What are the indications for pulmonary nodule resection?

Indications for Pulmonary Nodule Resection

Surgical resection is indicated for pulmonary nodules that show clear evidence of malignant growth on serial imaging, have a high probability of malignancy (>65%), are intensely hypermetabolic on PET, or when nonsurgical biopsy is suspicious for malignancy. 1

Solid Nodules >8mm in Diameter

High Probability of Malignancy (>65%)

• Surgical diagnosis is recommended when the clinical probability of malignancy is high (>65%) 1
• Surgical resection is indicated when the nodule is intensely hypermetabolic by PET or markedly positive by another functional imaging test 1
• Thoracoscopy (VATS) is the recommended approach to obtain a diagnostic wedge resection 1

Evidence of Malignant Growth

• Nodules showing clear evidence of malignant growth on serial imaging should undergo nonsurgical biopsy and/or surgical resection unless specifically contraindicated 1
• Malignant growth is best detected by comparing serial CT scans with all available prior studies, especially the initial scan 1

After Nonsurgical Biopsy

• Surgical resection is indicated when nonsurgical biopsy is suspicious for malignancy 1
• For nodules confirmed as lung cancer preoperatively or after wedge resection with intraoperative frozen section, lobectomy should be offered to patients fit enough to undergo the procedure 1

Subsolid Nodules

Part-Solid Nodules

• Part-solid nodules measuring >8mm with a solid component should be evaluated with PET, nonsurgical biopsy, and/or surgical resection if they persist beyond 3 months 1
• Part-solid nodules measuring >15mm in diameter should proceed directly to further evaluation with PET, nonsurgical biopsy, and/or surgical resection 1
• Consider sublobar resection for persistent ground-glass nodules (pGGNs) due to excellent long-term prognosis and low risk of local relapse 1

Pure Ground-Glass Nodules

• Pure ground-glass nodules >10mm that persist beyond 3 months have a 10-50% probability of malignancy and may require resection 2
• For pure ground-glass nodules >5mm in diameter, annual surveillance with chest CT for at least 3 years is recommended, with resection considered if they grow or develop a solid component 1

Surgical Approach Considerations

Preferred Surgical Technique

• Video-assisted thoracoscopic surgery (VATS) is strongly preferred over open thoracotomy for pulmonary nodule resection 1
• For nodules that are small (<1cm), deep, or subsolid, localization techniques may be necessary to increase diagnostic yield during thoracoscopy 1, 3
• Anatomical segmentectomy may be considered for nodules <2cm without nodal disease when preservation of functioning lung tissue is important 1

Intraoperative Management

• Intraoperative frozen section analysis is recommended to establish diagnosis 1
• If malignancy is confirmed, proceed to completion lobectomy during the same anesthetic procedure 1
• For patients unfit for lobectomy, consider anatomical segmentectomy 1

Special Considerations

Multiple Nodules

• When a patient has a dominant nodule and one or more additional small nodules, each nodule should be evaluated individually 1
• Curative treatment should not be denied unless there is histopathological confirmation of metastasis 1

Patient Factors

• Surgical resection should be considered when a fully informed patient prefers undergoing a definitive diagnostic procedure 1
• For patients unfit for surgery with high probability of malignancy nodules, consider stereotactic ablative body radiotherapy (SABR) or radiofrequency ablation (RFA) if technically suitable 1

Pitfalls and Caveats

• Small nodules (<8mm) generally do not require immediate resection and should be followed with appropriate surveillance 1, 2
• Resection of benign nodules carries a small but significant mortality risk and rarely benefits the patient 4
• Nodules that decrease in size but do not disappear completely should be followed to resolution or lack of growth over 2 years before considering resection 1
• The sensitivity of frozen section analysis is lower (87%) for nodules <1.1cm in diameter compared to larger nodules (94%) 1