Eduovisual
Respiratory
Lung cancer: USPSTF screening and pulmonary nodule follow-up
— Leading cause of cancer death in US men and women; ~85% non-small cell (adenocarcinoma > squamous > large cell), ~15% small cell
— Tobacco drives ~80–90% of cases; radon is the #2 cause and #1 in never-smokers
— Other risks: asbestos (synergistic with smoking), arsenic, diesel exhaust, prior chest radiation (e.g., Hodgkin, breast CA), pulmonary fibrosis, COPD independent of smoking, family history in first-degree relative
— Asymptomatic: incidentally found pulmonary nodule on CT/CXR ordered for another reason
— Symptomatic red flags in a smoker ≥40: new cough >3 weeks, change in chronic cough, hemoptysis (even a single episode), unexplained weight loss, focal wheeze, recurrent same-lobe pneumonia, dyspnea, hoarseness (recurrent laryngeal nerve), Horner syndrome, shoulder/arm pain (Pancoast)
— Paraneoplastic clues: SIADH or Cushing/Lambert-Eaton (small cell), hypercalcemia (squamous, PTHrP), hypertrophic osteoarthropathy/clubbing (adenocarcinoma)
— Screening = asymptomatic, eligible patient → low-dose CT (LDCT) annually
— Diagnostic = symptomatic or abnormal imaging → standard-dose CT chest with contrast, not LDCT
— Never use CXR for screening (PLCO trial showed no mortality benefit)
— Outpatient FM/IM physicians own screening uptake, shared decision-making, smoking cessation integration, and nodule follow-up coordination
— Missed nodule follow-up is a top malpractice claim in primary care radiology
Board pearl: A 58-year-old former smoker (quit 8 years ago, 30 pack-year history) presenting for an annual visit who has never had LDCT is the prototypical "order screening today" stem — don't be distracted by his normal CXR last year.
— Incidental nodule: CT ordered for PE, trauma, or cardiac workup reveals a 6–15 mm nodule. Patient is asymptomatic. Task = apply Fleischner or Lung-RADS.
— Screening-detected: Eligible patient enrolled in LDCT, baseline scan shows nodule. Task = Lung-RADS category and interval.
— Symptomatic mass: Heavy smoker with hemoptysis, weight loss, or hilar mass. Task = tissue diagnosis and staging, not screening.
— Smoking quantification: pack-years = (packs/day) × (years smoked); document quit date precisely — eligibility hinges on "within 15 years" of quitting
— Occupational/environmental: asbestos latency 20–40 years; uranium/radon mining; secondhand smoke; home radon testing status
— Prior imaging: a nodule stable ≥2 years on CT (solid) or ≥5 years (subsolid) is almost certainly benign — always request priors before workup
— Cancer history: prior breast, colon, renal, melanoma, head/neck cancers raise metastasis probability over primary lung CA
— Infectious exposures: TB, endemic fungi (histoplasmosis in Ohio/Mississippi valleys, coccidioidomycosis in Southwest) explain calcified granulomas
— Constitutional symptoms: weight loss >5%, fevers, night sweats
— Central tumor: cough, hemoptysis, obstructive pneumonia, wheeze
— Peripheral: often silent until pleural involvement → pleuritic pain, effusion
— Apical (Pancoast): shoulder/arm pain, T1 radiculopathy, Horner (ptosis, miosis, anhidrosis)
— Mediastinal: SVC syndrome (facial swelling, JVD, plethora), hoarseness, dysphagia
Key distinction: Hemoptysis in a smoker >40 always earns a CT chest, even if CXR is normal — central endobronchial tumors are radio-occult on plain film up to 25% of the time. Don't accept "probably bronchitis."
