Investigation and Management of the Indeterminate Pulmonary Nodule

Joseph B. Shrager, Joel D. Cooper, Graeme M Rosenberg

Key Points

  • Lung cancer screening is increasing the number of small nodules a thoracic surgeon encounters. Updated society guidelines provide a framework for decision-making.
  • 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. However, validated risk stratification calculators can be valuable for both clinicians and patients in determining further diagnostic steps.
  • 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.
  • Emerging technologies in radiomics and navigational bronchoscopy have increased diagnostic information available in the workup of indeterminate nodules. It is the responsibility of a thoracic surgeon to understand how to interpret and utilize these novel techniques.
  • In many cases, an individual 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 remains a very important consideration guiding how to proceed.

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 to aid our decision-making with nodules, a wide range of management options remain acceptable. Although some would argue that almost every persistent, indeterminate SPN in a cigarette smoker needs to be removed relatively promptly, this attitude will most certainly result in a high rate of excision of benign nodules and is a disservice to patients. On the other hand, insufficiently aggressive management or inadequate follow-up of SPNs may lead to cancer progression before removal, dramatically 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, including advanced imaging and diagnostic modalities that have recently been introduced into the surgeon’s armamentarium. We propose what we believe to be a reasonable set of algorithms based on both the available data and our own individual biases.

The increasing application of computed tomographic (CT) screening, as well as the overall increased application of scanning for diagnostic purposes, has led to the presentation of increasing numbers of patients in the thoracic surgeon’s office with smaller and smaller nodules. A recent evaluation of trends in lung nodule identification on chest CT imaging showed an increase in nodule identification from 24 - 31% of scans, representing a large number of imaging findings clinicians are asked to comment upon.[1] This development makes the problem of distinguishing malignant from benign nodules even more difficult. Fortunately, the evolving field of radiomics offers improved ways to evaluate the radiographic characteristics for a given nodule. Similarly, new bronchoscopic biopsy techniques such as cone-beam CT-guided biopsy have substantially increased the diagnostic yield for bronchoscopic biopsy.[2][3] 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.

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Last updated: March 1, 2023