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* From Division of Cardiovascular and Thoracic Surgery, Evanston Hospital, Evanston, IL.
Correspondence to: Michael J. Liptay, MD, FCCP, Evanston Hospital, Division of Cardiovascular and Thoracic Surgery, 2650 Ridge Rd, Evanston, IL 60201-1797; e-mail: m-liptay{at}nwu.edu
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Abstract |
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Introduction |
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A solitary pulmonary nodule is defined as an intraparenchymal lung mass < 3 cm in size not associated with atelectasis or adenopathy. Lesions > 3 cm are referred to as masses. These larger lesions have a distinctly higher proportion of malignancies and should be promptly resected, barring prohibitory factors. In 1999, approximately 185,000 lung cancers will be diagnosed in the United States.1 The resection of early-stage lesions remains the only chance for cure in this group of patients. Newly detected solitary pulmonary nodules must be assumed to be malignant until proven otherwise. If previous radiographs that date back 2 years are available and if there has been no change in the appearance of the lesion, then an observational approach is warranted and serial radiograph examinations every 3 to 6 months are appropriate. The options for diagnosis include observation for growth, biopsy, and resection. The appropriateness of each option depends largely on the assessment of the number of factors. Observation is most appropriate for the young nonsmoker with a small lesion, whereas prompt resection is best in the older smoker with a larger spicular nodule. Unfortunately, most patients fall between these two tidy extremes.
Radiologic assessment accuracy in diagnosing solitary pulmonary nodules has not changed appreciably in over 30 years. In multiple series, 25 to 40% of malignant nodules were misclassified as benign.2 3 Improvements in the technology of CT scanning have allowed for better characterization of calcification patterns and edge contours and the ability to detect discrete subcentimeter nodules that are more difficult to diagnose as benign or malignant.4
Bayesian analysis using patient age, smoking history, previous malignancy, size of nodule, edge characteristics, maximal cavitary wall thickness, growth rate, and presence or absence of a benign calcification pattern has been used to assess odds ratios for malignant diagnoses. This strategy improved the accuracy of radiologic interpretation from 63 to 78% in one study.2
The application of biological radioactive markers in positron emission tomography (PET) scanning has offered the most accurate method of noninvasive diagnosis to date. Recent series have reported using PET with 18-fluorodeoxyglucose to classify solitary pulmonary nodules as benign or malignant. Reported predictive values vary between 77% and 100% accuracy.5 6 Expense and availability have limited the application of PET technology to a few centers. Verification of these preliminary results awaits widespread application of this technology.
The use of CT-guided fine-needle aspiration biopsy in solitary
pulmonary nodules has been condemned historically as often being an
unnecessary step in the workup of these patients. False-negative
results of biopsies have been reported in 
22% of cases, while
inadequate samples of diagnostic material occur up to 18% of the time.
The best reported results came from studies that utilized onsite
cytopathologists to immediately examine aspirates for diagnostic
tissue. These authors claimed a 99% accuracy rate in 110 consecutive
patients.7
These results await confirmation, and with
increasing experience with PET scanning and minimally invasive surgical
techniques, the utility of fine-needle aspiration biopsy might be
limited further.
Minimally invasive thoracoscopic techniques are now widely used to diagnose indeterminate solitary pulmonary nodules in the outer third of the lung field. These lesions can be removed easily for diagnosis, and, if it is indicated, a definitive cancer operation can be performed under the same anesthesia. Thoracoscopic biopsy carries a significantly decreased risk of morbidity and mortality compared with open thoracotomy for wedge resection.8 9 Multiple techniques have been described to aid in the identification of these nodules intraoperatively, from preoperative needle or dye localization to intraoperative ultrasound. In most settings, an examination of the chest CT scan to aid in planning port placement and intraoperative finger palpation are all that is necessary.
In the patient who is a candidate for surgery whose nodule cannot be noninvasively characterized as benign, the minimally invasive surgical approach offers near 100% diagnostic accuracy, avoids a delay in the diagnosis of potentially curable lung cancers, and offers an acceptable morbidity rate with virtually no associated mortality.
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This article has been cited by other articles:
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  B. Mahesh, C. Forrester-Wood, A. Yunus, R. Ahsan, K. Amer, A. Morgan, and R. Ascione Value of wide-margin wedge resection for solitary pulmonary nodule: a single center experience Eur. J. Cardiothorac. Surg., September 1, 2004; 26(3): 474 - 479. [Abstract] [Full Text] [PDF]
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S. Andrea, C. Paolo, S. Ascanelli, S. Davide, and P. Enzo Significance of a single pulmonary nodule in patients with previous history of malignancy Eur. J. Cardiothorac. Surg., December 1, 2001; 20(6): 1101 - 1105. [Abstract] [Full Text] [PDF]
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A. Imdahl, S. Jenkner, I. Brink, E. Nitzsche, E. Stoelben, E. Moser, and J. Hasse Validation of FDG positron emission tomography for differentiation of unknown pulmonary lesions Eur. J. Cardiothorac. Surg., August 1, 2001; 20(2): 324 - 329. [Abstract] [Full Text] [PDF]
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