Pulmonary nodules in a tuberculosis-endemic region: real-world insights from a structured lung nodule clinic

Incidental pulmonary nodules (IPNs) are increasingly detected with widespread use of computed tomography (CT). In tuberculosis-endemic settings, distinguishing benign from malignant nodules remains challenging, and real-world Indian data is limited. This single-centre observational study analysed 101 consecutive patients enrolled in a dedicated pulmonary nodule clinic between December 2024 and July 2025. Clinical and radiological data were prospectively recorded and retrospectively analysed. Management was decided by multidisciplinary discussion. Final diagnoses were classified as benign, malignant, or indeterminate. Univariate logistic regression identified factors associated with malignancy. A total of 101 patients were included (mean age 56.7 ± 15.2 years; 53.5% males). Most nodules were incidental (83.2%), solitary (85.1%), and solid (93.1%), with 69.3% >8 mm. Patients were assigned to no intervention ( n = 20), biopsy ( n = 55), or surveillance ( n = 26). Overall adherence to recommended evaluation was 80.2%, higher in biopsy group (96.3%) but lower in the surveillance group (30.7%). Malignancy rate was 33.7% (34/101). Tuberculosis was the most common benign diagnosis (12.9%), and adenocarcinoma the most common malignancy (24.8%). Larger size, prior malignancy, and absence of calcification were associated with malignancy. Pulmonary nodules in this tuberculosis-endemic cohort showed a 33.7% malignancy rate, with tuberculosis accounting for 31.7% of benign lesions. Multidisciplinary evaluation achieved high diagnostic adherence (96.3%) but poor surveillance follow-up (30.7%). A structured pulmonary nodule clinic improves diagnostic workflow, but follow-up systems need strengthening. This study was retrospectively submitted for registration with the Open Science Framework (OSF) on 23 June 2026. The associated OSF project is available at https://osf.io/3s5ct . Registration activation is currently pending.