Evaluation of solitary pulmonary nodule

>20–40 mm
>40 mm
0–30 mm
>30 mm31
18
5
43
1174.1%
66.6%
100%
72.1%
81.8%0.422
0.378Makris D et al., 2007 [31]ENB0–10 mm
>10–20 mm
>20–30 mm
>30 mm4
16
7
1375%
43.7%
71.4%
76.9%Not reportedLamprecht B et al., 2012 [32]Combined FDG-PET, ENB, and ROSE0–20 mm
>20 mm45
6775.6%
89.6%0.066Pearlstein DP et al., 2012[33]ENB and ROSE<15 mm
15–20 mm
>20 mm16
14
7188%
71%
87%0.331


ENB = Electromagnetic navigation bronchoscopy, FDG-PET = fluorodeoxyglucose positron emission tomography, ROSE = rapid on-site examination of cytopathology.





High-risk nodules (>60% risk of malignancy)


Nodules that have radiographic features that are high risk for malignancy should be managed operatively with resection in patients who can tolerate surgery. Preoperative workup should consist of a thorough evaluation of fitness for surgery, including pulmonary function tests and assessment of baseline functional status. Surgery is performed via video-assisted thoracoscopic surgery (VATS) or robotic techniques whenever possible. We rarely recommend that a thoracotomy be performed. If a diagnosis has not been established, a wedge resection with adequate (R0) margins should be performed with frozen histologic assessment. Benign lesions, typical carcinoid tumors, and metastatic lesions from other sources (i.e. sarcoma, renal cell carcinoma) require no further resection. Currently, the standard of care for non-small-cell lung cancer in patients with adequate pulmonary function tests (PFTs) is anatomic lobectomy with mediastinal lymph node sampling or dissection. It is worth noting that small lesions, particularly GGOs and semisolid nodules, may be difficult to locate by manual palpation, particularly using VATS techniques. In these patients, we have found that radiotracer-guided resection with technetium-99m microalbumin aggregate safely facilitates resection of the nodule and is cost-effective[34–36].




Conclusions


SPNs are becoming increasingly common clinical entities, and thus thoracic surgeons should be comfortable with the evaluation and management of these lesions (Figure 11.1). Patients can be risk stratified into low-, intermediate-, and high-risk groups for malignancy based on a thorough history and review of radiographic studies. High-resolution CT scan is an important component of the initial workup. In general, low-risk nodules should be followed with serial imaging, intermediate-risk nodules should trigger additional workup via CT-FNA and/or PET-CT, and high-risk nodules should be managed surgically in patients with acceptable operative risk.



Figure 11.1

Workup algorithm for SPNs.





References


1Holin SM, Dwork RE, Glaser S, et al. Solitary pulmonary nodules found in a community-wide chest roentgenographic survey; a five-year follow-up study. Am Rev Tuberc 1959; 79(4):427–39.

2Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc 1999; 74(4):319–29.

3Alzahouri K, Velten M, Arveux P, et al. Management of SPN in France: pathways for definitive diagnosis of solitary pulmonary nodule: a multicentre study in 18 French districts. BMC Cancer 2008; 8:93.

4Swensen SJ, Silverstein MD, Ilstrup DM, et al. The probability of malignancy in solitary pulmonary nodules: application to small radiologically indeterminate nodules. Arch Intern Med 1997; 157(8):849–55.

5Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365(5):395–409.

6Tuddenham WJ. Glossary of terms for thoracic radiology: recommendations of the Nomenclature Committee of the Fleischner Society. AJR Am J Roentgenol 1984; 143(3):509–17.

7Ost D, Fein AM, Feinsilver SH. Clinical practice: the solitary pulmonary nodule. N Engl J Med 2003; 348(25):2535–42.

8Kruger S, Buck AK, Blumstein NM, et al. Use of integrated FDG PET/CT imaging in pulmonary carcinoid tumours. J Intern Med 2006; 260(6):545–50.

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Feb 24, 2017 | Posted by in CARDIAC SURGERY | Comments Off on Evaluation of solitary pulmonary nodule

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