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Based on clinical and radiologic data, the clinician should assign a specific probability of malignancy to the lesion The decision whether and how to obtain a diagnostic biopsy depends on the interpretation of this probability in light of the patient s unique clinical situation The probabilities in parentheses below represent guidelines only and should not be interpreted as prescriptive In the case of solitary pulmonary nodules, a continuous probability function may be grouped into three categories In patients with a low probability (< 8%) of malignancy (eg, age under 30, lesions stable for more than 2 years, characteristic pattern of benign calcification), watchful waiting is appropriate Management consists of serial imaging studies (CT scans or chest radiographs) at intervals that would identify growth that would suggest malignancy Three-dimensional reconstruction of high-resolution CT images provides a more sensitive test for growth Patients with a high probability (> 70%) of malignancy should proceed directly to resection following staging, provided there are no contraindications to surgery Biopsies rarely yield a specific benign diagnosis and are not indicated Optimal management of patients with an intermediate probability of malignancy (8 70%) remains controversial The traditional approach is to obtain a diagnostic biopsy either through transthoracic needle aspiration (TTNA) or bronchoscopy Bronchoscopy yields a diagnosis in 10 80% of procedures depending on the size of the nodule and its location In general, the bronchoscopic yield for nodules that are < 2 cm and peripheral is low Complications are generally rare TTNA has a higher diagnostic yield, reported to be between 50% and 97% The yield is strongly operator-dependent, however, and is affected by the location and size of the lesion Complications are higher than bronchoscopy, with pneumothorax occurring in up to 30% of patients, with up to one-third of these patients requiring placement of a chest tube Disappointing diagnostic yields and a high false-negative rate (up to 25 30% in TTNA) have prompted alternative approaches Positron emission tomography (PET) detects increased glucose metabolism within malignant lesions with high sensitivity (85 97%) and specificity (70 85%) Many diagnostic algorithms have incorporated PET into the assessment of patients with inconclusive highresolution CT findings A positive PET increases the likelihood of malignancy, and a negative PET correctly excludes cancer in most cases False-negative PET scans can occur.

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with tumors with low metabolic activity (well-differentiated adenocarcinomas, carcinoids, and bronchioloalveolar tumors), and follow-up imaging is typically performed at discrete intervals to ensure absence of growth PET has several drawbacks, however: resolution below 1 cm is poor, the test is expensive, and availability remains limited Sputum cytology is highly specific but lacks sensitivity It is used in central lesions and in patients who are poor candidates for invasive diagnostic procedures Researchers have attempted to improve the sensitivity of sputum cytology through the use of monoclonal antibodies to proteins that are up-regulated in pulmonary malignancies Such tests offer promise but remain research tools at this time Video-assisted thoracoscopic surgery (VATS) offers a more aggressive approach to diagnosis VATS is more invasive than bronchoscopy or TTNA but is associated with less postoperative pain, shorter hospital stays, and more rapid return to function than traditional thoracotomy These advantages have led some centers to recommend VATS resection of all solitary pulmonary nodules with intermediate probability of malignancy In some cases, surgeons will remove the nodule and evaluate it in the operating room with frozen section If the nodule is malignant, they will proceed to lobectomy and lymph node sampling, either thoracoscopically or through conversion to standard thoracotomy

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Gurney JW Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis Part I Theory Radiology 1993 Feb;186(2):405 13 [PMID: 8421743] MacMahon H et al Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society Radiology 2005 Nov;237(2):395 400 [PMID: 16244247] Winer-Muram HT The solitary pulmonary nodule Radiology 2006 Apr;239(1):34 49 [PMID: 16567482]

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