Pulmonary nodule medical therapy
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Risk calculators and risk factors for Pulmonary nodule medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]
Overview
The optimal management approach of solitary pulmonary nodule will mainly depend on the nodule size and growth. Other parameters, such as: location, and distribution may also be helpful for the therapeutical management of solitary pulmonary nodule. Moreover, the solitary pulmonary nodule risk assessment is useful to determine the likelihood for malignancy and prompt treatment. Surgical resection is often recommended among patients with the malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.
Therapeutic Management
Surgery
- Surgical excision is the mainstay therapy for malignant or high risk pulmonary nodules
- Surgical excision is also the primary choice for the definitive diagnosis of malignant pulmonary nodules
- In pulmonary nodule, surgical procedure selection will depend on the size, margins, and size of the tumor.
- Common surgical procedures for the treatment of pulmonary nodule, include:
- Wedge resection
- Lobectomy
- Segmentectomy
- Lung volume reduction surgery
- The preferred surgical procedure is wedge resection by video-assisted thoracic surgery and pathological evaluation.
- The majority of surgical excisions include preoperative localization techniques, such as: preoperative placement of dye, technetium-99 radioguidance, ultrasound, or fluoroscopy.
- In some cases, surgical excision may be preferred by patients with the following characteristics:
- Non-compliant with follow-up
- Desire for diagnostic certainty
- Willingness to accept the risks associated with surgery
Complications
Common complications of solitary pulmonary nodule, include:[1]
- Prolonged mechanical ventilation
- Respiratory failure
- Bronchospasm
- Pulmonary embolism
Follow-Up and Surveillance
- Guideline treatment and management recommendations for solitary pulmonary nodule, include:
- American College of Chest Physicians (ACCP) guidelines
- Fleischner Society guidelines
- The table below summarizes the follow-up and surveillance recommendations for solitary pulmonary nodule according to the Fleischner Society guidelines.
| Recommendations for Follow-up and Management of Nodules <8 mm Detected Incidentally at Non-screening CT |
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| Nodule Size (mm) | Low risk patients | High risk patients |
| Less than or equal to 4 | No follow-up needed | Follow-up at 12 months. If no change, no further imaging needed |
| > 4 - 6 | Follow-up at 12 months. If no change, no further imaging needed | Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change |
| > 6 - 8 | Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change. | Initial follow-up CT at 3 - 6 months and then at 9 -12 and 24 months if no change |
| > 8 | Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy | Same at for low risk patients |
- Note: Newly detected indeterminate nodule in persons 35 years of age or older.[2]
* Low risk patients: Minimal or absent history of smoking and of other known risk factors.
* High risk patients: History of smoking or of other known risk factors.
References
- ↑ Smetana GW, Lawrence VA, Cornell JE (2006). "Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians". Ann. Intern. Med. 144 (8): 581–95. PMID 16618956.
- ↑ Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 237: 395-400.