Pulmonary nodule. The surgeon's approach

Malignancy must be suspected with any pulmonary nodule detected on radiolog ic examination of the chest until its benign origin has been proven. This r equires further evaluation of the patient. The non invasive diagnostic step s include patient's history, clinical examination, lung function testing, a nd standard radiographs and a computed tomography (CT) of the chest. Based on these findings the presumed diagnosis claims the next appropriate diagno stic steps. If lung cancer is the most likely diagnosis and lung function t esting revealed that the patient is a candidate for lung resection than sur gery may be the next step. Preoperative proof of the histologic diagnosis i s not mandatory. It is the less required the more surgery may be curative. If curative resectability is in doubt or the patient is not candidate for l ung resection than histologic diagnosis should be confirmed prior to introd uction of radiotherapy or chemotherapy by the least invasive procedure (bro nchoscopy < lymph node biopsy < needle biopsy < mediastinoscopy/-tomy < VAT S). If metastatic disease must be suspected, staging should be completed as required for the primary malignancy. With local recurrence and other metas tases excluded the number of pulmonary nodules detected on CT scan points t o the appropriate surgical approach. In case of a solitary nodule or multip le but resectable nodules, complete (wedge) resection with lymph node disse ction through a lateral thoracotomy will be the procedure of choice. With m ultiple and unresectable nodules, surgery allows definitive diagnosis and v ideothoracoscopy affords the opportunity to accomplish wedge resection of t he lung along with low morbidity. When lesions are deemed indeterminate, de finitive diagnosis should nevertheless be attempted. If there is no history of malignancy routine evaluation for such in asymptomatic patients is not indicated. With small nodules (less than 3 cm in diameter) located in the p eriphery of the lung, video-thoracoscopic wedge resection is indicated with out preoperative sputum cytology, bronchoscopy or transthoracic needle biop sy. The histologic diagnosis obtained by intraoperative frozen sections tha n determines the further surgical approach. Benign lesion: completion of su rgery; lung cancer: proceed to thoracotomy with anatomic lung resection and mediastinal lymph node resection; metastatic disease: completion of surger y and further search for primary malignancy.