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 spiculated or growing pulmonary nodule with risk factors, requiring the suspected cancer pathway. A 9 mm solid nodule with no prior imaging raises it.
2. Adrenal insufficiency (including primary and secondary) Fatigue, weight loss and hyperpigmentation with hyponatraemia, a functional question rather than a structural one. A 9 mm solid nodule with no prior imaging makes it worth excluding.
3. Abdominal aortic aneurysm An incidentally found dilated aorta, followed by surveillance and repaired at 5.5 cm or with rapid growth. A 9 mm solid nodule with no prior imaging points to it.
4. Incidental findings correct Correct. The scan was done for pulmonary embolism and found something else. That does not make the nodule someone else's problem, and it is now the responsibility of whoever received the report.
5. Renal cysts Simple cysts are extremely common with age and need no follow-up; complex ones do. A 9 mm solid nodule with no prior imaging makes the appearance decisive.

The point: An incidental finding still belongs to the patient. The duty is to tell them, to say what is and is not known, and to follow the relevant surveillance guidance rather than either ignoring it or over-investigating. A finding reported on a scan that nobody acts on is one of the commonest sources of avoidable harm and of successful complaints.

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 an adrenal incidentaloma, a metanephrine measurement, an overnight dexamethasone suppression test and an aldosterone-to-renin ratio if hypertensive. A 9 mm solid nodule with no prior imaging makes it necessary.
2. PET-CT For a nodule above the size threshold with intermediate malignancy risk. A 9 mm solid nodule with no prior imaging indicates it.
3. Discuss at the multidisciplinary meeting Where an incidental finding is indeterminate and management is not clear from guidance alone. A 9 mm solid nodule with no prior imaging makes it sensible.
4. Interval CT surveillance correct Correct. A solid nodule of this size in a smoker is indeterminate, too small to biopsy comfortably, too large and too high-risk to ignore. Nodule guidance sets a surveillance interval based on size and risk score, and growth over that interval is what triggers escalation to PET-CT or biopsy.
5. Repeat imaging in 12 months For a low-risk finding where the guidance sets that interval. A 9 mm solid nodule with no prior imaging makes it appropriate.

The point: An incidental finding still belongs to the patient. The duty is to tell them, to say what is and is not known, and to follow the relevant surveillance guidance rather than either ignoring it or over-investigating. A finding reported on a scan that nobody acts on is one of the commonest sources of avoidable harm and of successful complaints.

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 Correct only where the finding is definitively benign, and it must still be explained. A 9 mm solid nodule with no prior imaging makes it appropriate.
2. Refer to the relevant specialist clinic For findings with an established surveillance pathway, such as an aneurysm or an adrenal mass. A 9 mm solid nodule with no prior imaging makes it the route.
3. Inform the patient and arrange guideline-based follow-up correct Correct. He must be told what was found, what it might be, what will happen next and when. A nodule noted in a report that nobody actions is one of the commonest routes to a late lung cancer diagnosis and to a justified complaint.
4. Repeat the scan immediately Rarely useful; the guidance sets an interval for a reason, and repeating too soon cannot show change. A 9 mm solid nodule with no prior imaging makes the interval the point.
5. Do not mention it to avoid causing anxiety Indefensible. Withholding a finding removes the patient's ability to act on it and breaches the duty of candour. A 9 mm solid nodule with no prior imaging makes it wrong.

The point: An incidental finding still belongs to the patient. The duty is to tell them, to say what is and is not known, and to follow the relevant surveillance guidance rather than either ignoring it or over-investigating. A finding reported on a scan that nobody acts on is one of the commonest sources of avoidable harm and of successful complaints.

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