— Cachexia, temporal wasting → advanced disease
— Resting tachycardia or hypoxia (SpO₂ <92%) suggests effusion, lymphangitic spread, or PE (lung CA is highly thrombogenic)
— Document ECOG performance status (0 = fully active → 4 = bedbound); drives treatment eligibility and prognosis more than stage in many cases
— Supraclavicular or cervical lymphadenopathy (Virchow node) — easiest biopsy target, often confirms N3/M1 in one stick
— Horner syndrome (Pancoast)
— Hoarseness → flexible laryngoscopy for vocal cord paralysis (recurrent laryngeal nerve, left more common due to aortic arch loop)
— Facial plethora, JVD, dilated chest wall veins → SVC syndrome
— Focal monophonic wheeze that doesn't clear with cough = endobronchial lesion until proven otherwise
— Dullness to percussion + decreased breath sounds + decreased fremitus = pleural effusion (malignant if cytology+ → automatic M1a, stage IV)
— Egophony or bronchial breath sounds over consolidation that won't clear = post-obstructive pneumonia
— Clubbing (Schamroth sign loss) — strong association with NSCLC
— Hypertrophic pulmonary osteoarthropathy: clubbing + periostitis + painful, swollen wrists/ankles
— Acanthosis nigricans, dermatomyositis (heliotrope rash, Gottron papules), migratory thrombophlebitis (Trousseau)
— Bone tenderness → metastasis screening
— Focal deficits, seizures, headache → brain MRI for staging
— Proximal weakness improving with exertion → Lambert-Eaton (small cell)
Step 3 management: When the exam reveals a supraclavicular node in a suspected lung CA patient, biopsy that node first (FNA in clinic or ultrasound-guided) before pursuing bronchoscopy or CT-guided lung biopsy — it simultaneously diagnoses and stages, sparing the patient a second procedure.
— Age 50–80 years
— 20 pack-year smoking history (down from 30 in 2013)
— Currently smoking OR quit within the past 15 years
— Modality: annual low-dose CT (LDCT) chest without contrast
— Stop screening when: age >80, quit >15 years ago, develops health problem that limits life expectancy or willingness/ability to undergo curative lung surgery
— Same age/pack-year/quit window as USPSTF
— Requires a documented shared decision-making visit before the first LDCT, including discussion of benefits, harms (false positives ~12–14%, overdiagnosis, radiation, incidental findings), and smoking cessation counseling
— Must be ordered by qualified provider; facility must participate in registry
— NLST (2011): 20% relative reduction in lung cancer mortality with LDCT vs CXR in high-risk smokers
— NELSON (2020): 24% reduction in men, 33% in women, confirmed European data
— Number needed to screen ≈ 320 to prevent one lung cancer death
— Never-smokers regardless of radon/secondhand smoke exposure (no current USPSTF recommendation)
— Symptomatic patients — they need diagnostic CT, not screening
— Pack-year math examples: 1 ppd × 20 yr = 20 (qualifies); ½ ppd × 30 yr = 15 (does not); 2 ppd × 10 yr = 20 (qualifies)
— Risk of false positives leading to invasive procedures
— Radiation (~1.5 mSv per LDCT, cumulative)
— Incidental findings (coronary calcium, thyroid, adrenal)
— Smoking cessation is more impactful than screening itself
Board pearl: A 49-year-old with a 40 pack-year history does not qualify — age cutoff is firm at 50. Conversely, an 81-year-old healthy patient also does not qualify — age stop is 80. The exam tests these edges relentlessly.
— Solid nodule stable ≥2 years → benign, stop workup
— Subsolid (ground-glass or part-solid) needs ≥5 years stability because adenocarcinoma-in-situ grows slowly
— Size: measure mean of long and short axes; <6 mm, 6–8 mm, >8 mm are the critical thresholds
— Density: solid vs part-solid vs pure ground-glass
— Number: solitary vs multiple
— Morphology: spiculated, lobulated, cavitary with thick walls (>15 mm) → malignant features; smooth, round, "popcorn" or "central nidus" calcification → benign (hamartoma, granuloma)
— Location: upper lobes higher cancer risk; perifissural triangular nodules usually intrapulmonary lymph nodes (benign)
— Growth: volume doubling time 30–400 days suggests malignancy; <30 days = infection/inflammation; >400 days = benign
— Benign: diffuse, central, laminated (granuloma), popcorn (hamartoma)
— Indeterminate/malignant: eccentric, stippled, amorphous
— Brock (PanCan) model or Mayo Clinic model integrates age, smoking, family history, size, spiculation, upper lobe, count
— Pretest probability: low <5%, intermediate 5–65%, high >65% — drives surveillance vs biopsy vs resection
— PET-CT useful for solid nodules ≥8 mm (SUV >2.5 suspicious); poor sensitivity for subsolid/ground-glass and <8 mm lesions (false negatives)
— Contrast-enhanced CT not routine for nodule characterization
Key distinction: Ground-glass nodules are not "less concerning" — they're slow-growing adenocarcinoma in situ until proven otherwise. They get longer surveillance windows, not dismissal. Never tell a patient a 10-mm pure ground-glass nodule is "nothing."
