Solitary pulmonary nodules: new wine in old bottles.

Management strategies for solitary pulmonary nodules have evolved slowly during the last 50 years. The goal has always been to facilitate the resection of malignant nodules without undue delay and to avoid exploratory thoracotomy for benign nodules. In the past decade, the development of reliable nodule enhancement techniques has replaced or become incorporated within some of the older strategies. In addition, some of the well-accepted concepts of the past have been undergoing critical reviews and reevaluations. These concepts include retrospective study of nodule diameters to recognize 2-year stability, the use of a watch-and-wait strategy using standard chest radiographs for prospective determination of stability, detection and recognition of calcification patterns on standard chest radiographs, and computed tomography for mediastinal staging.

Primary non-small-cell lung cancer: determining the suitability of the patient and tumor for resection.

Choosing resective surgery for patients with bronchogenic carcinoma requires assessments of tumor suitability and patient suitability. Tumor suitability is largely dependent on the assessed stage of the tumor complex, based on characteristics of the primary tumor, detection of lymph node metastases, and detection of distant metastases. Imaging tests that assist in the determination of tumor stage include computed tomographic scans and positron emission tomographic (PET) scans. PET scans are more sensitive and specific than computed tomography. PET is also helpful in screening for distant metastases. Mediastinoscopy is required in most cases of mediastinal adenopathy. Patient suitability is assessed by predicting short-term surgical mortality, and the likelihood of crippling long-term respiratory failure. There is no single test that provides such information. Pulmonary function tests can be used to calculate the "predicted postoperative" function, and several algorithmic approaches have been devised to predict surgical risk. Assessments of regional pulmonary function are obtained with quantitative perfusion scintiscans. Cardiac function is also an important factor.

Smoking cessation. Techniques and benefits.

Tobacco dependency syndrome is an organic disease caused by chronic use of inhaled tobacco smoke. It is occasionally controlled by willpower alone, but often requires pharmacotherapy in conjunction with various techniques to manage the psychological manifestations. The two effective drugs are bupropion, which is an oral antidepressant, and nicotine, which can be administered by several modalities, including a skin patch, an oral inhalant, a nasal spray, and a chewable oral preparation. Successful therapy may require both drugs, and multiple simultaneous nicotine modalities. High-dose nicotine therapy may achieve an abstinence rate of 80% during therapy, but maintaining drug-free abstinence at such high levels over long periods is less successful, possibly because the tobacco smoke-induced changes in brain structure and function are not easily reversed.

Strategy and cost in investigating solitary pulmonary nodules.

OBJECTIVE: To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2-[F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan. SETTING: A university hospital and a teaching Veteran Affairs Medical Center. METHODS: Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard. RESULTS: The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign. CONCLUSION: FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.

Management of solitary pulmonary nodules. How to decide when resection is required.

Although each case must be considered individually, there are several basic principles of management in cases of solitary pulmonary nodules: Every nodule must be regarded as potentially malignant until proven otherwise. Malignant nodules should be resected unless the procedure is contraindicated because of an unacceptably high surgical risk or evidence of metastasis. Resection of a benign nodule rarely benefits the patient and carries a small but significant mortality risk. Ruling out malignancy by less-invasive means than thoracotomy is desirable wherever possible. A management decision should be reached with reasonable promptness once a solitary pulmonary nodule has been detected. Under certain circumstances, a decision to observe the nodule for a period of time with serial chest films may be appropriate, but this must be a considered approach and not a "default" position.

Needle, transbronchial, thoracoscopic, or open lung biopsy in interstitial lung disease.

The specific diagnosis of interstitial lung disease has conventionally been determined by lung biopsy. Lung biopsy also is useful for assessing disease activity and prognosis, and is sometimes useful in deciding on the necessity of therapy. The availability of newer biopsy techniques and the interaction of these techniques with current generation imaging modalities has changed the role of biopsy in interstitial lung disease. This review reports on the indications, techniques, and limitations of biopsy procedures and places them in the context of the use of current imaging methods, as reflected in recent literature.

Management of the solitary pulmonary nodule.

Large lesions are often malignant and call for prompt resection. Small lesions are likely to be benign but nonetheless raise difficult questions. For example, how to estimate the potential for malignancy? Or, how to weigh the possible effectiveness of an aggressive surgical approach against possible complications? Probability techniques can provide support for clinical judgment.

Evaluation and management of solitary and multiple pulmonary nodules.

Solitary pulmonary nodules are malignant in 50% of cases. The 5-year cure rate after resection of a malignant nodule averages 50% and is even higher if the nodule is small. Stability for 2 years suggests benignity, and the presence of calcification in certain patterns indicates that the nodule is probably benign. Biopsy of the nodule may establish benignity. The "wait and watch" strategy may be advisable under certain circumstances. Multiple pulmonary nodules are usually due to metastatic spread from an extrapulmonary primary tumor. Biopsy is usually advisable because the nodules may be due to a curable benign process.