An Update on the Evaluation and Management of Small Pulmonary Nodules

Alexandre M Furman; Jihane Zaza Dit Yafawi; Ayman O Soubani


Future Oncol. 2013;9(6):855-865. 

In This Article

Surgical Approaches to the Management of Solitary Pulmonary Nodules

Indeterminate lung nodules that cannot be diagnosed by one of the above methods may require a surgical procedure that can be both diagnostic and therapeutic. VATS used for excisional biopsy of the nodule in question involves general anesthesia and is performed in the operating room. It does require an average of 2–3 days of inpatient care but appears to be a safe procedure and carries a negligible morbidity and mortality risk.[88,89] While VATS is not necessarily recommended for centrally located lesions and/or those over 3 cm in diameter, the experience with a minimally invasive approach is growing. Conversion rates from VATS lobectomy to open thoracotomy vary from 54% in some studies to 4.6% in a recently published series of over 700 patients.[90] Risk for conversion was attenuated by nodules located more than 0.5 cm from pleural surface, vascular anomalies, fibrotic complications of the underlying disease process and anatomical aberrations. Moreover, it appears that surgical outcomes do not significantly differ from VATS to VATS with conversion to thoracotomy.[90,91] Several techniques exist to improve the detection of nodules during VATS. These include, but are not limited to, use of microvascular embolization coils with and without a suture attached, hook wire insertion, injection of dye, radiographic contrast media and radioactive peptide and other nucleotides. Discussion of these methods is beyond the scope of this article.[92]