Solitary Pulmonary Nodule

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Questions to Ask Your Pulmonary Care Team
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Treatment

The treatment for SPNs depends on the risk for malignancy. If the patient opts for surgery, a single surgical procedure is used to diagnose and remove the SPN.

If the patient is healthy enough to have surgery, the nodule should be surgically removed, unless:

• the calcification is typical of a benign nodule; and
• there is no radiological change in the size of the nodule for 2 years; and
• the patient is not at high risk for lung cancer.

Studies have shown that the prognosis (outcome) is the same whether immediate action involves no action at all, surgery, or biopsy. In other words, a watch-and-wait attitude does not necessarily worsen the prognosis if the nodule is malignant.

Patients with low risk for cancer

If the patient is at low risk for cancer and all signs indicate that the nodule is benign, whether or not a biopsy has been done, the treatment is relatively conservative and should include:

• PPD skin test;
• repeat chest x-rays in 1-2 months (if there is no change at that time, repeat again in 2-4 months, and again in another 2-4 months)

If there is any growth, the patient should be considered moderate to high risk.

Patient with moderate to high risk for cancer

If the patient is at moderate to high risk for cancer and clinical signs indicate that the nodule is malignant, or if the malignancy of the nodule cannot be determined even after a biopsy, the SPN should be surgically removed. The patient should undergo pulmonary function tests to make sure they are healthy enough for surgery.

If the patient is a candidate for surgery and the the nodule is likely malignant, either a thoracotomy (open lung surgery) or a video-assisted thoracoscopic surgery (VATS) is performed. The latter has proven nearly 100% diagnostically accurate in patients for whom noninvasive biopsies prove indeterminate, and it carries a significantly lower risks compared to open lung surgery.

Thoracotomy
Deciding on a thoracotomy requires considerable thought, as there is a small risk for mortality. About 5% of patients who undergo the surgery are left with an air leak in the lungs. The surgery involves making an incision in the chest wall and removing small wedges of lung tissue. The patient usually stays in the hospital for several days afterwards.

Video-assisted thoracoscopy
Video-assisted thoracoscopy involves inspecting and sampling the abnormal lung tissue using an instrument called a thoracoscope. The procedure involves inserting a flexible tube that looks like a miniature telescope, a tiny camera, and surgical instruments through an incision in the chest. The camera displays the image on a TV screen and the surgeon uses the display to guide the operation. Its advantages over traditional thoracotomy include shorter recovery time and a smaller incision.

Video-assisted thoracoscopy is especially advantageous for patients undergoing a combined diagnostic (biopsy) and therapeutic (surgical removal) procedure. Its complications are rare and death is extremely uncommon, making it preferable to open lung biopsy or surgery.

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