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Ann Thorac Surg 2004;78:752-753
© 2004 The Society of Thoracic Surgeons
Carlo Forlanini Hospital, The Thoracic Surgery Unit, Via Portuense 332, Rome 00149, Italy
e-mail: gcardillo{at}scamilloforlanini.rm.it
To the Editor:
We thank Dr Sortini and colleagues from the University of Ferrara for their comments on our article.
The first two questions refer to the same subject: the relationship between the need for thoracotomy in order to locate the pulmonary nodule and/the probability of a nodule to be malignant, and the high conversion rate of malignant lesions.
In our experience (429 cases) the need for thoracotomy for localizing the nodule proved to be a strong, statistically significant factor (univariate and multivariate analysis) in predicting the probability of a solitary pulmonary nodule (SPN) to be a neoplasm (OR 7.4; 95% CI 4.1–13.3; OR adjusted 6.6; 95% CI adjusted 3.2–13.2). The reason for this ratio between the location of a nodule and the risk of malignancy is related to the firm consistency of benign nodules (83.5% being hamartomas, 7.3% being tubercular lesions, and 5.7% being fibrous scars) compared with neoplasms (either non-small cell lung cancer or metastases). The slight difference in size between benign and neoplastic lesions (1.88 cm vs. 2.31 cm) did not alter this ratio.
Ultrasound or radio-guided techniques appear promising, although the low number of reported patients—13 in the experience of Dr Sortini and colleagues [1], and 18 in the experience of Santambrogio 1999 [2]—raises some doubt about their use on a wide scale.
The last question regards the high number of benign nodules resected in our series (379/429, 86.2%). Many surgeons consider operating on benign lesions to be a failure or a waste of time. We, on the contrary, believe that great importance should be given to the patients' sentiments: most patients prefer a quick and safe video-assisted thoroscopic operation rather than repeated computed tomographic scans and consequential anxiety.
We should never risk leaving any cancer in a patients' chest, even if this involves operating on many patients with resulting benign tumors. Furthermore, we remind our colleagues from Ferrara that the computer-aided diagnosis to distinguish benign from malignant SPN proposed by Shirashi and co-workers [3] represents an initial experience only. Finally, the assessment of the doubling time over a short period needs further improvement.
The 18-fluorodeoxyglucose positron emission tomographic scan will certainly help us in the decision making, even if in our published series we employed this procedure very rarely (1.8%).
References
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