Non-calcified Pulmonary Nodules Referral Access Criteria

• Nil

• Suspected primary thoracic cancer
• Nodule of any size associated with hilar lymphadenopathy, distal atelectasis or pleural effusion
• Significant growth/change of a non-calcified nodule on serial chest CT

NB: Best practice is for patients to be seen within 14 days

To contact the relevant service, see Clinician Assist WA: Acute Respiratory assessment (external site).

• Patients appropriate for referral to a tertiary centre include:
  • Incidental nodules in high-risk patients defined as:
    • current or former tobacco smoker
    • asbestos exposure
    • interstitial lung disease
    • confirmed COPD/emphysema
    • positive family history of primary lung cancer
    • southeast Asian ethnicity
  • Incidental nodules >8mm in low- risk patients defined as:
    • never smoked
    • <50-55 years of age
    • no history of underlying lung disease

NB: Pulmonary nodules very rarely cause any symptoms and are a frequent incidental finding on chest imaging.

Referrals missing 'mandatory information' with no explanation provided may not be accepted by site. If 'mandatory information' is not included, the explanation must be provided in the body of the referral (e.g. patient unable to access test in regional or remote areas or due to financial reason).

This information is required to inform accurate and timely triage. If unable to attach reports, please include relevant information/findings in the body of the referral and advise where (provider) investigation/imaging was completed.

• Relevant history, onset, duration and severity of symptoms
• Recent clinical events (particularly viral symptoms, infective bronchitis)
• Smoking/vaping status and history
• Any known allergies
• Asbestos or other occupational exposures
• Family history of lung cancer
• Ethnicity

• Nil

•  Chest CT scan (contrast not required; thin sections preferred ≤1.25mm slice width)

• Exposure to TB
• Personal cancer history (including skin cancers)
• Relevant past medical history
• Current medication list

• Nil

• Nil

Category 1

Appointment within 30 days

• High-risk nodule in high-risk patient with no prior CT scan imaging
• Nodule with PanCan/Brock score ≥30%
• Endobronchial nodule

Category 2

Appointment within 90 days

• Moderate-risk nodule in high-risk patient with no prior CT scan imaging
• Incidental nodules that are >8-10mm in low-risk patient with no prior CT scan imaging
• Nodule with PanCan/Brock score >5-30%

Category 3

Appointment within 365 days

• Low-risk nodules in high-risk patient with no prior CT scan imaging
• PanCan/Brock score <5%
• Stable nodules in high-risk patient that have not completed longitudinal surveillance [2 years for solid lesion and 5 years for subsolid lesion]

• Pulmonary nodules not requiring ongoing surveillance include:
  • Stable pulmonary nodules defined as no change/growth detected on CT surveillance in solid nodules ≥ 2 years and subsolid ≥ 5 years
  • Perifissural nodule <10mm that demonstrates characteristic morphology (triangular or oval shape in the axial plane, and a flat or lentiform morphology in the sagittal and coronal planes)
  • Completely calcified pulmonary nodules
• Pulmonary nodule in acutely unwell patient:
  • Detection of an incidental lung nodule in acute clinical setting such as CT chest performed for other scenarios such as pulmonary infection/sepsis/pulmonary embolism/ cardiac failure/trauma etc
  • In this scenario, if no prior chest CT imaging available for comparison recommend repeat short-term interval chest CT (6-12 weeks) to reassess lesion
  • If lesion persistent on short term review or has worrisome CAT 1 features refer according to indicative triage category
• Pulmonary masses/nodules suspicious of metastases in patients with suspected non-thoracic primary malignancy
  • Refer to most appropriate specialist service for primary cancer
• New pulmonary nodules/masses in patients with known current thoracic or non-thoracic malignancy
  • Refer to clinician/oncologist currently treating the known malignancy

•  When writing the referral, it is useful for the referrer to note in the referral that the patient is aware:
  1. The referral has been made
  2. The underlying clinical concern
  3. If there have been multiple referrals made (i.e. to the public and private outpatients)
  4. For country patient, indicating the patient has also been referred to the Rural Cancer Nurse for suspected cancer work up
• UpToDate: Calculator: Solitary pulmonary nodule malignancy risk in adults (Brock University cancer prediction equation) (external site)
  • NB: The referring doctor is not required to calculate the risk/Brock score of the nodule. This will be completed by the hospital.