What should be done if an abnormality is discovered on
a chest x-ray?
This page was last updated on November 6, 2004.
The most common scenario is this. An abnormal shadow is seen on a chest x- ray, ordered either for screening or for investigation of an unrelated illness, such as influenza or pneumonia. A new pulmonary density in a smoker or ex- smoker is an ominous finding and may represent a cancer in as many as 50- 70% of cases. Because of this high risk, prompt evaluation by a physician, expert in the management of lung cancer, is imperative. Depending on the circumstances, this will require a series of tests that may include further non- invasive radiographic tests like CT scans, blood tests, sputum cultures and cytology. Invasive tests, including bronchoscopy, trans-thoracic needle biopsy and or surgical operation may be necessary for effective diagnosis and therapy. Transthoracic needle biopsy is often used inappropriately, and should be reserved for carefully selected instances. Transthoracic needle biopsy has a very substantial risk of failing to diagnose a lung cancer. In general, the smaller the pulmonary density, the higher the chance that it will be missed on needle biopsy. In pulmonary nodules 1 cm. in diameter, the risk that a cancer will be missed by needle biopsy can be as high as 50-75% even in experienced medical centers. We have learned a lot about the best management of pulmonary nodules from the International Early Lung Cancer Action Project (I-ELCAP). Based upon data from this study on more than 26,000 high risk individuals who have undergone CT screening for lung cancer a protocol for management of small pulmonary nodules has been developed. THis protocol is updated by a panel of investigators from the medical centers participating in I-ELCAP each six months. I-ELCAP There is a full-text as well as a diagram version. The protocols can make complicated reading for non-MDs. It might help to print them out and take them to your next consultation with your doctor. In general, if the patient is a smoker or an ex-smoker, the risk that of a pulmonary density represents a lung cancer is very high.In general, the larger the mass, the higher the chance that it is a lung cancer. In the never-smoker, the risk that a pulmonary density is a lung cancer is lower, but there is still a substantial risk.What this boils down to is that new, pulmonary nodules carry a high risk and require workup by experienced physicians. In many cases they should be surgically resected unless cancer can be carefully ruled out. Using modern techniques, including thoracosopy, pulmonary nodules can be resected with low risk in most patients. If the patient has substantial risks for surgery, for example, advanced age, severe emphysema or severe cardiac disease, a more conservative approach may be necessary. A second scenario, in which abnormal cells are seen on examination of a sputum specimen is less common, since screening sputum cytology is seldom done in the US today. If abnormal cells are seen on a cytology specimen, bronchoscopy is indicated.
Frederic W. Grannis Jr. M.D |