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Ann Thorac Surg 1997;64:303-306
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Incidence of Lung Nodules Found in Patients Undergoing Lung Volume Reduction

Divisions of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois and St. Louis University Medical Center, St. Louis, Missouri

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The risk of lung cancer is increased with cigarette smoking and obstructive lung disease. Patients having a lung volume reduction operation represent a high-risk population for cancer.

Methods. Between March 1994 and December 1996, 281 patients underwent a lung volume reduction operation. All had severe obstructive lung disease with hyperinflation. The incidence of lung nodules and their management were addressed.

Results. Of the 281 patients, 39.5% had at least one lung nodule identified. Fifty-two nodules had typical benign calcification patterns. Of the remaining nodules, 78 were resected and 20 were followed up. Seventeen nodules resected were cancerous, of which 13 were primary lung cancers. Of the resected nodules there were 28 nodules not identified by the preoperative radiologic evaluation.

Conclusions. Nodules are frequently seen in patients undergoing lung volume reduction operations. The overall incidence of cancer was 6.4%, with several only identified in the pathologic examination. Survival at short follow-up has been excellent for those with primary lung cancer. Nodules seen in this group of patients should be aggressively diagnosed and managed.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 306.

Lung cancer is presently the most frequent malignant cause of death in men and women. A clear correlation between smoking as well as chronic obstructive lung disease and this cancer exists [1]. Hence, the presentation of patients with severe obstructive lung disease, an extensive smoking history, and a new lung nodule may create difficult clinical decisions. The recent emergence of surgery to improve the breathing and function of patients with severe emphysema resulted in the evaluation of a group of patients already at risk for the development of lung cancers [2–5]. Debates regarding how best to diagnose and manage incidental lung nodules became frequent and were the impetus for our reviewing our experience with nodules in patients being evaluated for lung volume reduction surgery (LVRS).

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between March 1994 and December 1996, 281 patients underwent LVRS. All patients met our previously published criteria, which included severe hyperinflation with forced expiratory volumes in 1 second (FEV₁) that were less than 30% predicted [5]. Institutional review board approval for the study of LVRS was obtained at the Divisions of Cardiothoracic Surgery, Southern Illinois University School of Medicine and the Medical Center, St. Louis University. Patients underwent a rigorous preoperative evaluation, which included physical examination, chest roentgenogram, chest computed tomography (CT), echocardiography, pulmonary function with arterial blood gases, ventilation perfusion scans, and exercise testing.

The LVRS was performed unilaterally using video-assisted techniques (n = 260) or bilaterally via median sternotomy (n = 20) or thoracoscopy (n = 1). In unilateral procedures the side with the most disease was selected for operation based upon the ventilation perfusion and CT scans. The presence of lung nodules could influence this decision.

All lung nodules identified on radiologic examination preoperatively or identified in resected specimens were recorded. Patient follow-up has been completed to follow all nodules not resected.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Lung volume reduction was performed in all patients either by stapled techniques (n = 278) or using the Nd:yttrium-aluminum garnet laser (n = 3). There were 190 men (68%) and 91 women (32%) with a mean age of 66.3 years and an average of 53.9 pack-years of cigarette smoking. Presenting symptoms included dyspnea (100%), fatigue (58%), cough (29%), recent weight loss (16%), and chest pain (4%). One patient complained of hemoptysis. Exposure to asbestos, silicon, or industrial fumes was reported in 80 (28.5%) (Tables 1, 2). The mean FEV₁ was 26.2% predicted, residual volume 235%, diffusing capacity of carbon monoxide, 43.8%, and 6-minute walk distance 792 ft.

There were 20 lesions identified on CT that were not calcified and not resected. One of the nodules had a preoperative needle biopsy, which showed it to be benign. Eighteen were thought to be benign or inaccessible radiographically and followed up with repeat scans. One of the lesions was planned to be resected; however, it could not be identified at sternotomy due to adhesions and its deep location in the right lower lobe. Upon follow-up this proved to be a squamous cell cancer and the patient died at 18 months of follow-up. The remaining 19 nodules were unchanged during 18.5 months of follow-up.

Seventy-eight nodules were resected, of which 61 (78.2%) were benign and 17 (21.8%) neoplastic:

The size of the primary lung malignancies ranged from 0.5 to 3.2 cm with a mean of 1.6 cm (Table 3). The entire group of 281 LVRS patients had 14 (5.0%) in-hospital deaths.

Of the neoplastic lesions resected 3 were identified by CT scan only, 5 by chest roentgenogram and CT, 4 in the operating room (not seen radiographically), and 5 identified incidently in the pathologic specimen. The average size of the primary lung cancers not seen radiographically was only 0.76 cm. All patients underwent wedge resection for their malignancies and had node dissections when the malignancy was recognized. The primary lung cancers resected that were not identified preoperatively (n = 4) have been followed up an average of 15.8 months with no evidence of recurrence.