— <6 mm (low risk): no routine follow-up
— <6 mm (high risk): optional CT at 12 months
— 6–8 mm (low risk): CT at 6–12 months, then consider 18–24 months
— 6–8 mm (high risk): CT at 6–12 months, then 18–24 months
— >8 mm: CT at 3 months, PET-CT, or tissue sampling
— <6 mm low risk: no follow-up
— <6 mm high risk: optional CT at 12 months
— ≥6 mm: CT at 3–6 months, then 18–24 months based on dominant nodule
— Pure ground-glass <6 mm: no follow-up
— Pure ground-glass ≥6 mm: CT at 6–12 months, then every 2 years for 5 years total
— Part-solid <6 mm: no follow-up
— Part-solid ≥6 mm with solid component <6 mm: CT at 3–6 months, then annually for 5 years
— Part-solid with solid component ≥6 mm: highly suspicious → CT at 3–6 months, PET-CT, or biopsy
— Heavy smoking, older age, upper lobe location, larger size, spiculation, family history, asbestos/radon, emphysema, pulmonary fibrosis
— Round to nearest mm; use average of long + short axis
— Document baseline carefully — growth definition is +2 mm increase
— Stop surveillance at 5 years for subsolid (or 2 years for solid if stable)
Step 3 management: For a 7 mm solid nodule in a 65-year-old smoker (high-risk), the answer is CT at 6–12 months, not biopsy and not PET. Reserve PET/biopsy for >8 mm or growing lesions. Over-investigation is a wrong-answer trap.
— Category 0: incomplete/prior comparison needed → additional imaging or retrieve priors
— Category 1 (negative, no nodule or definitively benign calcification): annual LDCT in 12 months
— Category 2 (benign appearance/behavior, <1% malignancy risk): annual LDCT in 12 months
— Solid <6 mm, part-solid <6 mm total, ground-glass <30 mm and stable, or stable >3 months
— Category 3 (probably benign, 1–2% risk): 6-month LDCT
— New solid 4–<6 mm, ground-glass ≥30 mm, part-solid <6 mm new
— Category 4A (suspicious, 5–15% risk): 3-month LDCT, consider PET if solid ≥8 mm
— Solid 8–<15 mm, growing <8 mm solid, part-solid ≥6 mm with solid 6–<8 mm
— Category 4B (very suspicious, >15% risk): PET-CT, tissue sampling, or referral
— Solid ≥15 mm, new ≥8 mm solid, part-solid with solid ≥8 mm
— Category 4X: 3 or 4 with additional features (spiculation, lymphadenopathy) → manage as 4B
— Category S: clinically significant or potentially significant non-lung finding (modifier, not exclusive)
— Patient ages out (>80), quit >15 years, or develops limited life expectancy
— A Category 4B requiring workup is not "screening" anymore — switches to diagnostic pathway
Board pearl: Step 3 will give you a screening LDCT report with a 9-mm solid nodule. The correct next step is 3-month follow-up LDCT or PET-CT (Lung-RADS 4A) — not immediate biopsy and not 12-month routine screening. Match category to interval precisely.
— Lung-RADS 4B, Fleischner >8 mm with high-risk features, growing nodule, hypermetabolic on PET
— Goal: confirm malignancy AND provide enough tissue for molecular testing (EGFR, ALK, ROS1, BRAF, KRAS G12C, MET, RET, NTRK, PD-L1)
— Peripheral lesion: CT-guided transthoracic needle biopsy (sensitivity ~90%; complications: pneumothorax 15–25%, hemoptysis)
— Central lesion or endobronchial: flexible bronchoscopy with EBUS (endobronchial ultrasound) — also samples mediastinal nodes in same procedure
— Pleural effusion: thoracentesis with cytology (×3 if first negative); if still negative → pleuroscopy
— Supraclavicular/cervical node: FNA or excisional biopsy — easiest, often diagnostic and staging in one
— Solitary brain or adrenal lesion: biopsy may give both dx and M staging
— Contrast-enhanced CT chest + upper abdomen (adrenals, liver)
— PET-CT for whole-body metastatic survey
— Brain MRI for stage II or higher (or any neurologic symptoms)
— EBUS-TBNA for mediastinal nodal staging — required before resection in most cases
— Mediastinoscopy if EBUS nondiagnostic
— Generally staged as limited (one radiation port) vs extensive
— Brain MRI and PET-CT or CT chest/abdomen + bone scan
— FEV1 and DLCO; predicted postoperative FEV1 <40% or DLCO <40% → high risk; consider stereotactic body radiation therapy (SBRT) instead
CCS pearl: Order biopsy AND staging in parallel, not sequentially — on a CCS case, advancing the clock between "biopsy" and "PET" wastes simulated time. Order PET-CT, brain MRI, and EBUS the same visit when malignancy is highly likely.
