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By Louis Neipris, M.D., Staff Writer, myOptumHealth

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Each year about 150,000 people in the U.S. have a routine chest x-ray only to learn they have a lung nodule, or pulmonary nodule. After hearing those words it may seem that life revolves around that small spot on your lung. Most of the time, spots seen on x-ray are benign, or noncancerous, lung nodules.

What is a pulmonary nodule?

A lung nodule is a small mass of tissue that may be seen on a chest x-ray. Your doctor may call it a solitary pulmonary nodule. Most do not cause symptoms. Most are not cancer, but are benign growths often caused by infections or the scars left by past infections.

Some, though, may be early-stage cancer. The chance a nodule is cancerous increases if you have a history of smoking or other risk factors for lung cancer.

Imaging tests

Your doctor will compare any earlier chest imaging studies (x-ray or CT scans) with the most recent one to see if the nodule was present before and whether it has grown or changed in any way. If the nodule has changed in shape or size, more tests will likely be needed to see if it is cancer.

Your options: observe or have further testing

This important choice may seem like a decision that your doctor should make. But in some cases, there may not be a clear-cut answer about how to go forward. You will need to take part in this very important decision. You may need to balance the pros and cons of whether to monitor the nodule for a period of time with x-ray studies or have further tests.

• Monitoring. Your doctor may recommend a period of watching and waiting if:
  
  • No change is seen when comparing earlier studies or the nodule is seen for the first time and you are a low risk for lung cancer. This usually means follow-up chest CT scans, the first after three months. If after two years of follow-up the nodule hasn't grown, it is usually considered benign.

Other reasons to observe:

•  
  • The nodule looks benign on CT scan.
  • The nodule is probably due to an infection.
  • Surgery is too risky due to medical problems or location of the nodule.
• Have a biopsy. In some cases your doctor will recommend a biopsy to determine whether it might be cancer:
  • Comparison of current to old films shows that the nodule has grown.
  • A nodule is seen for the first time and you have risks for lung cancer (history of smoking).
  • The nodule looks cancerous on CT scan.
• Further noninvasive testing. A special imaging test called a positron emission tomography (PET) scan may be suggested to see if the nodule is suspicious for cancer. This may help determine if a biopsy is needed and, if so, what kind.

Biopsy

A biopsy is a test in which a sample of tissue is removed and sent to the lab for examination. A lung biopsy can be done by:

• Transthoracic needle biopsy. In this procedure a needle is used to penetrate the chest wall and remove a sample tissue. An x-ray is used to guide the needle to the nodule.
• Bronchoscopy. Here, a long flexible lighted instrument is passed down a main airway. When the nodule is found, a tissue sample can be taken for diagnosis.
• Video assisted thoracic surgery (VATS). In some cases, surgery needs to be done to perform a biopsy. It can often be done by a limited surgery called VATS. In this procedure two to four openings are made between the ribs through which tissue can be removed. A tiny video camera is passed into one opening and guides the surgeon to the nodule. Instruments are passed through another opening to remove the nodule.
• Major lung surgery. This is sometimes needed if the nodule is large or located in a place that cannot be reached by VATS.

Observing: pros and cons

Pros

• You do not have a biopsy, so you don't face the risks of this procedure.
• Most nodules are not cancerous, so you may be able to observe for a while before seeking further tests or treatment.

Cons

• You may worry that you have cancer during the watchful waiting period.
• You may have cancer and observing would delay treatment. The delay would most likely be minimal because your doctor will monitor the nodule closely.

Biopsy: pros and cons

Pros

• You can lessen your anxiety by finding out one way or another.
• You can get treatment right away if it is cancer.

Cons

• Having a biopsy has some risks, including bleeding, infection and a punctured lung.
• In some cases, the surgeon is not able to get tissue in a biopsy and lung surgery must be done.

What is important to me?

Other things to consider:

• Think about your personality. If you tend to worry, you may want to have the biopsy to know the answer.
• You might be more nervous about having a biopsy. If you are comfortable with waiting and willing to have scheduled x-rays, watching and waiting might be your best bet.
• Your doctor might strongly suggest one alternative over the other.
• Get involved with decision-making. Compare surgeons and find the one with the most experience.
• Rely on support from family and friends. Find someone you trust to help you sort through this decision.

View the original Pulmonary nodule: could it be lung cancer? article on myOptumHealth.com 

SOURCES:

• American College of Chest Physicians. Lung cancer guides. What if I have a spot on my lung? Do I have cancer? Accessed: 08/13/2009

• Savage C, Walser EM, Schnadig V, Woodside KJ, Ustuner E, Zwischenberger JB. Transthoracic image-guided biopsy of lung nodules: when is benign really benign? Journal of Vascular and Interventional Radiology. 2004;15:161-164.

• Klein JS, Braff S. Imaging evaluation of the solitary pulmonary nodule. Clinics in Chest Medicine. 2008;29(1):15-38.

• Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: When is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3):108s-130s.

• National Lung Health Education Program. Solitary pulmonary nodule. Accessed: 08/13/2009

• Smythe WR, Reznik SI, Putnam JB Jr. Solitary pulmonary nodule. In Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th edition. Philadelphia, PA: Saunders Elsevier; 2008.