Management of Pulmonary Nodules in Oncologic Patients: AJR Expert Panel Narrative Review

Abstract

Cancer survivors are at higher risk than the general population for development of a new primary malignancy, most commonly lung cancer. Current lung cancer screening guidelines recommend low-dose chest CT for highrisk individuals, including patients with a prior history of cancer and a qualifying smoking history. However, major lung cancer screening trials have inconsistently included cancer survivors, and limited data assess management of lung nodules in this population. This narrative review highlights relevant literature and provides expert opinion for management of pulmonary nodules detected incidentally or by screening in oncologic patients. In patients with previously treated lung cancer, a new nodule most likely represents distant metastasis from the initial lung cancer or a second primary lung cancer; CT features such as nodule size and composition should guide decisions among biopsy, PET/CT, and CT surveillance. In patients with extrapulmonary cancers, nodule management requires individualized risk assessment; smoking is associated with increased odds of primary lung cancer, whereas specific primary cancer types are associated with increased odds of pulmonary metastasis. Non-neoplastic etiologies, such as infection, medication toxicity, and post-radiation or post-surgical change, should also be considered. Future prospective studies are warranted to provide evidence-based data to assist clinical decision-making in this context.