— Technically eligible per USPSTF up to age 80, but benefit attenuates with competing mortality
— Estimate life expectancy (ePrognosis, Lee index) — if <5–10 years, screening unlikely to benefit because lung CA mortality reduction takes ~5 years to accrue
— Functional status (ECOG, gait speed, frailty index) matters more than chronologic age
— Document shared decision-making explicitly; many patients elect to stop
— Severe COPD with FEV1 <30% predicted who could not tolerate lobectomy or SBRT
— Advanced CHF, ESRD on dialysis, dementia, metastatic non-lung cancer
— Key principle: only screen if you would treat
— LDCT is non-contrast → safe regardless of GFR
— Diagnostic CT with contrast: caution if eGFR <30; use isotonic IV fluids, consider non-contrast or MRI
— PET-CT uses FDG (not iodinated) — safe in CKD; however, fasting glucose <200 required for adequate uptake (diabetics need glucose optimization)
— Does not affect screening
— Affects systemic therapy (chemo dose adjustments, immunotherapy hepatitis risk)
— Pre-op PFTs, cardiopulmonary exercise testing (VO₂ max <10 mL/kg/min = prohibitive)
— Consider SBRT for stage I NSCLC in non-surgical candidates — equivalent local control
— Re-assess capacity for shared decision-making; involve health care proxy
— Avoid screening if patient cannot consent to/tolerate downstream workup (biopsy, surgery)
Step 3 management: An 82-year-old former smoker (quit 6 years ago) with mild COPD requests screening. Correct answer: do not initiate screening — age >80 falls outside USPSTF/CMS criteria. Counsel on cessation maintenance, radon testing, and symptom-prompted evaluation instead.
— ~10–15% of US lung CA; rising proportion globally
— Strong female predominance, adenocarcinoma histology, EGFR/ALK driver mutations
— Risk factors: secondhand smoke, radon, occupational (asbestos, silica, diesel), prior chest radiation, COPD/IPF, family history
— No current USPSTF screening recommendation for never-smokers even with risk factors — emphasize radon testing (home kit, mitigate if >4 pCi/L) and symptom evaluation
— Consider individualized LDCT in non-smokers with multiple risk factors only after specialist discussion (not standard of care, not on Step 3)
— Higher rates of adenocarcinoma and EGFR mutations
— NELSON trial showed greater mortality benefit in women
— Same USPSTF eligibility criteria — do not lower threshold by sex
— First-degree relative with lung CA roughly doubles risk
— Familial syndromes are rare (Li-Fraumeni, germline EGFR T790M)
— Does NOT alter USPSTF eligibility, but qualifies as "high risk" within Fleischner framework
— Lung CA in pregnancy is rare; if found, CT chest with abdominal shielding is acceptable; MRI without gadolinium preferred for staging
— Defer LDCT screening during pregnancy (no benefit data, radiation concern); resume postpartum
— Lung CA essentially nonexistent; pulmonary nodules usually infectious (histo, TB), congenital (CCAM), or hamartoma
— Carcinoid tumors possible in adolescents — endobronchial mass with recurrent pneumonia
— Increased lung CA risk, especially squamous
— No separate screening guideline; apply USPSTF if eligible by smoking criteria
Board pearl: A 55-year-old never-smoker woman whose mother died of lung CA at 60 asks for LDCT. The Step 3 answer is no screening, but recommend home radon testing and review symptoms — current evidence does not support LDCT outside USPSTF criteria.
