Pulmonary nodules: bringing order out of chaos

Picture the scene: a lung cancer multidisciplinary team (MDT) meeting, somewhere in the UK, January 2015. CT images from a patient with suspected colorectal cancer, whom no one present has ever met, are discussed at the request of the colorectal team. An abnormality is present in the right lower lobe of lung. A week earlier, following two clicks and a drag from the colorectal radiologist's mouse, a 5 mm incidental pulmonary nodule was identified and is now destined to take its unwitting host on an unpredictable journey, which may span years. Imperfectly remembered advice from multiple professional society guidelines, some a decade old, will be proffered and contested in repeated meetings. How should the nodule be measured, how often, by whom? What is the risk that it is malignant? Is now (ever?) the right time for a biopsy? This scenario, which is likely familiar to many readers, has often served to relegate nodule follow-up to a tedious chore shared widely to ease the burden. Help is at hand. With this issue of Thorax, David Baldwin, Mat Callister and colleagues publish the British Thoracic Society (BTS) guidelines for the investigation and management of pulmonary nodules,1 together with their own clear summary,2 which will support good, evidence-based patient care, effective resource use and audited outcomes. The precise and detailed distillation of a burgeoning evidence base—one-third of the 360 references are from 2012 or later—into four graphic algorithms represents a huge step from chaos towards order. It offers chest physicians everywhere the opportunity to channel the growing number of patients with incidental pulmonary nodules into a consistent and systematic process of investigation and, where appropriate, treatment. A number of helpful simplifications emerge. Data from several large screening studies, including the Dutch NELSON study,3 provide clear evidence that nodules …