Clinical Diagnosis and Treatment for Patients with Small Pulmonary Nodules_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Tao , CHEN Baojun , FAN Xiaohong

1. Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School of Nanjing Medical University, Nanjing 210008, P. R. China;;
2. Department of Old-age, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School of Nanjing Medical University, Nanjing 210008, P. R. China;

Corresponding author：

Keywords：

Small pulmonary nodule; CT-guided localization; Treatment

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Abstract： Objective To explore the approach of clinical diagnosis and treatment strategy for patients with small pulmonary nodules （SPN）≤ 1.0 cm in size on CT. Methods We retrospectively analyzed the clinical records of 39 patients with SPN less than 1.0 cm in size who underwent lung resection at Nanjing Drum Tower Hospital from January 2005 to June 2011. There were 23 males and 16 females. Their age ranged from 31-74 （51.0±7.4） years. Nine patients had cough and sputum and other patients had no symptom. All the patients were found to have SPN less than 1.0（0.8±0.1）cm in size but not associated with hilum and mediastinal lymphadenectasis in chest CT and X-ray. The results of their sputum cytology and electronic bronchoscope were all negative. All the patients had no histologic evidence and underwent pulmonary function test prior to operation. Eleven patients had positron emission tomography/computer tomography （PET/CT）or single-photon emission computed tomography （SPECT）which was all negative. Thirteen patients underwent video-assisted minithoracotomy（VAMT） and 26 patients underwent video-assisted thoracoscopic surgery （VATS）. Results The average operation time was 121.0±48.0 min. Patients after partial lung resection were discharged 4～5 d postoperatively, and patients after lobectomy were discharged 7 d postoperatively. All the patients had no postoperative complications. Twenty one patients were identified as lung malignancy by postoperative pathology, including 9 patients with adenocarcinoma, 7 patients with bronchioloalveolar carcinoma, 1 patient with small cell lung carcinoma, and 4 patients with pulmonary metastasis. Eighteen patients had benign lesions including 4 patients with sclerosing hemangioma, 4 patients with inflammatory pseudotumor, 2 patients with pneumonia, 3 patients with granuloma, 2 patients with tuberculosis, and 3 patients with pulmonary lymph node hyperplasia. The SPN were located in left upper lobe in 11 patients, left lower lobe in 6 patients, right upper lobe in 14 patients, right middle lobe in 1 patient, and right lower lobe in 7 patients. Conclusion The diagnosis of SPN ≤1.0 cm in size on CT should consider malignance in the first step to avoid treatment delay. Patients may have a 3-month observation period to receive selective antibiotic treatment, chest CT and X-ray review after 2 to 4 weeks. CT- guided hook-wire fixation is useful to help in precise lesion localization for surgical resection. VATS and VAMT are common and effective methods for the diagnosis and treatment for SPN.

Citation： WANG Tao ,CHEN Baojun,FAN Xiaohong,et al.. Clinical Diagnosis and Treatment for Patients with Small Pulmonary Nodules. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2012, 19(3): 274-279. doi: Copy