— Malignant pleural effusion: dyspnea, dullness; thoracentesis for relief, tunneled pleural catheter or pleurodesis for recurrence
— SVC syndrome: facial/upper extremity swelling, plethora, JVD, headache; elevate head, urgent radiation or stenting, steroids if airway threatened
— Post-obstructive pneumonia: recurrent same-lobe pneumonia is lung CA until proven otherwise — image and bronchoscope
— Massive hemoptysis (>200 mL/24h): position bleeding side down, intubate with large-bore ETT, bronchial artery embolization
— Spinal cord compression from vertebral metastasis: emergent MRI, IV dexamethasone, radiation or decompressive surgery within 24 h
— Paraneoplastic: SIADH, hypercalcemia, Cushing, Lambert-Eaton, cerebellar degeneration
— VTE: lung CA is among highest-risk solid tumors; low threshold for D-dimer/CT-PE; treat with LMWH or DOAC (apixaban/rivaroxaban preferred per CARAVAGGIO/Hokusai)
— False positives (~12–14% on baseline LDCT) → anxiety, repeat imaging, invasive procedures
— Overdiagnosis: ~10–20% of screen-detected cancers may never have caused symptoms
— Radiation exposure: cumulative across annual screens (~1.5 mSv each); theoretical secondary cancer risk
— Biopsy complications: pneumothorax (15–25% CT-guided), hemoptysis, infection; chest tube needed in ~5–10%
— Incidental findings: thyroid nodules, adrenal masses, coronary calcium → cascade workups
— Psychological distress: documented anxiety after positive screens; mitigate with structured shared decision-making
Key distinction: Recurrent pneumonia in the same lobe ≠ same bug — it's mechanical obstruction. The correct response is CT and bronchoscopy, not another azithromycin course. This stem appears in multiple forms on Step 3.
— Massive hemoptysis → ED, IR for bronchial artery embolization, thoracic surgery
— SVC syndrome with airway compromise or cerebral edema → admit, urgent oncology/radiation
— Suspected cord compression → ED, MRI whole spine, dexamethasone, neurosurgery/radiation oncology
— Symptomatic large pleural effusion → ED or same-day thoracentesis
— New focal neuro deficit/seizure → brain imaging
— Pulmonology: nodule ≥8 mm, growth on surveillance, Lung-RADS 4, abnormal PET
— Thoracic surgery: resectable nodule/mass after staging
— Medical oncology: confirmed malignancy, especially for systemic therapy planning
— Radiation oncology: SBRT candidates (early-stage non-surgical), palliative bone/brain mets
— Palliative care: early integration for stage IV NSCLC improves QoL and survival (Temel NEJM 2010)
— Genetics: rare familial clusters
— Smoking cessation program: every encounter — combine behavioral + pharmacotherapy (varenicline first-line, or combination NRT)
— Required for borderline-resectable, oligometastatic, or molecularly complex cases
— Coordinates pathology, molecular testing, staging, treatment sequencing
— Establish a nodule registry in your practice; missed follow-up of incidental nodules is a leading malpractice claim
— Close the loop on every radiology recommendation; document patient notification
CCS pearl: On a CCS case with a 2.5-cm spiculated upper-lobe mass and 4-cm mediastinal node, your orders should include: contrast CT chest/upper abdomen, PET-CT, brain MRI, EBUS-TBNA, PFTs, and consults to pulmonology, thoracic surgery, and medical oncology — all in the same visit block. Parallel ordering wins the clock.
— Tuberculoma: upper lobe, calcified, often with satellite lesions; TB exposure or endemic area
— Histoplasmoma: Ohio/Mississippi valleys; central laminated calcification; often multiple
— Coccidioidoma: Southwest US; can cavitate
— Aspergilloma: cavity with mobile fungal ball, "air crescent" sign; usually in pre-existing cavity (TB, sarcoid)
— Pulmonary hamartoma: smooth, "popcorn" calcification, fat density on CT — pathognomonic when both features present
— Carcinoid tumor: central endobronchial, recurrent same-lobe pneumonia, hemoptysis; "raisin" appearance; octreotide scan positive
— Hemangioma, chondroma, lipoma: rare
— NSCLC subtypes: adenocarcinoma (peripheral, ground-glass), squamous (central, cavitary, hypercalcemia), large cell
— Small cell: central, rapid growth, paraneoplastic
— Bronchioloalveolar/lepidic adenocarcinoma: ground-glass, slow, may be multifocal
— Pulmonary lymphoma: rare, often MALT type
— Pleural mesothelioma: asbestos exposure, pleural thickening/effusion
— Multiple, peripheral, lower-lobe predominant
— Common primaries: breast, colon, kidney, melanoma, sarcoma, head/neck, thyroid
— Cannonball metastases: classic for RCC, choriocarcinoma
— Rheumatoid nodules (RA, often cavitary, subpleural)
— Granulomatosis with polyangiitis (cavitary, c-ANCA, sinus + renal disease)
— Sarcoidosis nodules (hilar adenopathy, upper lobe reticulonodular)
— Organizing pneumonia, eosinophilic pneumonia
— Pulmonary infarct from PE (Hampton hump, wedge-shaped)
Key distinction: Popcorn calcification + fat density = hamartoma, no biopsy needed. Eccentric calcification or no calcification + spiculation = malignancy, biopsy or resect. Calcification pattern is high-yield CT pearls Step 3 loves.
