[Pulmonary nodule. The surgeon's approach]

Malignancy must be suspected with any pulmonary nodule detected on radiologic examination of the chest until its benign origin has been proven. This requires further evaluation of the patient. The non invasive diagnostic steps include patient's history, clinical examination, lung function testing, and standard radiographs and a computed tomography (CT) of the chest. Based on these findings the presumed diagnosis claims the next appropriate diagnostic steps. If lung cancer is the most likely diagnosis and lung function testing revealed that the patient is a candidate for lung resection than surgery may be the next step. Preoperative proof of the histologic diagnosis is not mandatory. It is the less required the more surgery may be curative. If curative resectability is indoubt or the patient is not candidate for lung resection than histologic diagnosis should be confirmed prior to introduction of radiotherapy or chemotherapy by the least invasive procedure (bronchoscopy < lymph node biopsy < needle biopsy < mediastinoscopy/-tomy < VATS). If metastatic disease must be suspected, staging should be completed as required for the primary malignancy. With local recurrence and other metastases excluded the number of pulmonary nodules detected on CT scan points to the appropriate surgical approach. In case of a solitary nodule or multiple but resectable nodules, complete (wedge) resection with lymph node dissection through a lateral thoracotomy will be the procedure of choice. With multiple and unresectable nodules, surgery allows definitive diagnosis and videothoracoscopy affords the opportunity to accomplish wedge resection of the lung along with low morbidity. When lesions are deemed indeterminate, definitive diagnosis should nevertheless be attempted. If there is no history of malignancy routine evaluation for such in asymptomatic patients is not indicated. With small nodules (less than 3 cm in diameter) located in the periphery of the lung, videothoracoscopic wedge resection is indicated without preoperative sputum cytology, bronchoscopy or transthoracic needle biopsy. The histologic diagnosis obtained by intraoperative frozen sections than determines the further surgical approach. Benign lesion: completion of surgery; lung cancer: proceed to thoracotomy with anatomic lung resection and mediastinal lymph node resection; metastatic disease: completion of surgery and further search for primary malignancy.