Coexisting pulmonary nodules in operable lung cancer: Prevalence and probability of malignancy

doi:10.1016/j.lungcan.2011.03.012

Lung Cancer

Volume 74, Issue 2, November 2011, Pages 233-238

https://doi.org/10.1016/j.lungcan.2011.03.012 Get rights and content

Abstract

Introduction

Coexistence of pulmonary nodules in operable non small cell lung cancer (NSCLC) may influence the therapeutic indication. The aim of this study was to evaluate prospectively the prevalence and the probability of malignancy of pulmonary nodules in operable lung cancer.

Methods

From a prospective database, all surgically treated patients diagnosed with NSCLC from 1998 to 2003 were retrospectively reviewed. Patients presenting pulmonary nodule(s) were identified.

Results

Two hundred thirty nine patients had a complete resection for a NSCLC and 56 patients (24%) presented altogether 88 nodules on thoracic CT. Twenty-four of these nodules (27%) were malignant, 28 (32%) benign and 36 (41%) of undetermined nature. Five factors associated with nodule's malignancy were identified: tumour histology (non-squamous (non-SCC) 44% vs. SCC 7%, p = 0.001), localization of the nodules in an upper lobe (vs. other lobe, p = 0.004), co localization in the same lobe as the NSCLC (vs. another lobe, p = 0.03), nodule size (p = 0.05) and shape (speculated vs. non spiculated, p = 0.02). From these factors, a probability score was assessed with a malignancy rate in SCC of 0% in nodules presenting ≤1 feature, 33% with 2 features and 100% with ≥3 features and in non-SCC of 40% with 1 feature, 82% with 2 features and 100% with 3 ≥ features.

Conclusion

Diagnosis of satellite nodules associated with early stage NSCLC is common. We developed a predictive score to estimate the probability of malignancy which may be a precious aid in the management of pulmonary nodules associated to a NSCLC.

Introduction

Recent advances in thoracic imaging with the widespread use of computed tomography (CT) has improved the management of non-small cell lung cancer (NSCLC) [1]. However, the sensitivity of this technique has increased and the detection of small pulmonary nodules is common during the staging evaluation for patients with lung cancer. In patients with an operable lung cancer, the coexistence of satellite lesions may change TNM status and influence the therapeutic indication. If a nodule is considered as malignant, NSCLC may be classified as stage T4 (nodule in the same lobe) or M1 (nodule in another lobe), or as synchronous multiple lung cancer in the 1997 classification [2] and T3 (nodule in the same lobe), T4 (ipsilateral nodules in different lobes) or M1a (controlateral pulmonary nodules) in the 2009 classification [3]. As prognosis is significantly better in patients with stage I (T1-2N0M0) or synchronous primary lung cancer than those with stage IIIB (T4N0M0) or stage IV (T1-2N0M1), the existence of malignant pulmonary nodules could be considered as a contraindication to surgery. Thus, to obtain a differential diagnosis between metastases and benign lesions is essential to choose the best therapeutic strategy.

Few studies have focused on pulmonary nodules in lung cancer patients. However, the diagnosis of these nodules coexisting with a known primary lung cancer remains a diagnostic challenge. Fiberoptic bronchoscopy is not often helpful in the diagnosis of peripheral pulmonary nodules [4] and the diagnostic sensibility of CT guided transthoracic needle aspiration is conflicting. For certain authors, transthoracic needle aspiration is less accurate in small pulmonary nodules [5], whereas other authors report a good diagnostic value, but a high rate of pneumothorax [6]. Interest in non-invasive procedures as 18F-fluorodeoxyglucose positron emission tomography (PET-FDG) is high, because of a good sensitivity (96%) and specificity (73%) [7]. However pulmonary nodules which are less than 1 cm in size or show ground glass opacities on CT cannot be evaluated accurately by PET [8].

The aim of this study was to evaluate prospectively the prevalence of pulmonary nodules coexisting in operable lung cancer, the rate and the probability of malignancy of these nodules.

Section snippets

Patients

All patients diagnosed with lung cancer are registered in a prospective database. Data from surgically treated patients diagnosed with NSCLC between 15/08/1998 and 15/08/2003 were retrospectively reviewed to identify patients presenting at least one pulmonary nodule coexisting with lung cancer on initial thoracic CT.

Preoperative evaluation and follow up

All patients presented histological proven NSCLC according to the World Health Organization guidelines and tumour stage was defined by the 7th TNM classification [2], [9].

Patient's characteristics

Between 15/08/1998 and 15/08/2003, 604 patients were diagnosed with NSCLC and 239 patients had complete resection. Seven of these patients were not included (five presented active pulmonary tuberculosis with multiple pulmonary nodular lesions, and data of two patients were incomplete).

Fifty-six patients (24%) presented at least one pulmonary nodule coexisting with NSCLC on initial thoracic CT (Fig. 1). No significant difference in age, gender, smoking status, histology or tumour stage was noted

Discussion

In patients with a potentially operable lung cancer, the diagnosis of coexisting small nodules of 1 cm or less is critical to avoid insufficient or excessive surgical procedures. Previous studies estimated the prevalence of pulmonary nodules in the global population between 8 and 51%, with a rate of malignancy of 1, 1–12% [10], [11], [12], [13], [14]. This disparity depends on the used CT methodology and the population study, particularly the percentage of smokers and the frequency of

Conflict of interest statement

None declared.

Acknowledgments

This work was supported by the Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, France and the Faculté de Médecine Université PARIS VI, France. We thank Eliane Bertrand for technical work.

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the lower zone with the paraesophageal [8] and pulmonary ligament [9] lymph nodes; the hilar and interlobar zone [10,11]; the peripheral zone [12–14].
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Coexisting pulmonary nodules in operable lung cancer: Prevalence and probability of malignancy

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Preoperative evaluation and follow up

Patient's characteristics

Discussion

Conflict of interest statement

Acknowledgments

Chest

J Thorac Oncol

Chest

Lung Cancer

Chest

Chest

Chest

Lancet

J Thorac Imaging

Clin Radiol