Diagnosis and management of pulmonary nodules

Abstract

There are an increased number of pulmonary nodules discovered on CT scan images in part due to those performed for lung cancer screening. Risk stratification and patient involvement is critical in determining management ranging from interval imaging to invasive biopsy or surgery. A definitive diagnosis requires tissue biopsy. The choice of a particular biopsy technique depends on the risks/benefits of the procedure, the diagnostic yield and local expertise. This review will focus on the evaluation and management of pulmonary nodules based on the Fleischner Society and American College of Chest Physician guidelines. There have been recent changes to both societies’ recommendations for incidental detection of solid and subsolid nodules, risk stratification, imaging, minimally invasive diagnostic techniques and definitive surgical options.

Keywords::

• bronchoscopy
• CT screening
• lung cancer
• solitary pulmonary nodule
• transthoracic needle biopsy
• VATS

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Both the American College of Chest Physician and the Fleischner Society recently updated their guidelines for management of incidentally detected solid and subsolid pulmonary nodules. There are no definitive guidelines regarding those detected on lung cancer screening computed tomography.

• Risk stratification is an integral component of management. No good prediction models currently exist to estimate likelihood of malignancy in patients with intermediate probability of malignancy.

• Positron emission tomography computed tomography is suggested for certain nodules based on the probability of malignancy and as part of presurgical staging.

• Suggested intervals for repeat surveillance imaging are similar between both societies, but subtle differences do exist.

• Transbronchial needle biopsy has a role in diagnosis of pulmonary nodules, particularly when guided by likelihood of malignancy, ease of accessibility and size.

• Many different and emerging modalities exist to augment bronchoscopic biopsy, however, diagnostic accuracy may vary. Identifying patients who should forgo bronchoscopic biopsy is important.

• Surgical diagnosis with concomitant curative resection is advocated for those with high likelihood of malignancy (>65%) without evidence of metastatic disease.