Lung Nodule Diagnosis and Treatment: When to Seek a Second Opinion

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• The Critical Importance of a Second Medical Opinion
• Understanding Lung Nodule Types: Solid vs. Sub-Solid
• Diagnostic Algorithm for Solid Lung Nodules
• Management of Sub-Solid (Ground-Glass) Lung Nodules
• Tailoring the Diagnostic Path to the Individual Patient
• The Advantage of Consulting a Lung Nodule Expert

The Critical Importance of a Second Medical Opinion

Dr. Michael Lanuti, MD, strongly advocates for patients to seek a second or even third medical opinion when facing a serious diagnosis. He notes that surgeons' opinions can differ and change over time, making multiple consultations a vital step in ensuring the best possible treatment decision. Dr. Michael Lanuti, MD, emphasizes that this process does not hurt and can provide immense value, especially when a patient needs to feel comfortable with their medical team.

Dr. Anton Titov, MD, the interviewer, agrees, sharing that this was true in his own experience. Dr. Michael Lanuti, MD, explains that well-trained surgeons are found worldwide, but their judgment is not constant. An 84-year-old lung cancer patient might be considered a surgical candidate by one surgeon but not by another. Finding a surgeon with a broad range of experience across all patient ages is crucial, and this is often best achieved at larger university medical centers.

Understanding Lung Nodule Types: Solid vs. Sub-Solid

The approach to a solitary pulmonary nodule discovered on a CT scan is a complex art in medicine. Dr. Michael Lanuti, MD, clarifies that physicians must first differentiate between the two main types of lung nodules: solid and sub-solid. A sub-solid nodule is also frequently described as a ground-glass opacity on imaging. Solid nodules have a different diagnostic pathway than sub-solid nodules, and it is critical to understand that a nodule is not necessarily cancer.

Diagnostic Algorithm for Solid Lung Nodules

For a small solid lung nodule under 8 millimeters in a patient with no history of cancer, Dr. Michael Lanuti, MD, explains the initial step is usually surveillance with an interval CT scan in three months to check for growth. Solid lung nodules that grow are always suspicious and typically require intervention. A PET CT scan can be employed to assess the nodule's metabolic activity, as lung cancer tends to avidly take up the radioactive glucose tracer.

A PET-positive result points a surgeon toward a more aggressive approach, like surgical removal if the patient is a candidate. However, a solid nodule that is PET CT negative may allow the medical team to pull back and continue monitoring. The key, as Dr. Michael Lanuti, MD, states, is that these decisions are not made from a cookbook but are tailored to the individual.

Management of Sub-Solid (Ground-Glass) Lung Nodules

Sub-solid or ground-glass lung nodules are managed very differently from their solid counterparts. Dr. Michael Lanuti, MD, describes them as either inflammatory changes or precursors to lung cancer. These nodules are common in both smokers and non-smokers and require long-term vigilance because they can develop into cancer over many years.

The management strategy for stable sub-solid nodules involves surveillance imaging. If a nodule is stable at a three-month scan, the next scan might be scheduled for six months later. If it remains stable for a longer period, annual CT scans are often sufficient. Dr. Michael Lanuti, MD, notes he will follow a ground-glass nodule for years. The critical indicators for action are if the nodule starts to grow or, more importantly, if it develops a new solid component, which suggests an invasive cancer and necessitates surgical removal.

Tailoring the Diagnostic Path to the Individual Patient

A central theme in Dr. Michael Lanuti, MD's explanation is the absolute necessity of tailoring the diagnostic and treatment plan to the specific patient. He provides a clear example: a patient with a history of colon cancer who presents with a new solid lung nodule will be managed much more aggressively than a lifelong non-smoker with no cancer history who has the same-sized nodule. This personalized approach ensures that resources are used effectively and patients receive care appropriate to their risk level.

Dr. Anton Titov, MD, highlights that at each branch of the diagnostic algorithm, there is a subjective decision-making step based on a physician's knowledge and experience. Dr. Lanuti agrees completely, noting this complexity is why expert consultation is so valuable.

The Advantage of Consulting a Lung Nodule Expert

Dr. Michael Lanuti, MD, concludes that primary care physicians are often not equipped to manage the nuances of lung nodule diagnosis, and even pulmonologists who do not focus on this area daily may benefit from expert consultation. Consulting a specialist who manages lung nodules every day can be highly advantageous, saving patients unnecessary procedures, reducing anxiety, and controlling healthcare costs.

This expert opinion can frequently be obtained remotely. Dr. Lanuti confirms that his team regularly reviews outside CT scans from across the world to provide recommendations on how to proceed with a found lung nodule. As experts in lung disease, they are well-suited to make these critical diagnostic calls, underscoring the immense value of seeking a specialized second opinion.

Full Transcript

Dr. Anton Titov, MD: Leading lung cancer surgeon and gene therapy expert discusses best medical treatment decisions. How to get the best treatment for any serious disease? You must get a second medical opinion. Sometimes you need to get a third medical opinion.

Surgeons have different opinions. Surgeons’ opinions change in time.

