eMedicine Specialties > Pulmonology > Lung Tumors

Solitary Pulmonary Nodule: Treatment & Medication

Author: Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Coauthor(s): Asif Alavi, MD, Resident Physician, Department of Internal Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View Medical Center; Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital; Sri R Navaratnam, MBBS, PhD, FRCPC, Assistant Professor, Department of Internal Medicine, Section of Hematology/Oncology, University of Manitoba; Consulting Medical Oncologist, Department of Hematology/Oncology, Cancer Care Manitoba
Contributor Information and Disclosures

Updated: Sep 11, 2009

Treatment

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.15 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 guidelines16 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 20073 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.17
  • 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

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.18 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.19
For proven malignant solitary pulmonary nodule, lobectomy if preferred over wedge resection of segmentectomy because of the lower rate of recurrence and trend toward increased 5-year survival with lobectomy.20

More on Solitary Pulmonary Nodule

Overview: Solitary Pulmonary Nodule
Differential Diagnoses & Workup: Solitary Pulmonary Nodule
Treatment & Medication: Solitary Pulmonary Nodule
Follow-up: Solitary Pulmonary Nodule
Multimedia: Solitary Pulmonary Nodule
References
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References

  1. Lillington GA. Management of solitary pulmonary nodules. Dis Mon. May 1991;37(5):271-318. [Medline].

  2. Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. Sep 2007;132(3 Suppl):94S-107S. [Medline].

  3. [Guideline] Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. Sep 2007;132(3 Suppl):108S-130S. [Medline]. [Full Text].

  4. Cardinale L, Ardissone F, Novello S, et al. The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. Radiol Med. May 29 2009;[Medline].

  5. Swensen SJ, Viggiano RW, Midthun DE, et al. Lung nodule enhancement at CT: multicenter study. Radiology. Jan 2000;214(1):73-80. [Medline]. [Full Text].

  6. Midthun DE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with low dose spiral computed tomography. Lung Cancer. Aug 2003;41 (suppl 2):S40.

  7. Ost D, Fein AM, Feinsilver SH. Clinical practice. The solitary pulmonary nodule. N Engl J Med. Jun 19 2003;348(25):2535-42. [Medline]. [Full Text].

  8. Behzadi A, Ung Y, Lowe V, Deschamps C. The role of positron emission tomography in the management of non-small cell lung cancer. Can J Surg. Jun 2009;52(3):235-42. [Medline].

  9. Gould MK, Maclean CC, Kuschner WG, Rydzak CE, Owens DK. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions: a meta-analysis. JAMA. Feb 21 2001;285(7):914-24. [Medline].

  10. Yi CA, Lee KS, Kim BT, Choi JY, Kwon OJ, Kim H. Tissue characterization of solitary pulmonary nodule: comparative study between helical dynamic CT and integrated PET/CT. J Nucl Med. Mar 2006;47(3):443-50. [Medline].

  11. Naalsund A, Maublant J. The solitary pulmonary nodule--is it malignant or benign? Diagnostic performance of Tc-depreotide SPECT. Respiration. 2006;73(5):634-41. [Medline].

  12. Herth FJ, Eberhardt R, Becker HD, Ernst A. Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: a prospective trial. Chest. Jan 2006;129(1):147-50. [Medline]. [Full Text].

  13. Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J. Oct 2002;20(4):972-4. [Medline]. [Full Text].

  14. Lacasse Y, Wong E, Guyatt GH, Cook DJ. Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis. Thorax. Oct 1999;54(10):884-93. [Medline].

  15. Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest. Jan 2003;123(1 Suppl):89S-96S. [Medline]. [Full Text].

  16. [Guideline] MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. Nov 2005;237(2):395-400. [Medline]. [Full Text].

  17. Gurney JW. Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis. Part I. Theory. Radiology. Feb 1993;186(2):405-13. [Medline]. [Full Text].

  18. Watanabe A, Koyanagi T, Obama T, et al. Assessment of node dissection for clinical stage I primary lung cancer by VATS. Eur J Cardiothorac Surg. May 2005;27(5):745-52. [Medline]. [Full Text].

  19. Shennib H. Intraoperative localization techniques for pulmonary nodules. Ann Thorac Surg. Sep 1993;56(3):745-8. [Medline].

  20. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. Sep 1995;60(3):615-22; discussion 622-3. [Medline].

  21. Cummings SR, Lillington GA, Richard RJ. Estimating the probability of malignancy in solitary pulmonary nodules. A Bayesian approach. Am Rev Respir Dis. Sep 1986;134(3):449-52. [Medline].

  22. Chhajed PN, Bernasconi M, Gambazzi F. Combining bronchoscopy and positron emission tomography for the diagnosis of the small pulmonary nodule < or = 3 cm. Chest. Nov 2005;128(5):3558-64.

  23. Chung T. Fine needle aspiration of the solitary pulmonary nodule. Semin Thorac Cardiovasc Surg. Jul 2002;14(3):275-80. [Medline].

  24. Decamp MM Jr. The solitary pulmonary nodule: aggressive excisional strategy. Semin Thorac Cardiovasc Surg. Jul 2002;14(3):292-6. [Medline].

  25. Erasmus JJ, Connolly JE, McAdams HP, Roggli VL. Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions. Radiographics. Jan-Feb 2000;20(1):43-58. [Medline].

  26. Erasmus JJ, McAdams HP, Connolly JE. Solitary pulmonary nodules: Part II. Evaluation of the indeterminate nodule. Radiographics. Jan-Feb 2000;20(1):59-66. [Medline].

  27. Ginsberg RJ. The solitary pulmonary nodule: can we afford to watch and wait?. J Thorac Cardiovasc Surg. Jan 2003;125(1):25-6. [Medline].

