| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2003;75:1611-1612
© 2003 The Society of Thoracic Surgeons
a School of Medicine Division of Cardiothoracic Surgery, 801 N. Rutledge, Room D319P.O. Box 19638Southern Illinois University, Springfield, IL 62794-9638, USA
e-mail: shazelrigg{at}siumed.edu
Solitary pulmonary nodules (SPN) are identified in over 150,000 patients annually in the United States alone, and their management has been the topic of much debate and consternation. While video-assisted thoracoscopic resection (VATS) has largely replaced open procedures for wedge resection of peripheral nodules, the use of modalities such as percutaneous needle biopsy (PNB) and ever improving scanners must assist us in diagnosis. Our ultimate goal is to minimize any delay in the diagnosis and management of malignant lesions while avoiding both false negative results and the resection of benign nodules.
This manuscript represents a fairly large series of VATS resections for SPN’s. The results, with regard to complications, are excellent and add to the evidence that VATS can be performed safely in most situations. The number of benign nodules resected, however, is very high (370/429 = 86.2%) with a particularly large number of hamartomas (309). The series employed nonsurgical technologies such as PNB (4.8%) and positron emission tomography (PET) scan (1.8%) infrequently. For comparison, most reported series of VATS resection for SPN have found benign nodules in 40%–45% of resections, and hamartomas can often be diagnosed preoperatively with computed tomography (CT) scans (showing intranodular fat) or PNB (showing characteristic histologic findings).
The risk of malignancy is related to patient age, size of the nodule, smoking history, evidence of adenopathy, increasing nodule size on serial studies, and irregular lesion borders. This series confirms many of those risk factors but adds the need to convert to open thoracotomy for nodule resection as an additional risk factor. More than half of their malignant SPN’s (59.3%) required conversion for diagnosis, compared to only 16.4% of those eventually proven benign. The reason for this finding is not entirely clear nor has it been my own personal experience. Nodules that are difficult to find and resect with VATS tend to be deeper, smaller, or both. Since smaller lesions are more often benign, sometimes in series we see more conversions in benign nodules. Metastases tend to be peripheral and easily resected again rarely requiring open conversion. The explanation may lie in the high number of hamartomas (which are usually peripheral and easily resected by VATS). In the VATS study group data there were only 38 hamartomas out of 267 benign nodules and the incidence of benign nodules resected was 43%.
Thoracoscopic (VATS) resection now clearly plays a major role in the evaluation of peripheral solitary pulmonary nodules. Resection can be done with low risk in most cases and provides a definitive diagnosis. All nodules that cannot be dismissed due to a proven radiographic evidence of stability for two years or a benign pattern of calcification (central or popcorn) should be investigated. Percutaneous needle biopsy may be used, although it provides a definitive benign diagnosis in only 10%–20% of cases and is not very useful at small sizes (< 1 cm). A retrospective study demonstrated avoidance of surgery in only 6% of SPN’s due to a percutaneous biopsy. Malignant and indeterminate biopsy results still necessitate surgical resection. Computed tomography scans, especially with nodule enhancement, have proven useful. Nodule enhancement of greater than 20 Hounsfield units suggests the need for biopsy or resection. Positron emission tomography scans now provide an option, especially in the high risk patient, but are also less accurate at small sizes.
The use of new radiographic techniques such as high resolution CT scanning with nodule enhancement and PET scans have improved our ability to predict malignancy in lesions. The emergence of VATS has allowed a minimally invasive approach to excisional biopsy of suspicious nodules. Our incidence of complications and length of stay continues to decrease with VATS such that even an outpatient wedge is possible in selected cases. No formula is perfect for all patients, and some individual variation in evaluation of the indeterminate nodule must be made based on the possibility of malignancy and the patient’s overall operative risk.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
