Clinical and radiological findings in relation to histopathological results of pulmonary nodule resections

Year 2025, Volume: 38 Issue: 2, 121 - 128, 30.05.2025

Shahab Ghivi Sehnaz Olgun , Caner Çınar , Cansu Yıldız Derya Kocakaya , Nezih Onur Ermerak Emine Bozkurtlar , Özlem Demircioğlu , Hüseyin Arıkan , Feyza Şen , Özlem Ercelep , Cagatay Çimşit , Emel Eryüksel , Sait Karakurt , Bedrettin Yıldızeli

Abstract

Objective: Despite technological advances and well-defined clinical scoring, pulmonary nodule management still remains a
controversial issue. Due to conflicting situations, many patients are referred to reference centers for evaluation.
The aim of this study is to reveal the relationship between clinical, radiological, and histopathological findings of patients with
surgically resected pulmonary nodules who were followed-up by a multicisciplinary team at a 3rd level reference center.
Patients and Methods: Patients, who were followed-up by the multidisciplinary team and underwent surgical resection per the
multidisciplinary team’s recommendations between October, 2018 and December, 2021, were included in the study.
Results: A total 209 eligible patients were identified. 133 (63.6%) patients had solitary pulmonary nodules, 61 (29.3%) patients had
2-4 nodules and 15 (7.2%) patients had 5 nodules, 29 (13.9%) of patients had the largest nodule less than 1 cm diameter. According
to nodule nature, solid nodules were detected in 154 (73.7%), subsolid in 43 (25.6%) and ground glass in 12 (5.7%) patients and
malignant histopathology was detected in 107 (69.5%), 37 (86%) and in 8 (66.6%) respectively. Among twenty-nine (13.9%) patients
with subcentimetric nodules, 16 (61.5%) patients were diagnosed with malignancy. Thirty-three (15.8%) patients showed no avidity
in PET-CT scan of whom 4 (12.1%) were diagnosed with adenocarcinoma metastasis. Totally, 185 (88.5%) surgical procedures were
performed by video assisted thoracic surgery (VATS), 24 (11.5%) patients needed thoracotomy without mortality. Multivariate analysis
showed that previous malignancy history (p<0.019), diameter of a nodule (>1 cm) (p<0.027), emphysema in lung parenchyma
(p<0.003), high Brock risk score (p<0.011), high Herder risk score (p<0.001), increased avidity of PET scan (p<0.001) were risk factors
for malignancy.
Conclusion: Clinical scoring, radiological findings and patient history are important factors in the prediction of malignancy, but
multidisciplinary follow-up, especially, in conflicting cases plays a critical role in terms of detecting malignancy. VATS is a safe surgical
method that can be used for definitive diagnosis in these patients.

Keywords

Pulmonary nodule , Malignancy prediction , PET-CT , VATS

References

• Harzheim D, Eberhardt R, Hoffmann H, Herth FJ. The solitary pulmonary nodule. Respiration 2015;90:160-72. doi:10.1159/000430996.
• Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132(3 Suppl):94S-107S. doi:10.1378/chest.07-1352.
• Choi HK, Ghobrial M, Mazzone PJ. Models to estimate the probability of malignancy in patients with pulmonary nodules. Ann Am Thorac Soc 2018;15:1117-26. doi:10.1513/ AnnalsATS.201803-173CME.
• Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med 1997;157:849-55. doi:10.1001/ archinte.1997.004.40290031002.
• Gould MK, Ananth L, Barnett PG. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest 2007;131:383-8. doi:10.1378/ chest.06-1261.
• McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013;369:910-9. doi:10.1056/NEJMoa1214726.
• Herder GJ, van Tinteren H, