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Investigation and Management of the Indeterminate Pulmonary Nodule

Joseph B. Shrager, Joel D. Cooper
Investigation and Management of the Indeterminate Pulmonary Nodule is a topic covered in the Pearson's General Thoracic.

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Key Points

  • There is no single test or combination of tests that can indicate, with a high degree of reliability, whether a nodule is benign or malignant.
  • Clinical history, size of the nodule, CT appearance, FDG-avidity on PET, and accessibility to excisional (VATS) versus transthoracic or bronchoscopic biopsy are among the more important factors that come into play in deciding which approach to take with an individual nodule.
  • Perhaps more important than any of the above factors is the particular patient’s relative concern about the risk and discomfort of an “unnecessary” procedure versus his or her concern over leaving an unresected malignancy in place.

An individual surgeon’s approach to the solitary pulmonary nodule (SPN) is the role that perhaps best defines his or her character as the decision-maker who sits at the center of the workup and therapy for suspected lung cancer. The SPN is among the most common clinical scenarios that thoracic surgeons encounter, yet, because of the clinical intricacies involved and the imprecise data available on the subject, a wide range of management options remain acceptable. Although some would argue that almost every indeterminate SPN in a smoker needs to be removed relatively promptly, this attitude will most certainly result in a high rate of excision of benign nodules and is probably a disservice to patients. On the other hand, insufficiently aggressive management or inadequate follow-up of SPNs may lead to cancer progression before removal, reducing the chances of cure. The ideal goal is the removal of all malignant nodules at a curable stage, with as few resections of benign lesions as possible. The practical goal must be to find a reasonable middle ground. This chapter reviews the evidence supporting the various approaches to the diagnosis and management of SPNs and proposes what the we believe to be a reasonable set of algorithms based on the admittedly limited available data and our own individual approach. It is important to note also that several organizations have offered their own criteria for when to follow versus excise/biopsy lung nodules -- the most widely used of these are the Fleischner guidelines, outlined below.

The increasing use of computed tomographic (CT) scanning for diagnostic purposes, as well as now-established CT screening to detect early lung cancer, has led to the presentation of increasing numbers of patients in the thoracic surgeon’s office with smaller and smaller nodules. This development makes the problem of distinguishing malignant from benign nodules even more difficult. The goal, however, remains the same: to provide the most efficient approach that will both minimize the excision of benign lesions and avoid delaying the excision of malignant lesions to a point at which cure is less likely. Management of screen-detected versus other nodules will vary slightly, but the principles are the same. The specific approach to screen detected nodules is discussed in the chapter on CT screening.

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Key Points

  • There is no single test or combination of tests that can indicate, with a high degree of reliability, whether a nodule is benign or malignant.
  • Clinical history, size of the nodule, CT appearance, FDG-avidity on PET, and accessibility to excisional (VATS) versus transthoracic or bronchoscopic biopsy are among the more important factors that come into play in deciding which approach to take with an individual nodule.
  • Perhaps more important than any of the above factors is the particular patient’s relative concern about the risk and discomfort of an “unnecessary” procedure versus his or her concern over leaving an unresected malignancy in place.

An individual surgeon’s approach to the solitary pulmonary nodule (SPN) is the role that perhaps best defines his or her character as the decision-maker who sits at the center of the workup and therapy for suspected lung cancer. The SPN is among the most common clinical scenarios that thoracic surgeons encounter, yet, because of the clinical intricacies involved and the imprecise data available on the subject, a wide range of management options remain acceptable. Although some would argue that almost every indeterminate SPN in a smoker needs to be removed relatively promptly, this attitude will most certainly result in a high rate of excision of benign nodules and is probably a disservice to patients. On the other hand, insufficiently aggressive management or inadequate follow-up of SPNs may lead to cancer progression before removal, reducing the chances of cure. The ideal goal is the removal of all malignant nodules at a curable stage, with as few resections of benign lesions as possible. The practical goal must be to find a reasonable middle ground. This chapter reviews the evidence supporting the various approaches to the diagnosis and management of SPNs and proposes what the we believe to be a reasonable set of algorithms based on the admittedly limited available data and our own individual approach. It is important to note also that several organizations have offered their own criteria for when to follow versus excise/biopsy lung nodules -- the most widely used of these are the Fleischner guidelines, outlined below.

The increasing use of computed tomographic (CT) scanning for diagnostic purposes, as well as now-established CT screening to detect early lung cancer, has led to the presentation of increasing numbers of patients in the thoracic surgeon’s office with smaller and smaller nodules. This development makes the problem of distinguishing malignant from benign nodules even more difficult. The goal, however, remains the same: to provide the most efficient approach that will both minimize the excision of benign lesions and avoid delaying the excision of malignant lesions to a point at which cure is less likely. Management of screen-detected versus other nodules will vary slightly, but the principles are the same. The specific approach to screen detected nodules is discussed in the chapter on CT screening.

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Last updated: May 6, 2020