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MULTIDISCIPLINARY LUNG NODULES PROGRAM STREAMLINES MANAGEMENT OF SUSPICIOUS LUNG
LESIONS

Despite advances in lung cancer treatment, the disease remains deadly, with the
stage of lung cancer at the time of detection being a major determinant in
survival. To improve early diagnosis and treatment, the Mount Sinai – National
Jewish Health Respiratory Institute is using a multidisciplinary approach to
managing lung nodules.

5 minute read

A multidisciplinary approach to managing lung nodules is streamlining diagnosis
and treatment for patients at the Mount Sinai – National Jewish Health
Respiratory Institute. Launched in 2022, the Mount Sinai Multispecialty Lung
Nodules Diagnostic and Treatment Program builds on Mount Sinai Health System’s
position as a leader in diagnosing and treating lung cancer. The program’s new,
integrated approach brings together multiple specialists to improve care for
patients with suspicious lung nodules.

Despite advances in lung cancer treatment, the disease remains deadly. “More
people die of lung cancer than the next three common cancers combined—colon,
breast, and prostate cancers,” says Timothy Harkin, MD, Associate Professor of
Medicine (Pulmonary, Critical Care and Sleep Medicine), and Thoracic Surgery, at
the Icahn School of Medicine at Mount Sinai. “And we know that the stage of lung
cancer at the time of detection is a major determinant in survival.”

Timothy Harkin, MD

Managing Lung Nodules From Screening and Incidental Findings

Fortunately, physicians and the public are becoming increasingly aware of the
importance of low-dose computed tomography (CT) screening for people who smoke
or smoked and others at high risk of lung cancer. Such screenings can identify
suspicious lung nodules that require further evaluation.

Incidental lung nodules also turn up on imaging done for other purposes, such as
coronary calcium scans or chest X-rays following trauma. Patients with a
nodule—whether identified through screening or incidentally—may be referred to
the Lung Nodules Program.

Next steps are informed by standardized approaches guided by cancer risk
assessment, including the Fleischner Society Guidelines for managing pulmonary
nodules detected incidentally on CT images and the American College of
Radiology's Lung CT Screening Reporting & Data System (Lung-RADS®) for nodules
identified on lung cancer screening CTs. Determining the best option among those
suggested by the guidelines involves several considerations. The Lung Nodules
Program takes an integrated approach to assessing those factors.

“In one visit, patients in the program meet with several specialists, including
a pulmonologist, interventional pulmonologist, oncologist, and/or thoracic
surgeon, as indicated by the presentation. Then our team members confer and
deliver a combined recommendation to the patient,” explains Charles A. Powell,
MD, MBA, the Florette and Ernst Rosenfeld and Joseph Solomon Professor of
Medicine at Icahn Mount Sinai, and Chief of Pulmonary, Critical Care and Sleep
Medicine for the Mount Sinai Health System. “This approach is unique because
multidisciplinary consultation has been integrated to a single point of care,
without having to refer the patient to multiple specialists.”

Lung Nodules Classification and Diagnosis

The multidisciplinary program was born from recent advances in classifying lung
nodules. Those discoveries have helped pinpoint which lung nodules likely
require immediate intervention and which can be monitored for change over time.
Smaller nodules, Dr. Harkin notes, are less concerning. “We’ve learned that size
matters a lot. Nodules under about 6 millimeters are much more likely to be
benign, while nodules over that size are more likely to be cancerous,” he says.

Yet even malignant nodules may not require immediate intervention. Much like
prostate cancers that can stay localized for years without causing problems,
some lung tumors are unlikely to grow and spread quickly, if at all. Research
from labs, including Dr. Powell’s, has helped paint a picture of which nodules
are concerning. “Our investigations have discovered distinct subtypes of lung
adenocarcinoma, which range from indolent to very aggressive,” he says.

Those subtypes look different from one another on CT scans. “Indolent lesions
tend to be characterized by nodules with a ground-glass appearance. Nodules that
are more aggressive tend to have a solid appearance on imaging studies,” Dr.
Powell says. “In the past, the management approach to those two types of nodules
would have been the same. Now that we can distinguish subtypes based on imaging,
we’re more comfortable following the low-risk lesions and intervening only when
there has been a significant change.”

1. CT image of ground-glass and part-solid nodules taken in 2019
2. Same patient rescanned in 2023

Importantly, research also suggests that this watch-and-wait approach doesn’t
increase risk to patients. “I’ve been monitoring some patients for 15 years with
no changes to their indolent tumors,” Dr. Powell says. “And we’ve learned that
when we do detect a change on imaging, we have sufficient time to intervene.”

Other recent innovations in lung cancer diagnosis and treatment are improving
care for patients in the Lung Nodules Program. “We have a wealth of research
experience to inform our management of patients with pulmonary nodules, and our
team is ahead of the curve in implementing advances in diagnostics and treatment
for patients with lung cancer,” Dr. Powell says.

In 2023, the Respiratory Institute adopted a robotic platform for bronchoscopy.
“The robotic system allows us to target small nodules more precisely and to
access and biopsy nodules in difficult-to-reach locations that we would never
have attempted before,” Dr. Harkin says. Performing bronchoscopy to biopsy
suspicious nodules also enables pulmonologists to use endobronchial ultrasound
to look for lymph nodes in the chest during the same procedure. “If we’re highly
suspicious of malignancy, we can perform a biopsy of the nodule and assess lymph
nodes essential for staging the cancer in a single procedure instead of the
traditional two,” he adds.

The Importance of Lung Cancer Screening

As leaders in research and management of lung nodules, the multidisciplinary
experts of the Lung Nodules Program are committed to raising awareness about the
latest findings in the field. In 2023, the team organized a pulmonary continuing
education course for professionals, with sessions allocated to diagnosing and
managing lung nodules.

Physicians should also be aware of the importance of following up with nodules
found incidentally, Dr. Harkin says. “Whenever nodules are discovered, they need
to be assessed. When a nodule is found on a scan ordered by a primary care
doctor or cardiologist, we are happy to take care of the follow-up to ensure the
patient is receiving the appropriate management,” he adds.

Although knowledge of lung cancer screening is growing, there is still work to
be done, adds Scott Scheinin, MD, Professor of Thoracic Surgery at Icahn Mount
Sinai.

“If you wait until you have symptoms of lung cancer, the likelihood of a cure is
much less. Research shows that, with early detection, mortality goes down,” Dr.
Scheinin says. “There’s a certain mindset in the general population of ‘don’t
ask, don’t tell.’ But we need to change that and continue educating the public
about the importance of screening and early detection.”

Multidisciplinary Lung Nodules Program Streamlines Management of Suspicious Lung
Lesions

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The Mount Sinai Hospital is ranked No. 12 in Pulmonology and Lung Surgery

in the nation by U.S. News & World Report® for 2023-24



mountsinai.org© Mount Sinai Health System
 * Timothy Harkin, MD


 * 1. CT image of ground-glass and part-solid nodules taken in 2019
 * 2. Same patient rescanned in 2023