Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Approach to the Solitary Pulmonary Nodule in the Elderly

  A solitary pulmonary nodule is a rounded opacity within the lung, usually measuring less than 3 cm and surrounded by normal lung tissue. It is often discovered incidentally on a chest CT performed for another reason, such as breathlessness, coronary assessment or pre-operative planning. In older adults, the finding may represent an early lung cancer, a benign scar or granuloma, or an inflammatory process.

  An effective approach balances the probability of malignancy against the person’s life expectancy, functional status and willingness to undergo investigation. Australian practice also has to account for access to PET-CT and respiratory services outside Sydney, Melbourne, Brisbane, Perth and Adelaide, as well as the practical implications of Medicare coverage and travel from rural or remote communities.

  Confirm the Finding and Establish Its Context

  The first step is to review the actual CT images rather than relying only on the report. Thin-slice CT can clarify whether the lesion is solid, part-solid or ground-glass, and whether it is truly solitary. Size, margins, location and growth pattern are central. A comparison with previous imaging is often the most valuable test; stability over two years supports benignity for many solid nodules, although subsolid lesions may require longer observation.

  Clinical context changes the pre-test probability. Age, current or former smoking, previous cancer, asbestos exposure and a family history of lung cancer all matter. Australian clinicians should also consider occupational exposure in mining and construction communities, as well as the higher burden of respiratory disease experienced by some Aboriginal and Torres Strait Islander populations.

  Symptoms such as haemoptysis, persistent focal chest pain, unexplained weight loss or progressive breathlessness should prompt a broader assessment rather than an isolated nodule pathway. A chest infection can leave a temporary inflammatory nodule, so recent fever, productive cough and antibiotic treatment should be recorded before deciding that an invasive test is necessary.

  Estimate the Risk of Malignancy

  Risk assessment combines patient factors with radiological features. Suspicious signs include spiculation, upper-lobe location, enlarging size and a solid component within a part-solid nodule. A smooth, calcified lesion with a classic benign pattern is less concerning, although appearances should be interpreted with the full clinical history.

  Validated prediction models can support shared decision-making. Models such as the Brock calculator use age, smoking history, nodule size, type, location and morphology. They are aids rather than replacements for specialist judgement, particularly when applied to populations or imaging protocols that differ from the original research setting.

  A low estimated risk may justify CT surveillance, while an intermediate risk often leads to PET-CT or tissue sampling. A high-risk lesion should be discussed promptly by a multidisciplinary team, including respiratory medicine, radiology, thoracic surgery, oncology and, when appropriate, geriatric medicine.

  Select Investigation According to Fitness

  PET-CT is useful when a nodule is large enough to characterise metabolically and the result will change management. It can identify unsuspected lymph-node or distant disease and help stage a likely lung cancer. Small lesions may produce false-negative results, while infection and granulomatous disease can cause false-positive uptake. This limitation is relevant in areas where inflammatory lung conditions are common.

  Biopsy may be performed through CT guidance, bronchoscopy or navigational techniques, depending on the lesion’s position and local expertise. The risks include pneumothorax, bleeding and non-diagnostic tissue. A peripheral upper-lobe nodule may be accessible to percutaneous biopsy, whereas a lesion near an airway may be better suited to bronchoscopy.

  In an older person, the question is not simply whether cancer can be proved. The team should ask whether the result would alter treatment. A frail patient with severe chronic obstructive pulmonary disease may face substantial harm from an invasive procedure, while a fit 78-year-old may be a candidate for curative surgery, stereotactic ablative radiotherapy or limited resection.

  Adapt Surveillance and Treatment to the Person

  CT surveillance is an active management strategy, not neglect. It requires a clearly documented interval, scan technique and threshold for escalation. The schedule depends on nodule size, morphology and estimated risk, with subsolid nodules often needing longer follow-up. Radiation exposure from repeated CT is generally modest, but unnecessary imaging should be avoided when it will not influence care.

  Treatment decisions should include frailty, cognition, mobility, nutrition, renal function, anticoagulant use and social support. A comprehensive geriatric assessment can reveal reversible problems, such as poor nutrition or medication burden, that affect procedural safety. The patient’s goals are equally important: some may prioritise diagnostic certainty, while others may prefer observation and symptom-focused care.

  Geography can influence the plan. Someone in regional New South Wales or rural Western Australia may need coordinated appointments to avoid repeated long-distance travel. Telehealth can support follow-up discussions, but it does not replace high-quality imaging or a local clinician who knows the patient’s baseline function.

  Practical Features That Shape Clinical Decisions

  The following findings generally favour closer assessment or multidisciplinary review:

  • Spiculated, enlarging or upper-lobe nodules
  • A substantial solid component in a subsolid lesion
  • Previous lung cancer or significant smoking exposure
  • New symptoms such as haemoptysis or unexplained weight loss

  Factors that may support surveillance or a less invasive pathway include:

  • Limited life expectancy or severe frailty
  • A benign calcification pattern or long-term stability
  • High procedural risk from emphysema, anticoagulation or poor lung reserve
  • A preference to avoid treatment that is unlikely to improve quality of life

  Management option	Common role	Main advantages	Important limitations
  CT surveillance	Low-risk or indeterminate nodules	Avoids invasive testing and tracks growth	Requires reliable follow-up and may prolong uncertainty
  PET-CT	Intermediate or high-risk lesions suitable for metabolic imaging	Assesses activity and possible spread	Less reliable for very small nodules; false positives occur
  CT-guided biopsy	Accessible peripheral lesions	Provides tissue diagnosis	Pneumothorax, bleeding and non-diagnostic samples
  Bronchoscopy	Lesions near airways or when nodal sampling is needed	Can sample airways and lymph nodes	Yield varies with lesion size and location
  Surgery or stereotactic radiotherapy	Confirmed or highly probable early cancer	Potentially curative local treatment	Requires assessment of fitness, lung function and patient goals

  The safest pathway is usually agreed at a lung cancer multidisciplinary meeting, even when the initial plan is surveillance. In Australia, referral may involve a public hospital respiratory service, a private thoracic team or a regional cancer network. Clear documentation should state the estimated risk, planned imaging date, responsible clinician and circumstances that require earlier review.

  For an elderly patient with a solitary pulmonary nodule, the practical takeaway is to confirm the CT findings, estimate malignancy risk, compare prior scans and match further testing to both biological risk and personal fitness. A documented shared decision, supported by multidisciplinary expertise and a reliable follow-up plan, is often more valuable than pursuing every available test.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)