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2.	van’t Westeinde SC， de Koning HJ， Xu DM， et al. How to deal with incidentally detected pulmonary nodules less than 10mm in size on CT in a healthy person. Lung Cancer， 2008， 60 （2）：151-159.
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15.	Gohagan J， Marcus P， Fagerstrom R， et al. Baseline findings of a randomized feasibility trial of lung cancer screening with spiral CT scan vs chest radiograph：the Lung Screening Study of the National Cancer Institute. Chest， 2004， 126 （1）：114-121.
16.	Zwirewich CV， Vedal S， Miller RR， et al. Solitary pulmonary nodule：high-resolution CT and radiologic-pathologic correlation. Radiology， 1991， 179 （2）：469-476.
17.	Swensen SJ， Viggiano RW， Midthun DE， et al. Lung nodule enhancement at CT：multicenter study. Radiology， 2000， 214 （1）：73-80.
18.	Winer-Muram HT， Jennings SG， Tarver RD， et al. Volumetric growth rate of stage I lung cancer prior to treatment：serial CT scanning. Radiology， 2002， 223 （3）：798-805.
19.	Swensen SJ， Silverstein MD， Ilstrup DM， et al. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med， 1997， 157 （8）：849-855.
20.	Colice GL. Chest CT for known or suspected lung cancer. Chest， 1994， 106 （5）：1538-1550.
21.	Steele JD， Buell P. Asymptomatic solitary pulmonary nodules. Host survival， tumor size， and growth rate.J Thorac Cardiovasc Surg， 1973， 65 （1）：140-151.
22.	Weiss W. Tumor doubling time and survival of men with bronchogenic carcinoma. Chest， 1974， 65 （1）：3-8.
23.	Garland LH， Coulson W， Wollin E. The rate of growth and apparent duration of untreated primary bronchial carcinoma. Cancer， 1963， 16：694-707.
24.	Diederich S， Wormanns D， Semik M， et al. Screening for early lung cancer with low-dose spiral CT：prevalence in 817 asymptomatic smokers. Radiology， 2002， 222 （3）：773-781.
25.	Thomas MD， Talissa AA， Patrice KR， et al. A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions. Ann Thorac Surg， 2004， 77 （5）：1756-1762.
26.	Torre M， Ferraroli GM， Vanzulli A， et al. A new safe and stable spiral wire needle for thoracoscopic resection of lung nodules. Chest， 2004， 125 （6）：2289-2293.
27.	Saito H， Minamiya Y， Matsuzaki I， et al. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg， 2002， 124 （6）：1198-1202.
28.	郭瑞军，于泽兴，曹文．胸腔镜超声协助胸腔镜下切除右肺小结节1例．中国超声医学杂志，2007，23 （1）：18．.
29.	Klöppel R， Friedrich T， Eichfeld U， et al. CT-guided marking of lung lesions before minimally invasive operation. Radiology， 2001， 41 （2）：201-204.
30.	Macmahon H， Austin JH， Gamsu G， et al. Guidelines for management of small pulmonary nodules detected on CT scans：a statement from the Fleischner Society. Radiology， 2005， 237 （2）：395-400.
31.	Ginsberg RJ. The solitary pulmonary nodule：can we afford to watch and wait? J Thorac Cardiovas Surg， 2003， 125 （1）：25-26.

