Amanda Wilde (Host): Long nodules are quite common, but why do they appear and what could that indicate? Thoracic surgeon, Dr. Brian Cohen is here to explain the diagnosis and treatment of lung nodules. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Amanda Wilde. Dr. Cohen, thank you for being here.

Brian Cohen, MD: Thank you so much for having me.

Host: What is the definition of a lung nodule?

Brian Cohen, MD: So it's a broad term, a nodule is essentially something we see in your lungs on imaging that doesn't belong there. So lungs, tissue is mostly empty space. The whole point of the organ is to exchange gas, so it's filled mostly with air you breathe in and out. There are these thin, microscopic walls where gas exchange takes place, and those are lined with blood vessels and lymphatic channels to help exhale carbon dioxide and bring oxygen to your heart.

But when you look at an X-ray or a CT scan, you should be seeing mostly air. A nodule is a general term for a small density that just shouldn't be there.

Host: And how are they typically identified? Where do you see them? Is it an x-ray, a CT scan?

Brian Cohen, MD: Either of those two are the most common, any imaging that you get of the chest. So it could be on an MRI, for example, but most commonly it's on an x-ray or a CT scan. The CT scan is much more sensitive. We get a lot more detail about the lungs and what's going on inside, so it would have to be a pretty big or dense nodule to see it on an x-ray.We see a lot more smaller ones on a CT.

Host: What are the potential implications of a lung nodule that is found on a CT scan?

Brian Cohen, MD: So lung cancer is still the leading cause of cancer death in the United States, and so oftentimes when we have that image finding of a nodule, we have to have our antennas up and make sure we're not missing an early stage lung cancer. That said, not all nodules are malignant. They could represent an infection, an old scar.

It could just be some transient imaging finding. It really depends on the specific imaging characteristics and patient risk factors to inform how suspicious a nodule may be.

Host: So if a nodule is found, what criteria is used to determine if the lung nodule is cancerous or benign?

Brian Cohen, MD: So there are a few characteristics of the image itself, the size of the nodule, if it's in the upper lobes, if it's more solid, if it's more spiculated, having these little tendrils coming out of it. And then there are factors of the patients themselves, if they're at higher risk, if they're older, or if they have a smoking history or a cancer history, or a family history of cancer. Those are the factors that we use to identify how suspicious a nodule may be.

Host: Then how do you know when, and what action needs to be taken? Who decides what type of treatment is best?

Brian Cohen, MD: So we have an incredible chest team at WakeMed. It's comprised of interventional pulmonologists, thoracic surgeons, and amazing nurse navigators. We meet weekly, along with radiologists and oncologists to discuss these nodules, and that's really just to make sure we don't miss anything and we could expedite whatever tests or whatever next steps or necessary.

Most important, the only person who decides the next action is the patient. Patient will meet with one or several members of that chest team and together we can discuss whatever results we have so far, walking through the specific risk factors we see and we could lay out our recommendations if there are characteristics we think warrant further study like biopsy or warrant treatment, and together we decide what the next steps would be.

Host: Okay. Are there routine screening options available to find lung nodules?

Brian Cohen, MD: Yes, absolutely. We have a bunch of societies that recommend routine screening with annual low dose CT scan. It's a non-invasive quick CT t hat helps identify nodules in higher risk patients. The United States Preventative Services task force, that's USPSTF, has a set of criteria of what it means to be high risk.

Those are adults, 50 to 80 years old, have a 20 pack year smoking history. That's the equivalent of a pack per day for 20 years. And if they've quit, have done so less than 15 years ago. In that population, we recommend yearly CT scans to screen for these nodules.

Host: When the nodules are found, are they typically found incidental to a CT scan or through a routine screening?

Brian Cohen, MD: Yes. So that's another extremely important avenue, uh, in which we find these nodules. In high risk patients, it's best to have a screening program set up. That said, there are a lot of CT scans that get done for other reasons, and we do have a good number of incidental nodules. They're not looking for them, but we see them on this imaging.

So we do follow those patients as well. And that could trigger a set of next steps or imaging or, or biopsy.

There's one more tool I should mention that helps inform us how suspicious a nodule is, and that's a PET scan or PET CT. If we see a nodule on a screening CT, we may follow that up with a PET scan. The PET gives similar views of what's going on inside the body, but importantly, the radiologist injects this sugar substance through your IV and that lights up areas in your body that are particularly active.

Cancer cells being more active than normal surrounding cells light up, so if a nodule is somewhat suspicious on a CT, and then that area lights up on a PET scan, it raises our suspicion that it's cancerous. It has the added benefit of showing if those cancer cells spread anywhere. We can see if areas of lymph nodes or adrenal glands or bones anywhere in the body.

We can see if something lights up or is PET avid in some suspicious way.

Host: Now if surgery is required to remove the nodule, with technology constantly advancing the way it is, are there minimally invasive procedures available?

Brian Cohen, MD: Yes, absolutely. I'd say the vast majority of lung resections today are done minimally invasively. That's either through VATS, which is small incisions, video assisted thoracoscopic surgery or robotic assisted surgery. Again, using small incisions and a robot to help the surgeon, maneuver instruments in order to remove whatever lung tissue is necessary.

These smaller incisions help spare a lot of pain after surgery, they decrease recovery times, and we have great outcomes with using these techniques.

Host: That's what I was going to ask. How successful are the procedures?

Brian Cohen, MD: Patients do extremely well after these procedures. Most commonly, it's one or two nights in the hospital recovery, and then, slowly getting back to their normal activity afterwards. We see a much better recovery time with minimally invasive surgery than with traditional open surgery. That said, there are some patients and some lung cancers that do require open surgery.

We are still able to get those out effectively and help patients recover through that process, in order to get back to what's important to them.

Host: Do you think there'll be further advancements in the field of thoracic surgery for treating lung cancer and lung nodules?

Brian Cohen, MD: Absolutely. It has come a extremely long way, in a very short period of time and I don't anticipate it stopping here. The tools that we have surgically have been getting better and better. We have great instruments that are able to allow us to take out these cancers, with minimal surgical morbidity and the tools that we have to find cancers and treat them both before surgery and after surgery are rapidly advancing. We have great medication that are making patients who had never been surgical candidates in pretty recent times are now surgical candidates and are living much longer after having been diagnosed with lung cancer.

Host: That is very encouraging news. Is there anything we can do to lower the risk of developing lung nodules?

Brian Cohen, MD: To developing lung nodules, the best tool we have is to continue decreasing smoking rates. So we have a great smoking cessation program at WakeMed. Getting involved with it, using the tools that we have to help stop smoking is the best way to avoid lung nodules. To treat cancer and to decrease the morbidity of cancer and the mortality from cancer, another tool we have is to find these nodules early. So signing up with a screening program, talking to your doctor about your risk factors, acting on a finding that we see incidentally on a CT scan. It's much better to address this early, find the nodules when it would be an early stage lung cancer as opposed to finding it later after somebody has symptoms or somebody presents with issues of more advanced disease.

Host: Well, Dr. Cohen, thank you so much for explaining all this about lung nodules and for the work you and your team are doing at WakeMed Cardiovascular and Thoracic surgery.

Brian Cohen, MD: Absolutely. Thank you so much for having me and happy to answer all these questions.

Host: That was thoracic surgeon, Dr. Brian Cohen. To learn more about WakeMed Lung and Chest Health services, please visit wakemed.org. If you found this podcast helpful, please share it on your social channels and you can check out our entire podcast library for other topics of interest to you. I'm Amanda Wilde with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.