  28. Goldsmith SJ, Kostakoglu L. Role of nuclear medicine in the evaluation of the solitary pulmonary nodule. Semin Ultrasound CT MR. Apr 2000;21(2):129-38. [Medline].

  29. Gould MK, Lillington GA. Strategy and cost in investigating solitary pulmonary nodules. Thorax. Aug 1998;53 Suppl 2:S32-7. [Medline].

  30. Hartman TE. Radiologic evaluation of the solitary pulmonary nodule. Radiol Clin North Am. May 2005;43(3):459-65, vii. [Medline].

  31. Herder GJ, van Tinteren H, Golding RP. Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography. Chest. Oct 2005;128(4):2490-6.

  32. Jain P, Kathawalla SA, Arroliga AC. Managing solitary pulmonary nodules. Cleve Clin J Med. Jun 1998;65(6):315-26. [Medline].

  33. Laurent F, Remy J. [Management strategy of pulmonary nodules]. J Radiol. Dec 2002;83(12 Pt 1):1815-21. [Medline].

  34. Lillington GA. Management of solitary pulmonary nodules. How to decide when resection is required. Postgrad Med. Mar 1997;101(3):145-50. [Medline].

  35. Lillington GA. Solitary pulmonary nodules: new wine in old bottles. Curr Opin Pulm Med. Jul 2001;7(4):242-6. [Medline].

  36. Lillington GA, Caskey CI. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med. Mar 1993;14(1):111-9. [Medline].

  37. Moses DA, Ko JP. Multidetector CT of the solitary pulmonary nodule. Semin Roentgenol. Apr 2005;40(2):109-25. [Medline].

  38. Ost D, Fein A. Evaluation and management of the solitary pulmonary nodule. Am J Respir Crit Care Med. Sep 2000;162(3 Pt 1):782-7. [Medline].

  39. Pepe G, Rossetti C, Sironi S, Landoni C, Gianolli L, Pastorino U. Patients with known or suspected lung cancer: evaluation of clinical management changes due to 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) study. Nucl Med Commun. Sep 2005;26(9):831-7. [Medline].

  40. Plachcinska A, Mikolajczak R, Kozak J, Rzeszutek K, Kusmierek J. A visual and semi-quantitative assessment of (99m)Tc-EDDA/HYNIC-TOC scintigraphy in differentiation of solitary pulmonary nodules. Nucl Med Rev Cent East Eur. 2004;7(2):143-50. [Medline].

  41. Pogodina VV. Elizaveta Nilolaevna Levkovich-75th birthday. Acta Virol. Nov 1975;19(6):509. [Medline].

  42. Schaefer JF, Schneider V, Vollmar J, Wehrmann M, Aebert H, Friedel G. Solitary pulmonary nodules: association between signal characteristics in dynamic contrast enhanced MRI and tumor angiogenesis. Lung Cancer. Jul 2006;53(1):39-49. [Medline].

  43. Schiavon F, Berletti R, Soardi GA. Multidisciplinary management of the solitary pulmonary nodule (SPN): our opinion. Radiol Med (Torino). Sep 2005;110(3):149-55.

  44. Shaham D, Guralnik L. The solitary pulmonary nodule: radiologic considerations. Semin Ultrasound CT MR. Apr 2000;21(2):97-115. [Medline].

  45. Siegelman SS, Zerhouni EA, Leo FP, Khouri NF, Stitik FP. CT of the solitary pulmonary nodule. AJR Am J Roentgenol. Jul 1980;135(1):1-13. [Medline].

  46. Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. Apr 28 1997;157(8):849-55. [Medline].

  47. Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest. Jan 2003;123(1 Suppl):89S-96S. [Medline].

  48. Tang AW, Moss HA, Robertson RJ. The solitary pulmonary nodule. Eur J Radiol. Jan 2003;45(1):69-77. [Medline].

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Further Reading

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Keywords

solitary pulmonary nodule, SPN, early lung cancer, histoplasmosis, coccidioidomycosis, blastomycosis, pulmonary mycosis, tuberculosis, TB, bronchogenic carcinoma, nocardiosis, asbestos exposure, radon exposure, nickel exposure, chromium exposure, vinyl chloride exposure, polycyclic hydrocarbon exposure, chemical exposure, industrial exposure, bronchogenic cancer, bronchogenic malignancy, pulmonary mycosis, mycosis, lung nodule, malignant nodule, lung lesion, lung malignancy, neoplasm, primary neoplasm, lung neoplasm, granuloma, infectious granuloma, lung granuloma, benign lung lesion, hamartoma, lymphoma, carcinoid, fibroma, neurofibroma, blastoma, sarcoma, lung abscess, round pneumonia, hydatid cyst, rheumatoid arthritis, RA, Wegener granulomatosis, sarcoidosis, lipoid pneumonia, arteriovenous malformation, AVM, lung cyst, pulmonary infarct, round atelectasis, mucoid impaction, mucus impaction, progressive massive fibrosis

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Contributor Information and Disclosures

Author

Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Nader Kamangar, MD, FACP, FCCP, FAASM, 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.

Coauthor(s)

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.

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Sri R Navaratnam, MBBS, PhD, FRCPC, Assistant Professor, Department of Internal Medicine, Section of Hematology/Oncology, University of Manitoba; Consulting Medical Oncologist, Department of Hematology/Oncology, Cancer Care Manitoba
Disclosure: Nothing to disclose.

Medical Editor

Stephen P Peters, MD, PhD, Professor, Department of Medicine, Wake Forest University
Stephen P Peters, MD, PhD 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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

,, Kathy Roarty Placeholder
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint 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, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
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.

 
 
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