1. 　Midthun DE， Swensen SJ， Jett JR. Approach to the solitary pulmonary nodule. Mayo Clin Proc， 1993， 68 （4）：378-385.
2. 　van’t Westeinde SC， de Koning HJ， Xu DM， et al. How to deal with incidentally detected pulmonary nodules less than 10mm in size on CT in a healthy person. Lung Cancer， 2008， 60 （2）：151-159.
3. 　Munden RF， Hess KC. Survey of members of the society of thoracic radiology. AJR Am J Roentgenol， 2001， 176 （6）：1363-1369.
4. 　Henschke CI. Early lung cancer action project：overall design and findings from baseline screening. Cancer， 2000， 89 （11 Suppl）：2474-2482.
5. 　Mcwilliams AM， Mayo JR， Ahn MI， et al. Lung cancer screening using multi-slice thin-section computed tomography and autofluorescence bronchoscopy. J Thorac Oncol， 2006， 1 （1）：61-68.
6. 　Swensen SJ， Jett JR， Hartman TE， et al. Lung cancer screening with CT：Mayo Clinic experience. Radiology， 2003， 226 （3）：756-761.
7. 　Mcwilliams AM， Mayo JR， English JC， et al. The usefulness of positron emission tomography（pet）in an early lung cancer detection program?. J Thorac Oncol， 2007， 2：S332.
8. 　Erasmus JJ， Mcadams HP， Patz EF Jr， et al. Thoracic FDG PET：state of the art. Radiographics， 1998， 18 （1）：5-20.
9. 　Higashi K， Ueda Y， Seki H， et al. Fluorine-18-FDG PET imaging is negative in bronchioloalveolar lung carcinoma. J Nucl Med， 1998， 39 （6）：1016-1020.
10. 　Herder GJ， Golding RP， Hoekstra OS， et al. The performance of （18）F-fluorodeoxyglucose positron emission tomography in small solitary pulmonary nodules. Eur J Nucl Med Mol Imaging， 2004， 31 （9）：1231-1236.
11. 　Winer-Muram HT. The solitary pulmonary nodule. Radiology， 2006， 239 （1）：34-49.
12. 　Sin DD， Anthonisen NR， Soriano JB， et al. Mortality in COPD：role of comorbidities. Eur Respir J， 2006， 28 （6）：1245-1257.
13. 　Van Klaveren RJ， de Koning HJ， Mulshine J， et al. Lung cancer screening by spiral CT. What is the optimal target population for screening trials? Lung Cancer， 2002， 38 （3）：243-252.
14. 　Alberg AJ， Samet JM. Epidemiology of lung cancer. Radiol Clin North Am， 2003， 123 （1 Suppl）：21S-49S.
15. 　Gohagan J， Marcus P， Fagerstrom R， et al. Baseline findings of a randomized feasibility trial of lung cancer screening with spiral CT scan vs chest radiograph：the Lung Screening Study of the National Cancer Institute. Chest， 2004， 126 （1）：114-121.
16. 　Zwirewich CV， Vedal S， Miller RR， et al. Solitary pulmonary nodule：high-resolution CT and radiologic-pathologic correlation. Radiology， 1991， 179 （2）：469-476.
17. 　Swensen SJ， Viggiano RW， Midthun DE， et al. Lung nodule enhancement at CT：multicenter study. Radiology， 2000， 214 （1）：73-80.
18. 　Winer-Muram HT， Jennings SG， Tarver RD， et al. Volumetric growth rate of stage I lung cancer prior to treatment：serial CT scanning. Radiology， 2002， 223 （3）：798-805.
19. 　Swensen SJ， Silverstein MD， Ilstrup DM， et al. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med， 1997， 157 （8）：849-855.
20. 　Colice GL. Chest CT for known or suspected lung cancer. Chest， 1994， 106 （5）：1538-1550.
21. 　Steele JD， Buell P. Asymptomatic solitary pulmonary nodules. Host survival， tumor size， and growth rate.J Thorac Cardiovasc Surg， 1973， 65 （1）：140-151.
22. 　Weiss W. Tumor doubling time and survival of men with bronchogenic carcinoma. Chest， 1974， 65 （1）：3-8.
23. 　Garland LH， Coulson W， Wollin E. The rate of growth and apparent duration of untreated primary bronchial carcinoma. Cancer， 1963， 16：694-707.
24. 　Diederich S， Wormanns D， Semik M， et al. Screening for early lung cancer with low-dose spiral CT：prevalence in 817 asymptomatic smokers. Radiology， 2002， 222 （3）：773-781.
25. 　Thomas MD， Talissa AA， Patrice KR， et al. A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions. Ann Thorac Surg， 2004， 77 （5）：1756-1762.
26. 　Torre M， Ferraroli GM， Vanzulli A， et al. A new safe and stable spiral wire needle for thoracoscopic resection of lung nodules. Chest， 2004， 125 （6）：2289-2293.
27. 　Saito H， Minamiya Y， Matsuzaki I， et al. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg， 2002， 124 （6）：1198-1202.
28. 　郭瑞军，于泽兴，曹文．胸腔镜超声协助胸腔镜下切除右肺小结节1例．中国超声医学杂志，2007，23 （1）：18．.
29. 　Klöppel R， Friedrich T， Eichfeld U， et al. CT-guided marking of lung lesions before minimally invasive operation. Radiology， 2001， 41 （2）：201-204.
30. 　Macmahon H， Austin JH， Gamsu G， et al. Guidelines for management of small pulmonary nodules detected on CT scans：a statement from the Fleischner Society. Radiology， 2005， 237 （2）：395-400.
31. 　Ginsberg RJ. The solitary pulmonary nodule：can we afford to watch and wait? J Thorac Cardiovas Surg， 2003， 125 （1）：25-26.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Clinical Diagnosis and Treatment for Patients with Small Pulmonary Nodules

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