cm or if it grows quickly. Here, a 9 mm solid nodule with no prior imaging points elsewhere.
4. Incidental findings correct Correct. The scan was done to look for a clot in the lungs and found something else instead. That does not make the nodule somebody else's problem, and it is now down to whoever received the report to deal with.
5. Renal cysts Plain fluid-filled cysts on the kidney are very common with age and need no follow-up; ones with a complicated appearance do. But a 9 mm solid nodule with no prior imaging does not point to it.

The point: An unexpected finding on a scan still belongs to the patient. The duty is to tell them, to say what is and is not known about it, and to follow the right monitoring guidance rather than either ignoring it or over-investigating it. A finding written on a scan report that nobody acts on is one of the commonest causes of avoidable harm and of complaints that succeed.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 58 year old smoker has a CT pulmonary angiogram for suspected pulmonary embolism, which is negative. The report notes an incidental 9 mm solid nodule in the right upper lobe with no previous imaging for comparison. He is asymptomatic from a respiratory point of view. What is the SINGLE most appropriate initial investigation?

1. Hormonal screening for functional activity For a hormone gland mass found by chance: a blood test for adrenaline-type hormones, an overnight steroid suppression test, and a hormone ratio test if the patient has high blood pressure. But a 9 mm solid nodule with no prior imaging does not point to it.
2. PET-CT For a nodule above the size cut-off with a middling risk of cancer. Here, a 9 mm solid nodule with no prior imaging points elsewhere.
3. Discuss at the multidisciplinary meeting Where an unexpected finding is unclear and what to do about it is not obvious from the guidance alone. It does not fit a 9 mm solid nodule with no prior imaging.
4. Interval CT surveillance correct Correct. A solid nodule this size in a smoker cannot yet be called benign or cancerous. It is too small to biopsy comfortably, and too large and too risky to just leave alone. Nodule guidance sets a time gap for a repeat scan based on the size and the risk score, and growth over that gap is what leads to a PET-CT or a biopsy.
5. Repeat imaging in 12 months For a low-risk finding where the guidance sets that time gap. That does not match a 9 mm solid nodule with no prior imaging.

The point: An unexpected finding on a scan still belongs to the patient. The duty is to tell them, to say what is and is not known about it, and to follow the right monitoring guidance rather than either ignoring it or over-investigating it. A finding written on a scan report that nobody acts on is one of the commonest causes of avoidable harm and of complaints that succeed.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 58 year old smoker has a CT pulmonary angiogram for suspected pulmonary embolism, which is negative. The report notes an incidental 9 mm solid nodule in the right upper lobe with no previous imaging for comparison. He is asymptomatic from a respiratory point of view. What is the SINGLE most appropriate immediate management?

1. Reassure and take no action Only right where the finding is clearly harmless, and it still has to be explained to the patient. It does not fit a 9 mm solid nodule with no prior imaging.
2. Refer to the relevant specialist clinic For findings that have a set monitoring pathway, such as an aneurysm or a hormone gland mass. Here, a 9 mm solid nodule with no prior imaging points elsewhere.
3. Inform the patient and arrange guideline-based follow-up correct Correct. He needs to be told what was found, what it might be, what happens next and when. A nodule written on a report that nobody acts on is one of the commonest ways a lung cancer diagnosis ends up being made late, and a complaint ends up being upheld.
4. Repeat the scan immediately Rarely useful; the guidance sets a time gap for a reason, and repeating the scan too soon cannot show any change. But a 9 mm solid nodule with no prior imaging does not point to it.
5. Do not mention it to avoid causing anxiety Indefensible. Keeping a finding from the patient takes away their chance to act on it and breaks the duty to be open and honest with them. That does not match a 9 mm solid nodule with no prior imaging.

The point: An unexpected finding on a scan still belongs to the patient. The duty is to tell them, to say what is and is not known about it, and to follow the right monitoring guidance rather than either ignoring it or over-investigating it. A finding written on a scan report that nobody acts on is one of the commonest causes of avoidable harm and of complaints that succeed.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance