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Progressive screen-detected subsolid pulmonary nodule — SCE Respiratory MCQ

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HardLung Cancer ScreeningProgressive screen-detected subsolid pulmonary noduleSCE Respiratory

A 62-year-old current smoker undergoes low-dose CT through the NHS Lung Cancer Screening Programme. He is asymptomatic, has an ECOG performance status of 0 and has lung function suitable for anatomical resection. Baseline CT shows a solitary 12 mm pure ground-glass nodule in the right upper lobe. Thin-section CT at 3 months confirms persistence without a solid component; the Brock malignancy risk is 7%, and CT surveillance is arranged. At the 1-year scan, the overall nodule diameter remains 12 mm, but a new 4 mm solid component has developed. There is no lymphadenopathy. PET-CT, performed before referral, shows no discernible FDG uptake in the nodule or elsewhere. Which is the most appropriate next management strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Discuss at the lung cancer MDT, favouring surgical resection over further observation

Explanation lettering: D = shown as B · B = shown as C · C = shown as D

The decisive change is not the stable overall diameter but the development of a solid component within a previously pure ground-glass nodule. BTS guidance recommends favouring resection or non-surgical treatment over observation when a pure ground-glass nodule develops a solid component. This patient is fit for surgery, making MDT assessment with resection favoured the best strategy. Absent FDG uptake does not reverse this conclusion: PET has reduced sensitivity for subsolid nodules, particularly when the invasive solid component is small. A was appropriate while the persistent subsolid nodule remained unchanged and its Brock risk was below 10%, but morphological progression supersedes that surveillance pathway. C repeats the initial persistence assessment unnecessarily and delays management of documented progression. D may appear attractive because tissue diagnosis is generally desirable, but targeting a 4 mm solid component is likely to have limited diagnostic yield; BTS guidance does not require percutaneous confirmation before favouring treatment in this situation. E incorrectly equates stable total diameter with stability: increasing attenuation or emergence of a solid component represents clinically important progression despite unchanged external dimensions.

Reference: BTS guidelines for the investigation and management of pulmonary nodules (2015) — https://www.brit-thoracic.org.uk/document-library/guidelines/pulmonary-nodules/bts-guidelines-for-the-investigation-and-management-of-pulmonary-nodules/