Incidental pulmonary nodules are a common finding on chest imaging, but one program is taking an uncommon approach to managing them.

Incidental nodules present a growing diagnostic and management dilemma as utilization of imaging increases and patient risk profiles can vary widely. Although only an estimated 5% of lung nodules prove to be malignant, determining which require further workup vs ongoing surveillance — while addressing patient anxiety — remains challenging, said Louis Lam, MD, pulmonologist at Cleveland Clinic. 

Under Lam’s leadership, the Cleveland Clinic’s Incidental Lung Nodule Program integrates multidisciplinary expertise to streamline risk assessment, coordinate follow-up, and provide individualized management strategies for patients identified with pulmonary nodules.

Imaging and Risk Stratification

At Cleveland Clinic, thoracic radiologists compare current imaging with prior studies to identify new or changing nodules. When a concerning finding is detected, results are automatically shared with the referring provider, and a referral is generated through the electronic health record system. Most patients can secure an appointment within a few days, ensuring timely evaluation.

At the initial visit, specially trained advanced practice providers perform a comprehensive risk assessment using validated prediction models and guideline-based algorithms. These tools are integrated with patient-specific factors to guide management pathways.

Lam emphasized the importance of tailoring recommendations to the individual patient and local context. “Risk-prediction models and guidelines are only valid for the cohort in which they were developed,” he explained. “For example, in regions where endemic fungal infections are more common, inflammatory nodules may be more likely. Management recommendations must also account for the patient’s overall health, competing comorbidities, and personal preferences.”

Identifying High-Risk Features

For many patients, continued surveillance is appropriate. However, certain clinical and radiographic features increase the likelihood of malignancy:

• Clinical risk factors: older age, smoking history, environmental exposures (eg, asbestos and radon), and a family history of lung cancer
• Imaging features: size > 8 mm, upper-lobe location, and spiculated or irregular borders

“Many patients fall into an intermediate-risk ‘gray zone,’” Lam explained. “With these cases, an expert team is needed to evaluate the patient to help balance risk of surveillance, feasibility of a biopsy, or whether a more aggressive approach is warranted.”

Streamlining Diagnosis and Staging

When tissue sampling is indicated, fellowship-trained physicians at Cleveland Clinic perform the bronchoscopy with rapid onsite cytology. During the procedure, a cytopathologist evaluates specimens in real time to determine malignancy.

“This helps the doctor decide whether there is need for additional biopsies or specific tests while the patient is still on the procedure table if cancer is suspected,” Lam said.

Importantly, rapid onsite cytology also enables mediastinal lymph node assessment for staging during the same session when cancer is suspected. This integrated approach minimizes the need for multiple procedures and accelerates time to treatment compared with centers where diagnosis and staging are performed separately.

Managing Anxiety While Avoiding Overtreatment

For patients in the intermediate-risk “gray zone,” simply being informed of a lung nodule often creates significant anxiety — even when malignancy risk is low. The program emphasizes patient education, transparent risk communication, and individualized surveillance strategies.

“Addressing patient anxiety is one of the key functions of any lung nodule program,” Lam said. “Our role as providers is to educate our patients on their relative risk of cancer while balancing the risks associated with additional diagnostic tests as additional radiation exposure, invasive procedures on benign findings, and procedural complications related to biopsy. Most nodule findings do not warrant immediate invasive testing such as a biopsy but should be monitored with follow-up imaging.”

This balanced approach aims to avoid unnecessary procedures while maintaining vigilance in cases where malignancy risk cannot be excluded.

Easing the Burden on Primary Care

Management of incidental findings can also be resource-intensive for primary care providers (PCPs), who may have limited capacity to coordinate follow up. Through its integrated electronic medical record, the program communicates directly with PCPs while assuming responsibility for surveillance and management.

“One of the biggest challenges in healthcare is the shortage of primary care providers,” Lam noted. “By managing lung nodule follow up within the program, we aim to reduce the burden on PCPs while ensuring patients receive appropriate monitoring.”

Lam reported research studies looking at use of biomarkers for lung nodule evaluation with Biodesix and Veracyte.