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Evaluation Methods

Lung lesions that are suspicious are evaluated by a variety of methods in order to determine whether they are malignant or non-malignant. The best method(s) will depend on the judgment of your physician, the location and size of the abnormality, as well as your clinical condition and your wishes.

If the nodule is small enough or if its features suggest a very low likelihood that it represents a cancer, your doctor is likely to follow the nodule over time with repeated chest imaging. If the nodule does not grow over time, it is likely to be benign. If growth is noted, then additional evaluation would be suggested. The interval between scans and the length of follow-up depends on the size of the nodule and the risk of malignancy.

Positron emission tomography (PET)—A PET scan can also help to find out if a nodule is malignant or benign. A PET scan uses a radiolabeled substance such as glucose that is absorbed by the nodule, and able to be imaged, providing a picture of the nodule’s activity level. Malignant cells have a faster metabolic rates than normal cells, so they require more energy and thus absorb more of the radiolabeled substance. Nodules can light up on PET imaging if they are malignant or if there is active inflammation. Nodules smaller than 8-10 mm are not seen well by PET imaging.

Genomic testing – blood test are in development that may help determine whether a lung nodule is likely to be malignant or non-malignant, some have already been FDA approved and may be useful in certain situations.

Biopsy—A biopsy is a procedure in which a small tissue sample is removed from the nodule so it can be examined under a microscope. It may be performed when other tests are inconclusive to rule out the chance that a growth is malignant. 

There are several ways to collect samples from lung tissue. The method used depends on the size and location of the nodule as well as the condition of the patient.

Bronchoscopy—This procedure is used if it appears the nodule can be reached through the breathing tubes. It uses a bronchoscope, which is a thin, lighted flexible tube that can be inserted into the mouth or nose and through the windpipe (trachea) into the bronchus (airway) of the lung. The bronchoscope has a very small camera at its end. Biopsy tools can be passed through the camera to reach the nodule. 

Navigational Bronchscopy-  this is bronchoscopy , but with the assistance of a “GPS” type navigational assistance. It is particularly useful if the nodule is some distance out in the lung away from the bronchus.

Needle biopsy (also known as transthoracic needleaspiration)—This test is most successful when the nodule is towards the edge of the lung, near the chest wall. A needle is inserted through the chest wall and into the nodule, usually under the guidance of a CT scan.  This may not be successful in smaller nodules (<1 cm) , which often take a different approach.

Wedge resection- the nodule is excised at surgery , often through a small incision that allows a scope to be passed (VATS)


If the nodule has a very concerning appearance or growth pattern, or it is somewhat concerning and its nature is not able to be clarified by the above tests, the best step may be to remove the nodule. This will clarify its nature while treating it. This requires the patient be fit enough to undergo the surgery.


How are pulmonary nodules treated? 


If the pulmonary nodule is benign, it usually does not require treatment. If an active infection is found or a disease of inflammation in the body is diagnosed, the treatment would be based on the condition identified and the symptoms that are present.


If the nodule is malignant, there does not appear to be any spread of the cancer, and the patient is fit, then the cancer should be surgically removed. If a non-surgical biopsy of a nodule with high concern for malignancy is done and the results are inconclusive, it is recommended that the nodule be taken out. 


Surgical techniques to take out pulmonary nodules include:

Thoracotomy—This procedure is considered open lung surgery. A cut is made in the wall of the chest in order to remove pieces of diseased lung tissue. Patients usually have to remain in the hospital for a few days after the operation. The mortality risk is low. When possible, a mini-thoracotomy that is less invasive may be performed. 

Video-Assisted Thoracoscopy—This procedure uses a thorascope, a flexible tube with a miniature camera on its end. The thorascope is inserted through a small cut into the chest wall. The camera allows the surgeon to view an image of the nodule on a television screen. This technique requires a smaller cut and a shorter recovery time than a thoracotomy does.