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Ann Thorac Surg 2004;78:752
© 2004 The Society of Thoracic Surgeons
Department of Surgical, Radiological and Anaesthesiological Sciences, University of Ferrara, Italy, Corso Giovecca 203, 44100 Ferrara, Italy
e-mail: sors{at}libero.it
To the Editor:
In response to the article of Cardillo and colleagues [1], we would like to express our opinion about the probability of malignancy of solitary pulmonary nodules (SPNs). We congratulate the authors on the results obtained in their study; however, we believe there are a few negative aspects in their article.
First, the need for thoracotomy to locate the nodule cannot be correlated to the histology of pulmonary lesions, whereas size of the lesion, age of the patient, and history of previous cancer are related to the probability of SPNs malignancy [2]. In order to locate the SPNs, the authors performed only an instrumental palpation of the lung surface. However, there are several thoracoscopic techniques (eg, ultrasound, radio-guided) to locate SPNs that can, in experienced hands, avoid the need for thoracotomy [3–5]. Specifically, ultrasound is safe, risk-free, quick, and reliable. In addition, a complete intraoperative scan of the lung can be performed, which is useful not only to locate the nodules, but also to study the surrounding structures such as vessels, bronchi, and lymphnodes. Thus, the authors could have used ultrasound or radio-guided thoracoscopy in order to avoid unnecessary thoracotomies.
Second, it is difficult to explain why malignant SPNs required a higher conversion rate for diagnosis compared with benign lesions, given the greater mean size of the malignant SPNs in their series (2.31 cm vs 1.88 cm). Nodules that are difficult to localize tend to be deep, small, or both [6], and even benign lesions if small and deep require open conversion. Moreover, to locate SPNs intraoperatively, it is also important to know the depth as well as the dimension of the pulmonary lesion.
Finally, Cardillo and collegues presented a very high rate of benign SPNs (85%) in their series compared with other authors [2, 6]. Recently, a computer-aided diagnosis and a serial computed tomographic (CT) scans algorithm have been proposed to distinguish benign from malignant SPNs [7, 8]. The computer-aided program can predict the histology of SPNs by means of a simple chest roentgenogram, while the serial CT scans algorithm enables volumetric modelling and may permit accurate assessment of doubling time over a relatively short period (20 days) [2, 7]. We really think, along with other authors, that is mandatory to avoid, whenever possible, a surgical operation in a patient with a benign lesion [9].
References
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