Jaime Lewis (Host): A lung nodule is a small abnormal mass in the lungs that is often found during lung cancer screenings. In this episode, Dr. Peter Olivieri, a Board Certified Pulmonary and Critical Care Physician at UM Baltimore Washington Medical Center and Director at the Interventional Pulmonary Program, will explain the different types of lung nodules, how they are detected, the latest treatments, how they can be prevented, and more.

 Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Jaime Lewis. Hello, Dr. Olivieri. Thank you so much for being here.

Peter Olivieri, MD: My pleasure, thanks for having me.

Host: All right, let's start with the definition of a lung nodule. What is it and what are the common causes or risk factors associated with them?

Peter Olivieri, MD: A lung nodule simply refers to an abnormal spot in the lungs, which is often seen on an x-ray or CAT scan of the chest. Some of these are completely benign and nothing to worry about, while others could represent cancer.

Host: Okay. Whatare the different types of lung nodules and how do they differ in terms of characteristics and potential implications?

Peter Olivieri, MD: That's a great question. One of the most important objectives in the evaluation of a lung nodule, is to estimate the likelihood that a given nodule could be cancer. Because that will determine how aggressive we should be with further evaluation and treatment. Some of what goes into that estimation has to do with the size, shape, location, and appearance of a nodule.

Larger nodules are generally more concerning, as are nodules with irregular or what we call spiculated edges. There are also other characteristics that we look at, such as the presence of calcium or calcification, which is often a sign of a benign nodule. Or whether or not a nodule is more or less solid appearing. As physicians evaluating nodules, we take all these factors into consideration, as well as factors related to the patient, such as their age, history of smoking, history of cancer when we're estimating risk.

Host: So are there any specific symptoms or warning signs that someone with lung nodules should be aware of?

Peter Olivieri, MD: Typically, nodules are asymptomatic. They're usually found incidentally when an x-ray or CAT scan is done for another reason. There are exceptions to this, as in the case of larger nodules that may be pressing or compressing an important structure in the chest, which may produce symptoms, and in such cases patients may experience cough, chest pain, or shortness of breath.

Host: Are there diagnostic tests that are commonly used to evaluate them?

Peter Olivieri, MD: Absolutely, so most nodules, as I mentioned, are incidentally found on chest x-rays or CT scans done for another reason. For example, in the emergency department or when ordered by an outpatient physician. If patients have not had a CT scan and have only had an x-ray, a CT scan will often be the first test because that provides the most detailed picture.

Depending on the situation, additional tests could include things like blood work, pulmonary function tests, something called a PET scan, or even invasive procedures such as bronchoscopy or various types of lung biopsies.

Host: Okay, you touched earlier on nodule being potentially cancerous, but I want to know what are the factors that determine whether a lung nodule is benign or possibly cancerous?

Peter Olivieri, MD: Well, size is important, as I mentioned. So these are just general factors, but in general, the larger something is, the more concerning it is. Another thing that we would look at would be something that's slowly and steadily growing. That would typically be more concerning for a potential cancer, as opposed to something that may have been stable for many years on follow up imaging.

 There are other things as well. Some of which I've already alluded to, such as patient factors, like if they've been a smoker in the past or are currently a smoker, that would certainly make us more concerned or if they may have already a history of cancer somewhere.

Host: So what are the recommended treatment options for lung nodules, depending on their size, type, and other factors?

Peter Olivieri, MD: So, it really depends on what we think the nodule represents. So what I tell patients is a nodule is almost like saying a spot on my skin. There's so many different things that a spot could represent. It could be nothing more than scar tissue, a freckle, or a sign of a recent trauma, burn, infection, only a very small number of them are actually cancer.

 So the treatment of the nodule will completely depend on what we think the nodule is due to. So that we can often determine by just looking at the CT scan or looking at how the lesion may change over time when we do follow up scans. Sometimes though, when we can't get all of the information we need from a CT scan, we need to do other tests, some of which I've alluded to, such as a PET scan or even a biopsy of the nodule. And a biopsy is typically the most definitive way to know what's causing a nodule. By taking a small piece of the nodule out and looking at it under a microscope, we can often determine the cause. And that will often guide treatment.

Host: Right. Well, we're always interested in new approaches to medicine, so are there any advancements or emerging technologies in this field for nodule diagnosis and treatment that listeners should know about?

Peter Olivieri, MD: Absolutely. So I work mostly in the diagnostic side. So often patients are referred to me when they have a nodule and we're trying to figure out what might be causing it. One of the most recent things that we've incorporated into our practice is what's called robot assisted bronchoscopy. So we've been doing bronchoscopy for a long time, which is a scope procedure where we use a long, thin instrument with a light and a camera on the end to go down the mouth, down the windpipe and into the breathing tubes to take biopsies. But because the lung is a moving organ while the patient breathes, and because many of these nodules are very small and very far out toward the edge of the lung, it's often difficult to get a good sample. And now that we've begun to use robotic technology to guide us, it's afforded us an incredible amount of stability and precision, and we're able to get accurate samples from very small modules. And this is exciting because our goal is really to be able to diagnose cancer at its earliest stage while it's still curable. And that's now what we're able to do as we partner with our other colleagues.

So that's on the diagnostic side. There are also other things on the diagnostic side that we've recently incorporated, such as the use of biomarkers or blood tests. These look at certain proteins in the blood that can help us predict the likelihood that a given nodule may represent cancer or could be benign, and that's often very helpful in allowing patients to avoid unnecessary procedures.

 On the treatment side, we could have a whole different discussion about that, but certainly there are better surgical approaches that are associated with very good outcomes, as well as very precise ways to administer radiation and other medical therapies when we do diagnose cancer.

Host: That's all so exciting for the future of medicine and patients health. Well, how often should patients with lung nodules undergo follow up screenings or imaging tests to monitor their condition?

Peter Olivieri, MD: It really depends on the patient's risk factors for cancer as well as the particular characteristics of the nodule. On the most benign side, you would have a patient at low risk for cancer, say someone who's never been a smoker that has a very tiny nodule, and in some cases it may be possible to avoid even doing a single follow up CT scan, although in general, you would often get at least one follow up scan.

On the other end of the spectrum, you may have a patient that has risk factors and or has a concerning looking nodule, and in those cases, you're always going to need to get a follow up scan, assuming you're not already making a decision to go ahead with a biopsy.

Host: Okay. Last question. Are there any lifestyle changes or preventative measures that can help reduce the risk of developing lung nodules?

Peter Olivieri, MD: By far and away, the most important thing we can tell people is to not smoke, and if they are smokers, to try to get some help to quit. We know that smoking is by far the leading risk factor for lung cancer, so I would emphasize that above and beyond everything else.

And, patients who are current or former smokers should ask their doctor if they may qualify for lung cancer screening. This consists of getting a low radiation CT scan annually to look for nodules which may represent early and curable lung cancer.

Outside of that, when we look at the various other causes of more benign nodules, some of which we didn't have a chance to discuss today, a lot of it is just common sense. If you're working in a profession where you may be breathing in large amounts of dust or other particles; it's sensible to try to minimize your risk to those things and wear the appropriate respiratory protective equipment such as a mask or respirator when appropriate, as breathing in these types of dust over the long term can result in various types of more benign nodules which are often due to inflammation or scar tissue.

Host: That makes sense. Well, thank you so much for shedding light on this subject, Doctor. I appreciate it.

Peter Olivieri, MD: Thank you for having me.

Host: Find more shows just like this one at umms.org/podcast, and on YouTube. I'm your host, Jaime Lewis. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media channels.