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Management of the Solitary Pulmonary Nodule^*

Role of Thoracoscopy in Diagnosis and Therapy

^* From the Division of Thoracic Surgery, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.

Correspondence to: Scott J. Swanson, MD, FCCP, Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115

	Abstract

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 
Objectives: The solitary pulmonary nodule remains a common clinical problem. The essential question is whether the lesion is malignant or not. This discussion presents the clinical practice and looks at the problem.

Design: Didactic.

Setting: Academic tertiary-care hospital.

Patients: Prospective thoracic database.

Interventions: Minimally invasive technique.

Results: The workup and treatment of the solitary pulmonary nodule is presented with particular emphasis on the role of minimally invasive techniques. A small single-institution series is referenced.

Conclusions: The approach is safe and highly effective in diagnosing and often in treating solitary pulmonary nodules.

	Introduction

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 
The finding of a solitary pulmonary nodule on a chest radiograph is one of the most common scenarios faced by clinicians. Typically, the most relevant question is whether the lesion is malignant or not. The differential diagnosis includes infectious, inflammatory, and other benign etiologies. The workup of these lesions has evolved, to some extent, over time. Tuberculosis, which made up a large percentage of these lesions in the past,¹ is now much less common. The advent of minimally invasive surgical techniques has made a definitive diagnosis likely when the lesion remains quite small, thus, at a more favorable time point in the natural history of the disease.² Newer radiologic techniques have been purported to increase the chance of making a diagnosis without the need for tissue samples; however, this clearly remains to be validated.³

Surgery is the mainstay of therapy for treatment of the solitary pulmonary nodule when either a malignant or recalcitrant infectious diagnosis is made.

	Diagnosis

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 
The presumed diagnosis of the solitary pulmonary nodule is based on several factors. The age of the patient, associated symptoms, risk factors, and appearance of the lesion on the radiograph, including the length of time lesion has been present, all give the clinician information on which to base a working diagnosis. Obviously, it is important to obtain a precise history that includes travel experience, details of nicotine and asbestos exposure, any symptoms related to the respiratory tract (eg, cough, hemoptysis, or pain), and systemic symptoms of infection or inflammation.

The physical examination should be directed at signs of generalized inflammation such as lymphadenopathy and the presence of malignancy. The latter includes an examination of the skin, naso/oropharynx, breast, and rectum for prostate evaluation, evidence of blood in the GI tract, and any palpable masses.

All prior radiographs should be obtained to determine the length of time the lesion has been present and whether there has been any change in size. Caution should be exercised in diagnosing a lesion as benign simply because it has not changed over time, because even lesions that have been stable for > 5 years have been found to be malignant. The characteristics of the lesion on radiograph can be suggestive, but not diagnostic, of either cancer or a benign growth. Even "popcorn" calcification may not always be diagnostic of a benign lesion.⁴

Noninvasive methods of diagnosis include antigen skin testing, blood testing for signs of inflammatory processes or infection, and sputum analysis (microbiological and cytologic). All of these tests are supportive but certainly not specific, and occasionally they may be misleading. More invasive diagnostic maneuvers include bronchoscopy with transbronchial biopsy, CT-guided needle biopsy, and surgical excision. Of the methods mentioned above, the most cost-effective procedure for making a definitive diagnosis would appear to be surgical biopsy.⁵ Nonsurgical techniques, including transbronchial biopsy and percutaneous needle aspiration, when used in combination, have reported sensitivity rates of 95% for detecting malignancy. The accuracy of transbronchial biopsy and percutaneous needle biopsy in diagnosing benign lesions is lower, with correct diagnoses reported in 60% of cases.⁶

	Thoracoscopic Diagnosis and Treatment

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 
Clearly, if a patient is a candidate for surgery, then surgery is the procedure of choice to make a definitive diagnosis and, in many instances, to provide therapy. Most diagnoses are very difficult to establish without excision of the lesion. Fungal infection and hamartomas on occasion can be diagnosed without removing the entire lesion. However, much caution must be exercised in accepting a benign diagnosis of a solitary pulmonary nodule on the basis of partial information.

Minimally invasive techniques lend themselves well to establishing the diagnosis of a solitary pulmonary nodule. A relatively small, peripherally located nodule may be resected with excellent success using a thoracoscopic technique.² Although exact parameters are not well defined, centrally located lesions, particularly those in the upper lobe⁷ or larger lesions, > 4 to 5 cm in diameter, will require a traditional thoracotomy for resection.

Smaller lesions may be difficult to localize using a thoracoscopic technique, and a number of methods have been reported to aid in detection.^{8 9} Most centers that are experienced with thoracoscopic techniques do not require specialized techniques. For example, a series from the Brigham and Women’s Hospital reported the successful resection of lesions < 1 cm in diameter without any special localization techniques.¹⁰ In that series, which was presented at the American College of Chest Physicians meeting in New York in 1995, the mean tumor size was 0.86 cm. Approximately half of the lesions were malignant, and two thirds of those were primary lung cancers (Table 1 ). There was no operative mortality, and the median length of stay was 3 days.

At surgery, if the lesion is a primary non-small cell lung cancer (NSCLC), then a definitive anatomic resection can be accomplished during the same operation. In other instances, a definitive diagnosis is made during surgery that will guide further therapy, and often, in these cases, the patient is able to leave the hospital within 24 to 48 h.²

	Conclusion

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 
The appearance of a solitary pulmonary nodule remains a common clinical problem. The essential question is whether the lesion is malignant. If the patient is a reasonable surgical candidate, surgical excision, in particular thoracoscopic resection, is the best strategy available for establishing a diagnosis. The sensitivity and specificity of this technique approaches 100%. Additionally, definitive therapy may be accomplished during the same operative procedure. Newer diagnostic techniques, such as positron emission tomography scans, are currently being evaluated, but they must be measured against the surgical "gold standard." Data are now becoming available that suggest that many subcentimeter lesions that traditionally have been observed are malignant.¹⁰ The typical practice is to follow these lesions with serial radiographs. Early intervention may favorably impact the prognosis in the instance of patients with NSCLC.

	Footnotes

 
Abbreviation: NSCLC = non-small cell lung cancer

	References

TOP Abstract Introduction Diagnosis Thoracoscopic Diagnosis and... Conclusion References

 

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