Dr. Michael Lanuti, MD: I think that you've articulated a very important point. Sometimes there is an important life decision for someone. To get a second opinion doesn't hurt you. Traveling for a medical second opinion sometimes might help you.

You've brought up a very good point of being comfortable with your team. You need to consider a second or sometimes third opinion. Not only a medical second opinion, but a third opinion, and however many it takes.

Dr. Anton Titov, MD: Correct.

Dr. Michael Lanuti, MD: And it was certainly true in our situation. Correct. Surgeons are different all over the world. I think well-trained surgeons can be found everywhere in the world. And surgeons have their own judgment.

Judgment of a surgeon is something that's not constant. Sometimes a patient who is 84 years old presents with lung cancer to one surgeon. The same patient then presents to a second surgeon. Both of these cancer surgeons might have different opinions. They may think the patients are candidates for surgery.

You're looking for someone who has a range of experience across all ages of patients. You are still going to get the best cancer treatment in larger universities.

Dr. Anton Titov, MD: It is common to find a single nodule in a lung on a CT scan. What to do with solitary pulmonary nodules is controversial. How do you approach solitary pulmonary nodules when you are consulted?

What is the general diagnostic algorithm? What people should know about pulmonary nodules?

Dr. Michael Lanuti, MD: That's a real art in the field. I think people cannot understand management of lung nodules very well. Physicians perhaps order too many diagnostic studies too fast.

Patients often present with a single nodule in the lung. We have to differentiate the type of lung nodule. There are nodules that are “solid". There are nodules that we call “sub-solid". Another term that you might see is "ground-glass" nodule, which is sub-solid.

Solid nodules have a different diagnostic algorithm than sub-solid nodules. Solid lung nodules can be several things, not necessarily cancer. It depends on where you are in the world.

Sometimes you see a single lung nodule. If it's under 8 millimeters we generally say "you need another interval scan”. We have to see if that lung nodule changes. Someone who had no history of cancer.

And the important thing here is that you really tailor the diagnostic path to the patient. There isn't any one cookbook way that you can say "every patient has to follow this diagnostic path".

I'll give you an example. Sometimes the patient comes to me. This patient had a history of colon cancer. This patient now has a solid lung nodule.

I'm going to manage that lung nodule very differently than in someone who never had cancer and who now has a solid lung nodule. So small solid lung nodules in someone who has never had cancer are diagnosed in this way.

Let's say they are a nonsmoker. We would usually get an interval scan in three months and see what it looks like. Solid lung nodules that grow are always suspicious.

Then the surgeon has to decide. Do you need a tissue biopsy? Or do you remove it? Most of the time we say, "Things that are growing in the lung should be removed if patients are candidates for surgery."

We can employ the use of a PET CT scan to look at the functionality of the lung nodule. Lung cancer tends to pick up the radioactive glucose that's given with a PET CT scan. That would point the surgeon more towards an aggressive approach.

Sometimes a solid lung nodule is PET CT negative. Such a lung nodule tends to make you pull back a little bit on a solid nodule. Again, you tailor diagnostic tests and therapy to the patient.

The flip side is we're seeing now many sub-solid lung nodules. Ground glass opacity nodules. Those are managed very differently.

Dr. Anton Titov, MD: What are sub-solid lung nodules?

Dr. Michael Lanuti, MD: They are either inflammatory or they can be precursors to lung cancer. And many people have sub-solid lung nodules, whether you're a smoker or not.

If you find sub-solid lung nodules, you can never stop watching them. Because sub-solid lung nodules can always over the years develop into a lung cancer. Some sub-solid lung nodules are so slow.

It takes three years for sub-solid lung nodules to start to grow. We've seen them take seven years to grow. But sub-solid lung nodules we manage a lot of time with surveillance imaging.

If sub-solid lung nodules are stable at three months, we then move the next chest CT scan to six months. If sub-solid lung nodules are really stable for a while, we get a CT scan once a year. And so I will follow a ground-glass nodule for years with an annual scan.

Whenever they start to grow, or if they ever start to develop a solid component, that's an indicator for an invasive cancer. That's where the treating team would say you need to do something about it.

Oftentimes we would say, "remove it surgically", if they're a candidate.

Dr. Anton Titov, MD: So there are nuances to diagnose sub-solid lung nodules. So there is a general algorithm that you described. But also at each instance, at each branch of the algorithm, there is a very subjective, but nevertheless subjective decision-making step. It is based on knowledge and experience.

Dr. Michael Lanuti, MD: Agreed, and so I think that primary care physicians are not equipped to diagnose lung nodules. Pulmonologists know more, but if they do it all the time, usually they cannot spend too much money and manage lung nodules efficiently.

I do think that providers that are not doing it every day should probably consult with someone who is an expert. So this is another example of the situation where consulting an expert could be very advantageous. It can save a lot of trouble and a lot of money for people.

Dr. Anton Titov, MD: Expert opinion can be based on the CT scans, even remotely.

Dr. Michael Lanuti, MD: Yes. In fact, we oftentimes are asked to review outside lung CT scans from across the world. We decide what to do with these lung nodules.

And I think being the expert in the lung, I think that we are well suited for diagnosing lung cancer in solitary lung nodules.