When analyzed separately, the group with neoplastic lesions had similar symptoms and industrial exposures. Their smoking history was not significantly different although slightly longer for those with cancer (57.9 versus 53.7 pack-years) (Table 1 and 2).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients who may benefit from LVRS represent a high-risk group for malignancy due to their smoking history as well as severe obstructive lung disease. Studies have identified an increased risk with lower FEV₁s over that incurred by cigarette smoking alone [1]. Although in the general population symptoms such as dyspnea, increased cough, wheezing, and recent weight loss have been associated with an increased chance of malignancy this is not the case in severely emphysematous patients. There were no symptoms or exposures that helped to select which of our patients had a neoplastic process.

Lung nodules are frequent in this group of patients (111/281 = 39.5%), which creates diagnostic dilemmas. If the calcified nodules are excluded the risk of a resected nodule being malignant in our population was 27.3% (18/66), and this includes several very small lesions. The average size of these neoplastic nodules in our group was 1.6 cm. The overall incidence of malignancy in the 281 patients was 6.4% (n = 18). This number is close to that seen in a similar group of patients from the University of Pittsburgh series at 7.8%. In their series they identified 1 patient with a microscopic adenocarcinoma in the pathologic specimen [6]. They also resected 2 carcinoids, 1 squamous dysplasia, and 1 chemodectoma that were unsuspected at the time of LVRS only to be seen in the pathologic examination. We identified 14 unsuspected nodules in the pathologic examination (incidence of 5.0%). Nine of these were benign (4 granulomas, 2 bone marrow emboli, 1 squamous cyst, 1 histiocytosis) and 5 neoplastic (2 adenocarcinomas, 1 metastatic renal cell, 1 bronchoalveolar carcinoma, 1 carcinoid). This reconfirms the need for a high level of suspicion for underlying malignancy in this group of patients.

Interestingly, nine of the seventeen resected neoplasms were not seen on the preoperative radiologic evaluation. A careful examination of the lung is important as 14 nodules were identified intraoperatively of which four were malignant including two primary lung cancers. All of the nodules that were resected but not seen preoperatively were removed using video-assisted techniques.

There has been debate about screening techniques in high-risk groups for lung cancer [7–9]. This group of patients clearly represents a high risk group, 66.7 years of age, 53.9 pack-years of smoking, and severe obstruction by disease (mean FEV₁ = 26%). Seventeen percent (3/18) of the neoplasms resected were identified only by CT scan and not seen on chest roentgenogram. This study was not designed to address screening issues; however, it is clear that CT scans will identify more cancers than chest roentgenograms alone. Sputum cytology was not used; however, its main utility is in identifying squamous cell cancers and all four of the resected squamous cell cancers were identified by radiographic means. Thus it is unlikely that sputum cytology would identify more lung cancers than CT scan alone. Because all of these patients underwent LVRS, all but 20 noncalcified nodules identified preoperatively were resected. One of the 20 nodules followed up (5%) proved to be malignant.

Our present follow-up is not quite long enough to make confident statements regarding treatment or survival. Of the 13 primary lung cancers 10 were pathologic stage I, 2 were stage II, and 1 stage IV. Cancer freedom is 90% in stage I patients at 13.5 months, 100% in stage II at 15.0 months, and 0% in the single stage IV patient. All resections were wedge resections due to poor pulmonary reserve, and to date there has been one local recurrence in a patient who died with distant metastases. It is possible that lobectomy could be performed in selected patients if the malignancy is located in a lobe that is largely destroyed with emphysema; however, in most cases a wedge resection will be the largest resection that will be tolerated.

We recommend a tissue diagnosis for all noncalcified nodules. There is a small subset with deep, relatively inaccessible lesion, which present the greatest difficulty. Deep lesions less than 1 cm in size may be followed up carefully with repeat CT scans. Our experience in following up nodules resulted in 5.3% (1/19) ultimately being malignant.

The four primary lung malignancies identified in the operating room have an average size of 0.76 cm and 100% tumor-free survival at a mean of 15.8 months. We were particularly concerned about the cancers identified at pathologic examination, believing that they may harbor other unsuspected cancers; however, to date they have done well.

We would conclude from this experience that nodules are frequent in this group of patients (39.5%) and a significant number of these patients will harbor malignancies (6.4%). Some will only be identified by CT scan, operative examination, or pathologic examination. Further attention to potential screening strategies seems warranted for this group with severe obstructive disease. Recently we have begun to use nodule enhancement studies in the CT scan to help stratify the risk of a nodule being malignant; however, the results are still early [10]. In the short term, limited resection has served as a viable treatment modality with the recognized potential for local recurrence. We recommend an aggressive attitude toward diagnosis and treatment of noncalcified lung nodules in patients being evaluated for LVRS.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Address reprint requests to Dr Hazelrigg, SIU School of Medicine, 800 N Rutledge, PO Box 19230, Springfield, IL 62794-9230.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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6. Pigula FA, Keenan RJ, Ferson PF, Landreneau RJ. Unsuspected lung cancer found in work-up for lung reduction operation. Ann Thorac Surg 1996;61:174–6.[Abstract/Free Full Text]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stephen R. Hazelrigg Mitchell J. Magee Keith S. Naunheim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hazelrigg, S. R. Articles by Naunheim, K. S. Search for Related Content PubMed PubMed Citation Articles by Hazelrigg, S. R. Articles by Naunheim, K. S. Related Collections Related Article