Solitary Pulmonary Nodule
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SPN On Chest Radiography would raise several questions

Is the nodule benign or malignant?

Should it be investigated or observed?
 Should it be surgically resected?
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 Definition :
Single, round and discrete pulmonary
opacity that measure <3 cm. in
diameter, surrounded by normal lung
tissue and not associated with
adenopathy or atelectasis.
 ~ 150,000 solitary pulmonary nodule (or coin
lesions) are detected annually in the US and
often discovered incidentally at CxR or CT
 or 1-2 SPNs per 500 CxR
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 Major question benign or malignant.
 Although most solitary pulmonary nodules have
benign cause, “healed granuloma” (TB or fungi),
30-40% of these nodules are malignant (range
3-80%)
 More recent studies generally show higher
percentage of malignancy among resected
nodules than do older studies, presumably
related to improved diagnostic techniques (CT,
PET)
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Malignant causes of Solitary Pulmonary
Nodules
Primary Lesions
Metastatic Lesions
Adeno CA
Squamous Cell CA
Large Cell CA
Breast
Head and Neck
Melanoma
Small Cell CA
Lymphoma
Colon
Kidney
Carcinoid
Sarcoma
Solitary Pulmonary Nodule
• “ Remember
that exploratory
incision should not be made a cloak
for diagnostic incompetence” –
Rutherford Morrison (1853-1939)
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Factors affecting the likelihood of malignancy

Age

History of Smoking

Presence of other malignancy

Size of lesion

Border characteristic of lesion

Calcification of Lesion

Growth rate of lesion
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Patient Age

The probability of a SPN being malignant
rises with increasing patient age.

A study of malignancy in 955 patients in 1983:
- 65% > 50 y/o
- 35% < 50 y/o

But have to be cautious in assuming that a
SPN in a young person is benign.
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Underlying Risk Factors

History of smoking – strong association
cigarette smoking with primary lung CA
of

Previously diagnosed malignancy increases the
likelihood that SPN may represent metastatic
disease.

~ 10-30% of resected
nodules are metastatic
malignancies.
malignant pulmonary
from extrathoracic
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
Size of the Lesion :
- Small lesions tend to be benign
- In fact, 25-35% of SPN under 1 cm have
been shown to be malignant
- Over 80% of lesion > 5cm. are malignant
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
Growth Rate :
- A nodule that is stable for 2 years is almost
always benign.
- Doubling time – a 25% increase in diameter
- Most malignancy doubling time: 30-465 days.
- Some like osteosarcoma or germ cell tumor
can double faster.
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
Calcification :
- Calcium are present in > 50% of benign
nodules.
- Benign calcification appears
central or diffuse pattern.
as
laminated
- Calcium may present in 15% of malignant
nodule, but usually eccentrically located.
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Diagnostic tools for evaluation of lung nodules:

X-ray or CT scan

Bronchoscopy (including direct biopsy, needle
biopsy and brushing and washing for cytology)

Percutaneous fine needle aspiration biopsy.

PET/CT Scan

Excisional Biopsy
- Video assisted
- Thoracotomy
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
Percutaneous Needle Biopsy (PNB)
- Reliable with reported sensitivity 64-97% for
diagnosis malignancy.
- In benign disease,
between 50-80%.
the
accuracy
varies
- Relatively
Safe
with
Pneumothorex
complication rate 30% and 5-10% requiring
chest tube drainage.
- There is no doubt that PNB reduce the
number of patients require thoracotomy.
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
PET/CT Scan
- The sensitivity of PET for diagnosing lung
cancer approaches 95% with a specificity of
over 85%.
- One study has demonstrated that for SPNs,
a negative PET scan associated with only a
4.7% risk of malignancy.
- False-negative
PET
scan
are
usually
associated with lesions < 1 cm. in size & in
BAC.
Tissue characterization of SPN:Comparative
study between helical CT and integrated PET/CT
• Methods: 119 Pt. with SPN-underwent both
enhanced spiral CT and PET/CT scan
• On spiral CT, a nodule was considered malignant
with enhancement of >25 HU
• On PET/CT, nodules were considered malignant
with Max. SUV >3.5
The sensitivity, specificity and accuracy were
compared
Results: There were 79 malignant & 40 benign
nodule
Sensitivity, specificity and accuracy of enhanced
CT were 81%, 93% & 85%
Those on PET/CT were 96% e p=0.008, 88% e
p=0.72 & accuracy 93% e p=0.011
Conclusion: PET/CT may be performed as 1st line
test for SPN
JNM 2006;47(3)443-
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
Video-Assisted thoracic excisional biopsy
- Safe and highly effective in diagnosing and
often in treating solitary pulmonary nodule.
- But smaller
localize.
lesion
may
be
difficult
to
- Series from the Brigham and Women’s
Hospital reported successful resection of
lesions < 1 cm in diameter without any
localization techniques.
(N Engl J Med
1995, 52:515)
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Who makes surgical decision?