— Anterior mediastinum (4 T's): thymoma (myasthenia gravis association), teratoma/germ cell, thyroid (substernal goiter), terrible lymphoma
— Middle mediastinum: bronchogenic cysts, lymphadenopathy (sarcoid, lymphoma, TB, mets)
— Posterior mediastinum: neurogenic tumors (schwannoma, neurofibroma), esophageal duplication
— Solitary fibrous tumor of pleura (can be huge, mostly benign)
— Mesothelioma (asbestos, pleural rind)
— Empyema, loculated effusion
— Rib fracture callus mimicking nodule on CXR
— Bone lesion (myeloma, mets) projecting over lung field
— Nipple shadow — always look for symmetric counterpart and mark for repeat
— Pulmonary AVM: serpiginous feeding artery/draining vein; consider HHT (Osler-Weber-Rendu)
— Pulmonary varix, aortic aneurysm, cardiac aneurysm
— Pericardial cyst (right cardiophrenic angle)
— Subpulmonic effusion mimicking mass
— Hiatal hernia (retrocardiac air-fluid level)
— Morgagni or Bochdalek hernia
— ECG electrode, button, hair braid, skin lesion (mole, lipoma) on CXR
— Always correlate with skin exam and repeat with marker if uncertain
— Sarcoidosis: bilateral hilar lymphadenopathy, upper lobe nodules
— IgG4 disease (rare pulmonary involvement)
— Amyloidosis (nodular pulmonary form)
Board pearl: A "nodule" on CXR that disappears on CT chest was likely a skin lesion or external artifact (nipple, mole, EKG lead, braid). Before ordering follow-up CT for a CXR-only finding, examine the skin and consider repeat CXR with a metallic marker.
— Quitting at any age reduces lung cancer risk; risk approaches (but never equals) never-smoker after ~15 years
— Continued screening only while patient remains within USPSTF window (within 15 years of quit)
— First-line pharmacotherapy: varenicline (most effective monotherapy) or combination NRT (patch + short-acting). Bupropion if comorbid depression and varenicline contraindicated
— Counseling: 5 A's (Ask, Advise, Assess, Assist, Arrange) at every visit; quitlines (1-800-QUIT-NOW)
— Combine pharmacotherapy + behavioral counseling — synergistic
— Test home (free or low-cost kits); EPA action level ≥4 pCi/L
— Mitigation systems reduce levels by 50–99%
— Asbestos: avoid further exposure; document for compensation; lifetime risk persists
— Counsel on secondhand smoke avoidance for household members
— Surveillance per NCCN: CT chest with contrast every 6 months × 2–3 years, then annually
— Continue smoking cessation (recurrence and second primary risk)
— Vaccinations: annual flu, COVID boosters, pneumococcal (PCV20 or PCV15→PPSV23), zoster, RSV (age-eligible)
— Screen for depression, fatigue, financial toxicity
— Don't drop colon, breast, cervical, prostate screening because of lung CA history — competing risks
— Address cardiovascular risk: most ex-smokers die of CAD, not lung CA
— Confirm LDCT done if eligible; document if declined
— Smoking status and intervention
— Symptom review (cough, hemoptysis, weight loss)
— Update problem list with nodule and Lung-RADS category
Step 3 management: A 62-year-old quit smoking 12 years ago with a 35 pack-year history wants to stop screening because "it's been so long." Counsel that he remains eligible until 15 years post-quit (3 more years) — continue annual LDCT.
