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High-risk solid pulmonary nodule with non-diagnostic percutaneous biopsies — SCE Respiratory MCQ

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HardPulmonary NoduleHigh-risk solid pulmonary nodule with non-diagnostic percutaneous biopsiesSCE Respiratory

A 70-year-old man with a 45-pack-year smoking history is referred after CT shows a solitary 16 mm solid, spiculated right upper-lobe pulmonary nodule. The Brock malignancy probability is 28%. PET-CT demonstrates intense FDG uptake in the nodule, with no nodal or distant uptake; the recalculated Herder probability is 82%. Two technically satisfactory CT-guided core biopsies have shown fibrosis and normal lung without a specific benign diagnosis. The nodule is peripheral and amenable to wedge excision. He has ECOG performance status 0, predicted postoperative FEV1 and TLCO above 60%, and no cardiac contraindication to lobectomy. Following discussion, he wishes to pursue definitive treatment. Which management strategy is most appropriate?

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Correct answer: C — Undertake VATS wedge excision with frozen section, proceeding to lobectomy with nodal sampling if malignant

Explanation lettering: E = shown as A · A = shown as B · B = shown as D · D = shown as E

The post-PET Herder probability is 82%, exceeding the BTS 70% threshold at which surgical resection is the favoured strategy in a patient fit for surgery. The two non-malignant biopsies do not reduce this risk to a surveillance range: BTS advises interpreting a negative lung biopsy in the context of the pre-test probability. Neither biopsy established a specific benign diagnosis, and repeated sampling has not resolved the radiological–pathological discordance. Because the peripheral nodule is amenable to wedge excision, VATS diagnostic wedge resection with intraoperative frozen section is appropriate. If malignancy is confirmed, lobectomy can be completed during the same anaesthetic, with hilar and mediastinal nodal assessment. A is inappropriate because surveillance is primarily favoured when calculated malignancy risk is below 10%. B is initially plausible because BTS permits repeat percutaneous biopsy when risk remains high, but two technically satisfactory attempts have already failed and the result is no longer required to determine management. D risks lobectomy for benign disease despite the feasibility of frozen-section confirmation. E is an accepted option for a high-probability nodule when surgery is declined or contraindicated, but this patient is operable and has chosen surgery.

Reference: British Thoracic Society guidelines for the investigation and management of pulmonary nodules (August 2015) — https://www.brit-thoracic.org.uk/document-library/guidelines/pulmonary-nodules/bts-guidelines-for-the-investigation-and-management-of-pulmonary-nodules/ Lung cancer: diagnosis and management (NG122) — Management (Published 28 March 2019; last updated 8 March 2024) — https://www.nice.org.uk/guidance/ng122/chapter/Management