Operating on a suspicious lung mass without a preoperative tissue diagnosis: pros and cons

Patients with a suspicious lung mass sometimes receive surgery with no preoperative tissue diagnosis despite-and sometimes in lieu of-modern medical investigations. The pros and cons of doing so have rarely been studied.

Pulmonary surgery was performed in 443 consecutive adult patients with a lung mass confirmed or suspected to be an early stage primary lung cancer. No diagnosis was confirmed preoperatively in 206 (46.5%) patients. Whether to take a core biopsy or wedge excision biopsy for frozen section assessment intraoperatively was decided at the surgeon's discretion.

Patients without preoperative diagnosis were on average younger than those with a diagnosis (61 vs 66 years, P < 0.01), but were otherwise similar to those who had a preoperative diagnosis confirmed. In all patients operated on without a preoperative diagnosis, there was no mortality or major complication, and the perioperative minor morbidity rate was 9.7%. Among patients ultimately found to have lung cancer and who received a lobectomy, performing a frozen section intraoperatively did not increase mean operation time or morbidity. Among those patients with no preoperative tissue diagnosis, 97 (47.1%) proceeded to surgery without attempts at preoperative diagnosis, and 109 (52.9%), after attempts at preoperative diagnosis failed to yield a positive diagnosis. After surgery, benign disease was found in 16 (7.8%) patients without preoperative diagnosis. A significantly lower proportion of patients without preoperative diagnosis waited an interval of over 28 days between presentation and being accepted for thoracic surgery (42.2 vs 54.9%, P < 0.01). However, they were not more likely to have Stage I disease and did not have better recurrence-free survival rates on survival analysis.

Proceeding to surgery without preoperative diagnosis in selected patients with a suspicious lung mass is safe and can potentially reduce the interval between presentation and surgical management. However, the shortened workup time is not associated with improved surgical or oncological outcomes.