— Annual LDCT for Lung-RADS 1, 2 indefinitely while eligible
— 6-month LDCT for Lung-RADS 3
— 3-month LDCT or PET for Lung-RADS 4A
— Diagnostic referral for 4B/4X
— Document next-due date in EHR with reminders; close-the-loop tracking
— Build a nodule registry; assign responsible clinician
— Communicate plan to patient in writing with copy of CT report
— Confirm subsequent imaging completed; flag no-shows
— At every visit ("Ask, Advise" at minimum); set quit date once motivated
— Follow up 1 week, 1 month, 3 months after quit attempt
— Adjust pharmacotherapy; treat for ≥12 weeks (varenicline often 6 months)
— Benefits: 20–24% lung CA mortality reduction
— Harms: false positives, anxiety, biopsy complications, overdiagnosis (~10–20%), radiation, incidental findings
— Cost/coverage: covered without cost-sharing under ACA for USPSTF Grade B (private insurance, Medicare with SDM visit)
— Document shared decision-making encounter explicitly (CMS requires for billing)
— % eligible patients offered LDCT
— % LDCT findings with documented follow-up
— Smoking cessation counseling rates
— Use plain language: "spot on the lung," "we want to watch it"
— Avoid the word "tumor" for indeterminate nodules
— Provide written instructions and patient portal access to images
Board pearl: The shared decision-making visit before first LDCT is a CMS requirement and a frequent Step 3 distractor. If a 60-year-old eligible patient has not had this visit, the answer is schedule SDM visit, not "order LDCT today."
— CMS mandates documented SDM visit before initial LDCT; must cover benefits, harms, and cessation counseling
— Use of a decision aid is recommended (multiple validated tools)
— Patients have the right to decline screening after informed discussion — document the conversation, not the decision alone
— Top driver of primary care malpractice in radiology: a CT done in the ED reveals a nodule, the discharge summary mentions it, but no one ensures outpatient follow-up
— Best practice: closed-loop communication — radiologist flags critical findings, ED notifies PCP and patient directly, PCP confirms tracking in registry, patient receives written instructions
— Build EHR alerts and nodule tracking dashboards
— Step 3 vignette: ED CT reads "8 mm spiculated RUL nodule, recommend follow-up CT in 3 months." Two years later patient returns with stage IV cancer. Question may ask about systems-based prevention (closed-loop notification, nodule registry, automated reminders)
— Black Americans develop lung CA at lower pack-years and younger ages; 2021 USPSTF update partially addresses this by lowering thresholds, but disparities persist
— Address access barriers: transportation, copays for downstream workup (LDCT itself is no-cost share), language
— Honest discussion that some screen-detected cancers would never have caused harm
— Avoid screening patients who would not undergo treatment — non-maleficence
— Lung CA is reportable to state cancer registries (provider/lab responsibility)
— Asbestos and occupational exposure: encourage workers' compensation filing; some states require reporting
— Cognitively impaired patients: assess capacity for SDM; involve health care proxy/POA
— Continue cessation counseling regardless of screening decision
Step 3 management: An ED CT incidentally shows a 9-mm nodule. The patient is discharged. The safest systems answer is direct PCP notification with documented receipt + patient written notification + nodule registry entry — not relying on the discharge summary alone.
— Adenocarcinoma: most common overall, peripheral, women, never-smokers, EGFR/ALK/ROS1, hypertrophic osteoarthropathy
— Squamous cell: central, cavitary, smokers, PTHrP → hypercalcemia
— Small cell: central, smokers, paraneoplastic (SIADH, Cushing, Lambert-Eaton), rapid progression, limited vs extensive staging
— Large cell: peripheral, undifferentiated, gynecomastia (β-hCG)
— Carcinoid: young, nonsmoker, central endobronchial, recurrent pneumonia, hemoptysis, carcinoid syndrome rare in lung primary
— EGFR (Asian, female, never-smoker) → osimertinib
— ALK rearrangement → alectinib
— ROS1, BRAF V600E, KRAS G12C, MET, RET, NTRK — targeted agents
— PD-L1 ≥50% → pembrolizumab monotherapy first-line
— Small cell: SIADH (hyponatremia), Cushing (ectopic ACTH), Lambert-Eaton (anti-VGCC), cerebellar degeneration (anti-Hu)
— Squamous: hypercalcemia (PTHrP)
— Adenocarcinoma: HPO, migratory thrombophlebitis (Trousseau), dermatomyositis
— Golden S sign: RUL collapse from central mass
— Air bronchograms in mass: lepidic adenocarcinoma or lymphoma
— Cavitary nodule with thick wall (>15 mm): malignancy (often squamous)
— Popcorn calcification: hamartoma; central/laminated: granuloma
— NLST: 20% mortality reduction with LDCT
— NELSON: 24% men, 33% women
— Temel 2010: early palliative care improves survival in metastatic NSCLC
— Pneumococcal (PCV20), flu, COVID, zoster, RSV (≥60)
Key distinction: Hypercalcemia + cavitary central mass = squamous; hyponatremia + central mass + rapid progression = small cell. These two pairings appear repeatedly on boards.