Important decisions made by
physician and by patient himself.
patient’s

Often patient decides between follow-up or
surgery
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
Decision may be influenced by numerous
factors including the probability that the
nodule is malignant, risks of surgery,
accuracy of biopsy technique and fear that
delay in surgical resection may forfeit the
possibility of cure.
In
addition,
surgeon
confidence
and
experience are important in decision making.
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
The management options : include
- “wait and watch” strategy
or
- Immediate surgery
- Biopsy of the nodule based on which decision
is taken.
Solitary Pulmonary Nodule
“Action is not a substitute for
judgment”
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
Wait and watch strategy
- There are no studies demonstrating a
decrease in survival when patient is kept
under observation for few months to assess
the growth of the nodule.
- Observation is advisable when the risk of
malignancy is low, the risk of surgery is high
or the patient refused further invasive
procedures.
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- The proponents of immediate surgery argue that
if surgery is delayed, it allows time for the
growth of the nodule and therapy reduce the
chance of a 5 year survival.
- Cummings et. al. (proposed the use of decision
analysis based on the probability that the nodule
is malignant using Bayes Theorem and four
variables I.e. age, history of smoking, diameter
of the nodule and prevalence of malignancy.
The average of life expectancy in years of
various strategies was then compared.
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Decision
 In patients with calculated probability of
malignancy greater than 75-80%, early surgery
appeared slightly superior to the needle biopsy.
 In patients with probability of malignancy less
than 75-80%, needle biopsy was slightly superior
to immediate surgery.
 Observation was suggested when the likelihood
of malignancy was <5% or the risk of surgery
was high. (Am Rev Respir Dis 1988; 134(3)453)
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New nodule identified on
standard CT scanning
Benign calcification pattern
on CT or stability for 2 yr.
on arcival films
Risk factors for surgery
•Predicted postoperative
FEV1 < 0.8 liter
•VO2 max < 10-15 ml/kg/min
Ye
s
No further testing
No
Does probability of cancer
warrant surgery, given the
Surgical risk?
Ye
s
No
Low probability of cancer
(<10%)
Serial high-resolution CT at
3, 6, 9, 12, 18 and 24 mo.
Moderate probability of cancer
(10-60%)
Negati
ve
tests
Additional testing
•PET if nodule >1 cm in diameter
•Contrast-enhanced CT, depending
on institutional expertise
•Transthoracic fine-needle aspiration
biopsy if nodule is peripherally located
* Bronchoscopy if air-bronchus sign present
Postiv
e
tsts
Video-assisted thoracoscopic
Surgery, examination of a
Frozen section, followed by
Lobectomy if nodule is malignant
Approach to the Management of Solitary Pulmonary Nodules
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Conclusions:

There is no one way to manage the indeterminate
nodule, but the diagnosis require a suitable clinical
evaluation. The judicious application of diagnostic
methods that based on the medicine evidence
based, will improve the quality of the medical
attention.

Excisional biopsy may be attractive for the surgeon
because it provides a definite diagnosis and place
the surgeon in a win position.
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Conclusions:

It is important to assess and respect the patient’s
anxiety and fears.
Most importantly, surgeons
must personally oversee the follow-up and be
willing to change their opinion, as new evidence is
available.

It is my bias that these nodules are best managed
by thoracic surgeons who must have confidence
that the algorithm followed in observing some
patients, will not alter the ultimate outcome, even
if the nodule should subsequently prove malignant.
THANK
YOU!