Diagnosing Peripheral Pulmonary Nodules

Abstract

I have read with great interest the letter by Dr. Streitz concerning our study (CHEST 1995; 108:131–37) on the integration of the transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses. All the patients included in the study were affected by a solitary pulmonary nodule or mass, and as you can read on page 133 (line 6, column 2), 436 patients (42%) had confirmation of their diagnosis by surgery (374 with malignant and 62 with benign lesions). We agree that in many cases the diagnosis of a peripheral pulmonary nodule does not change the need for surgical excision; however, this could occur or the surgical approach could be modified if the lesion is proved to be a metastasis, a nonepithelial tumor, or a definite benign process. Even if no single technique by itself gives more than 50% reliability in defining the specific diagnosis of a benign process, the integration of the three techniques that we employed permitted us to obtain a diagnostic definition of benign processes in 106 cases (59.5%); not one of these cases developed cancer in the follow-up period. If you identify (Table 3 of our work), among the specific diagnosis of benign peripheral pulmonary nodules or masses (PPN/M), those for which surgery would be not indicated (tuberculosis, abscess, silicosis, sarcoidosis, pneumonia, and fibrosis), then you can see that in about 70 patients the diagnostic procedures can save useless thoracotomies. Furthermore, if you consider the diagnosis of metastasis (that in some cases can contraindicate surgery or stimulate a more careful staging before excision) and of nonepithelial tumors such as lymphoma (for which surgery is not indicated), from our data one can estimate that for about 120 patients the bioptic techniques supplied essential information for a therapeutic strategy that did not include surgery. It must be emphasized that such results are obtained with safe and fast techniques and with a cost much lower than a direct surgical approach. Furthermore, in many cases (75.4%), the diagnosis was achieved with a transbronchial approach that, at the same time, led us also to obtain important information for disease staging. It should also be considered that most lung cancer patients are not good risks for surgery, and one could prefer not to send them for a thoracotomy without definitive evidence of malignancy. However, we agree that in some patients who are high risks for carcinoma and good risks for surgery, that sending them directly to surgery could be a strategy if they do not prefer to know that they have malignancy before submitting to a costly and painful procedure like thoracotomy. Diagnosing Peripheral Pulmonary NodulesCHESTVol. 109Issue 6PreviewGasparini and colleagues are to be congratulated for a thoughtful and comprehensive study (CHEST 1995; 108:131–37) regarding the diagnosis of peripheral pulmonary nodules. What is not evident in their article is how many of these nodules were solitary, nor is it clear how many of the final diagnoses were confirmed ultimately by surgical excision. Clinicians faced with a solitary pulmonary nodule, especially in those patients at high risk for carcinoma of the lung, must have near-absolute certainty in their diagnosis to recommend observation. Full-Text PDF