— "55-year-old smokes 1 ppd × 25 years, no quit attempts." → 25 pack-years, age 55 → eligible, order LDCT after SDM visit
— Trap: pack-year just below 20 or age just below 50 or above 80, or quit >15 years ago → not eligible
— Incidental 5 mm solid nodule in a low-risk never-smoker → no follow-up
— 7 mm solid nodule in a 60-year-old smoker → CT 6–12 months
— 10 mm spiculated solid nodule → PET-CT or biopsy
— 9 mm solid new nodule → Lung-RADS 4A, 3-month LDCT or PET
— 18 mm solid → Lung-RADS 4B, tissue diagnosis
— Hyponatremia + central hilar mass + smoker → small cell with SIADH; treat hyponatremia (fluid restrict ± tolvaptan), biopsy
— Hypercalcemia + cavitary mass → squamous; treat with IV fluids ± bisphosphonate
— ED CT shows nodule, patient returns years later with advanced cancer → systems-based answer: closed-loop notification, nodule registry
— 82-year-old, ESRD on HD, ECOG 3 → no screening, address goals of care
— Patient unwilling to undergo workup if positive → no screening
— Hemoptysis in 50-year-old smoker → contrast CT chest + bronchoscopy, not screening LDCT
— 4 cm nodule with popcorn calcification and fat density → hamartoma, no further workup
— → CT and bronchoscopy for obstructing lesion (carcinoid or NSCLC)
Board pearl: When the stem mentions "annual physical, asymptomatic, smoker," think USPSTF eligibility. When it mentions "incidental finding," think Fleischner. When it mentions "screening LDCT result," think Lung-RADS. Matching the right framework to the right scenario is half the battle.
Lung cancer screening is annual low-dose CT for adults 50–80 with ≥20 pack-years currently smoking or quit within 15 years, paired with shared decision-making and smoking cessation; nodule follow-up uses Fleischner for incidental findings and Lung-RADS for screening-detected lesions, with size, density, growth, and patient risk dictating surveillance interval vs PET vs biopsy.
— USPSTF 2021: age 50–80, ≥20 pack-years, current smoker or quit ≤15 years; stop at 80, 15 years post-quit, or limited life expectancy/treatability
— Shared decision-making visit required by CMS before first LDCT; document benefits, harms, cessation counseling
— Fleischner (incidental) thresholds: <6 mm low-risk = no follow-up; 6–8 mm = 6–12 month CT; >8 mm = 3-month CT, PET, or biopsy; subsolid nodules need longer (5-year) surveillance
— Lung-RADS (screening): 1/2 → annual; 3 → 6 months; 4A → 3 months or PET; 4B → tissue diagnosis
— Diagnostic, not screening: hemoptysis, weight loss, focal wheeze, recurrent same-lobe pneumonia → contrast CT and bronchoscopy
— Cessation > screening: varenicline or combination NRT plus behavioral counseling; radon home testing for all
— Histology shortcuts: hypercalcemia + cavitary central = squamous; SIADH/Cushing/Lambert-Eaton = small cell; peripheral ground-glass in never-smoker = adenocarcinoma (EGFR/ALK)
— Systems safety: closed-loop nodule communication and registry prevent the #1 missed-diagnosis malpractice claim in primary care
Step 3 management: Whenever you see "smoker, asymptomatic, annual visit," map the case to USPSTF eligibility → SDM visit → LDCT → Lung-RADS interval → cessation pharmacotherapy. That five-step chain is the most testable longitudinal workflow in preventive pulmonary medicine.