Chest
Chest
Chest
Chest 2007;132;108S-130S
DOI 10.1378/chest.07-1353
The online version of this article, along with updated information and
services can be found online on the World Wide Web at:
http://chestjournal.chestpubs.org/content/132/3_suppl/108S.full.htm
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Key words: emission CT; granulomas; lung metastasis; lung neoplasms; needle biopsy; pulmonary coin lesion; radiograph CT;
thoracic radiography; thoracic surgery
Abbreviations: ACCP ! American College of Chest Physicians; CXR ! chest radiography; FDG ! F-18 fluorodeoxyglu-
cose; HU ! Hounsfield unit; NSCLC ! non-small cell lung cancer; OR ! odds ratio; PET ! positron emission tomography;
SCLC ! small cell lung cancer; SPN ! solitary pulmonary nodule; TTNA ! transthoracic needle aspiration/biopsy
efits of alternative management strategies and dates with nodules of this size, because of the
elicit patient preferences. Grade of recommenda- relatively high probability of malignancy. The opti-
tion, 1C mal time interval between imaging tests has not been
determined for patients with SPN, but the standard
Observation or Watchful Waiting: In some pa- clinical practice is to obtain follow-up CT scans at
tients with lung nodules, observation with serial least at 3, 6, 12, and 24 months. More frequent
imaging tests may be used as a diagnostic tool. When follow-up may be considered in patients who are at
this strategy is used, detection of growth at any time higher risk for malignancy. Less frequent follow-up
is presumptive evidence of malignancy, and surgical is indicated in patients with small, subcentimeter
resection should be performed in patients who are nodules.
operative candidates. Two-year radiographic stability The disadvantage of the observation strategy is that it
is strong presumptive evidence of a benign cause. potentially delays diagnosis and treatment in patients
Because it may be difficult to detect growth in with malignant nodules. Depending on the growth rate
nodules on plain CXRs, CT is usually preferred. and metastatic potential of the nodule and the length of
Although it may be possible to detect growth on observation, some malignant tumors will progress from
serial CXRs when the nodule is large (" 1.5 to 2 cm) resectable to unresectable disease during the observa-
and has sharp, clearly demarcated borders, the ob- tion period, and opportunities for surgical cure will be
servation strategy is seldom used in operative candi- missed. Empirical data relevant to the hazard of delay
Patients Who Are Not Surgical Candidates: Man- Size: Studies of CT screening in volunteers at risk
agement is uncertain in patients who have an SPN for lung cancer confirm a strong association between
and refuse surgery or are judged to be at unaccept- nodule diameter and the likelihood of malignancy.4
ably high risk for complications from even a limited Data from baseline screening in three US tri-
pulmonary resection. No randomized trials have als49,151,152 of low-dose CT show that the probabil-
compared early treatment before the development ity of malignancy is extremely low (# 1%) in
of symptoms vs later treatment when symptoms prevalent nodules that measure # 5 mm in diam-
develop. Discussion of potential risks and benefits eter. For nodules that measure 5 to 9 mm in
with patients is limited by the paucity of data. For diameter, the prevalence of malignancy varies
patients who prefer treatment, the diagnosis of lung from 2.3 to 6%.151,152 In one Japanese study,130 the
cancer should first be confirmed by biopsy whenever prevalence of malignancy in subcentimeter nod-
possible. Although external-beam radiation ther- ules was " 20%, considerably higher than in the
apy with curative intent is the current standard of US studies.
months and then again between 18 and 24 nodules and are not candidates for curative
months if unchanged. Grade of recommendation, treatment, we recommend limited follow-up (in
2C 12 months) or follow-up when symptoms de-
velop. Grade of recommendation, 1C