1. ISKANDER AL-GITHMI, MD, FRCSC, FACS, FCCP
February 22, 2011
Division of Cardiothoracic Surgery
SURGICAL APPROACH TO THE MANAGEMENT
OF SOLITARY PULMONARY NODULE (SPN)

5. Solitary Pulmonary Nodule

6. Is the nodule benign or malignant?
Is the nodule benign or malignant?
Should it be investigated or observed?
Should it be surgically resected?
SOLITARY PULMONARY NODULE
SPN On Chest Radiography would raise several questions

7. SOLITARY PULMONARY NODULE
~ 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
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.

8. SOLITARY PULMONARY NODULE
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)

9. Primary Lesions
Adeno CA
Squamous Cell CA
Large Cell CA
Small Cell CA
Lymphoma
Carcinoid
Metastatic Lesions
Breast
Head and Neck
Melanoma
Colon
Kidney
Sarcoma
SOLITARY PULMONARY NODULE
Malignant causes of Solitary Pulmonary Nodules

10. Solitary Pulmonary Nodule
“ Remember that exploratory incision should not be made a cloak for diagnostic incompetence” – Rutherford Morrison ( )

11. 
Age
History of Smoking
Presence of other malignancy
Size of lesion
Border characteristic of lesion
Calcification of Lesion
Growth rate of lesion
SOLITARY PULMONARY NODULE
Factors affecting the likelihood of malignancy

12. 
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.
SOLITARY PULMONARY NODULE
Patient Age

13. 
History of smoking – strong association of cigarette smoking with primary lung CA
Previously diagnosed malignancy increases the likelihood that SPN may represent metastatic disease.
~ 10-30% of resected malignant pulmonary nodules are metastatic from extrathoracic malignancies.
Underlying Risk Factors
SOLITARY PULMONARY NODULE

14. 
Size of the Lesion :
- Small lesions tend to be benign
- Over 80% of lesion > 5cm. are malignant
SOLITARY PULMONARY NODULE -
In fact, 25-35% of SPN under 1 cm have been shown to be malignant

15. 
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: days.
Some like osteosarcoma or germ cell tumor can double faster.
SOLITARY PULMONARY NODULE

16. 
Calcification : -
Calcium are present in > 50% of benign nodules.
Benign calcification appears as laminated central or diffuse pattern.
Calcium may present in 15% of malignant nodule, but usually eccentrically located.
SOLITARY PULMONARY NODULE

17. 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
SOLITARY PULMONARY NODULE

18. 
Percutaneous Needle Biopsy (PNB) -
Reliable with reported sensitivity 64-97% for diagnosis malignancy.
In benign disease, the accuracy varies between 50-80%.
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.
SOLITARY PULMONARY NODULE

19. 
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.
SOLITARY PULMONARY NODULE

20. 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

21. 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-

22. SOLITARY PULMONARY NODULE
Video-Assisted thoracic excisional biopsy -
Safe and highly effective in diagnosing and often in treating solitary pulmonary nodule.
But smaller lesion may be difficult to localize.
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)

23. 
Important decisions made by patient’s physician and by patient himself.
Often patient decides between follow-up or surgery
SOLITARY PULMONARY NODULE
Who makes surgical decision?

24. 
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.
SOLITARY PULMONARY NODULE

25. 
The management options : include -
“wait and watch” strategy or
Immediate surgery
Biopsy of the nodule based on which decision is taken.
SOLITARY PULMONARY NODULE

26. Solitary Pulmonary Nodule
“Action is not a substitute for judgment”

27. 
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.
SOLITARY PULMONARY NODULE

28. -
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.
SOLITARY PULMONARY NODULE

29. SOLITARY PULMONARY NODULE
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.
Decision
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)

30. SOLITARY PULMONARY NODULE
Approach to the Management of Solitary Pulmonary Nodules
SOLITARY PULMONARY NODULE
New nodule identified on
standard CT scanning
Benign calcification pattern
on CT or stability for 2 yr.
on arcival films
Yes
No further testing No
Risk factors for surgery
Predicted postoperative
FEV1 < 0.8 liter
VO2 max < ml/kg/min
Does probability of cancer
warrant surgery, given the
Surgical risk?
Moderate probability of cancer
(10-60%)
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
Low probability of cancer
(<10%)
Postive
tsts
Video-assisted thoracoscopic
Surgery, examination of a
Frozen section, followed by
Lobectomy if nodule is malignant
Negative tests
Serial high-resolution CT at
3, 6, 9, 12, 18 and 24 mo.

31. SOLITARY PULMONARY NODULE
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.

32. SOLITARY PULMONARY NODULE
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.

33. THANK YOU!