Management strategies for the solitary pulmonary nodule

The challenge of diagnosis and management of solitary pulmonary nodules is among the most common yet most important areas of pulmonary medicine. Ideally, the goal of diagnosis and management is to promptly bring to surgery all patients with operable malignant nodules while avoiding unnecessary thoracotomy in patients with benign disease.

Effective management of the solitary pulmonary nodule depends upon an understanding of decision analysis principles so that diverse technologies can be integrated into a systematic approach.

In almost all patients computed tomography (CT) is the best first step. Three key questions can then help guide the workup of the SPN. These are what is the pretest probability of cancer, what is the risk of surgical complications, and does the appearance of the nodule on CT scan suggest a benign or malignant etiology. In patients with average surgical risk, positron emission tomography (PET) scan is warranted when there is discordance between pretest probability of cancer and the appearance of the nodule on CT scan. Thus, when either the patient has a low risk of cancer and the CT suggests a malignant origin, or when there is high risk of cancer and the CT appears benign, PET scan will be cost effective. In most other situations, PET scanning is only marginally more effective than CT and fine needle aspiration strategies but costs much more.