Solitary Pulmonary Nodule Treatment & Management

  • Author: Asif Alavi, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jan 18, 2012
 

Medical Care

Lesions that have typical benign features, such as lack of change over 2 years or a benign pattern of calcification, especially in low-risk patients, do not require further workup. On the other hand, lesions that are strongly suggestive of malignancy (eg, >3 cm diameter) or those with documented growth should be referred for surgical resection.[23] Management decisions for lesions with intermediate probability (which are most lesions) are more complex. Although management varies amongst individual institutions and practitioners, several guidelines have been published.

In 2005, the Fleischner Society published guidelines[24] for follow-up imaging of solitary pulmonary nodules (SPNs). They specified different strategies based on patient risk factors and the size of the nodule

  • Low-risk patients
    • Less than or equal to 4 mm - No further investigation
    • 4-6 mm - CT scanning at 12 months
    • 6-8 mm - CT scanning at 6-12 months and 18-24 months
    • Greater than 8 mm - CT scanning at 3, 9, and 24 months; contrast-enhanced CT scanning; positron-emission tomography (PET) scanning; and/or biopsy
  • High-risk patients
    • Less than or equal to 4 mm - CT scanning at 12 months
    • 4-6 mm - CT scanning at 6-12 months and 18-24 months
    • 6-8 mm - CT scanning at 3–6 months, 9–12 months, and 24 months
    • Greater than 8 mm - Same as low-risk patients

The American College of Chest Physicians (ACCP) proposed new guidelines in 2007[3] for the management of solitary pulmonary nodules, which are summarized below.

  • Carefully calculate pretest probability for malignancy, either through experienced clinical judgment or through the use of a validated model, such as Bayesian analysis.[25]
  • Previous chest radiographs should be reviewed to determine if the lesion has been stable over 2 years. If so, no further follow up is necessary, with the exception of pure ground-glass lesions on CT scans, which can be slower growing.
  • For lesions with a benign pattern of calcification, further testing is not necessary.
  • Management of indeterminate lesions greater than 8-10 mm depends on clinical probability of malignancy, as follows:
    • Low probability - Serial CT scanning at 3, 6, 12, and 24 months
    • Intermediate probability - 18-Fluorodeoxyglucose (FDG) PET scanning, contrast-enhanced CT scanning, transthoracic needle aspiration (TTNA), and/or transbronchial needle aspiration (TBNA) (Thoracoscopic diagnosis is recommended for patients who wish to have a surgical diagnosis if the lesion is in the peripheral third of the lung.)
    • High probability - Surgical resection
  • Subcentimeter lesions - Same as Fleischner Society, as listed above
  • Any unequivocal growth noted during follow up - Definitive tissue diagnosis needed

Management of pure ground glass lesions or lesions with mixed ground glass and solid components is more controversial and no formal guidelines have been made. Thus careful consideration of available data and clinical judgement should be utilized on a case-by-case basis to manage these lesions.

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Surgical Care

When a lesion is likely to be malignant, surgical resection—not TTNA or observation—is often used.

  • The 2007 ACCP guidelines recommend that patients who have indeterminate lung nodules with a high probability of malignancy undergo thoracoscopic wedge resections if the lesion is in the peripheral third of the lung. This is because of the relatively low morbidity and mortality associated with the procedure compared with thoracotomy.[26] If frozen sections show evidence of malignancy, anatomic resection with mediastinal lymph node sampling or dissection may be performed.
  • Localization using methylene blue injection or wire placement has facilitated successful resection of smaller nodules with video-assisted thoracoscopic surgery (VATS). Intraoperative ultrasonography is also suggested as a means of nodule localization during VATS.[27]

For proven malignant solitary pulmonary nodule, lobectomy is preferred over wedge resection or segmentectomy because of the lower rate of recurrence and trend toward increased 5-year survival with lobectomy.[28]

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Contributor Information and Disclosures
Author

Asif Alavi, MD  Resident Physician, Department of Internal Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View Medical Center

Asif Alavi, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Nader Kamangar, MD, FACP, FCCP, FCCM  Associate Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View-UCLA Medical Center; Associate Program Director, Pulmonary and Critical Care Multi-Campus Fellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/Olive View-UCLA Medical Center; Site Director, Pulmonary/Critical Care Fellowship Program, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP  Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Sat Sharma, MD, FRCPC, and Sri R Navaratnam, MBBS, PhD, FRCPC, to the development and writing of this article.

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Mediastinal windows of the patient in the image above.
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CT scan of the patient presented in the image above. After needle biopsy, the presence of classic sulfur granules confirmed actinomycosis.
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A left upper lobe solitary pulmonary nodule. The differential diagnosis is large, but CT scan findings help narrow the differentials and establish the diagnosis.
Cavitating right lower lobe nodule later confirmed to be primary pulmonary lymphoma. Calcium deposits may also be present in the lesion.
This left lower lobe carcinoid tumor was quite bloody after a percutaneous needle biopsy was performed.
A lateral radiograph of the case in the image above.
CT scan of the patient in the previous 2 images shows a well-circumscribed lesion.
A "popcorn" calcification in the left lung nodule indicates a benign lesion or hamartoma. No further tests or observations are needed for this patient.
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The parenchymal lesion in this CT scan demonstrates low attenuation within the lesion, indicating the presence of fat. Fat density is only observed in hamartoma and lipoid pneumonia. The likely diagnosis is hamartoma.
This patient has a low risk for the right upper lobe nodule to be malignant; therefore, continued observation with repeat chest radiographs to establish a growth pattern is the best treatment option.
 
 
 
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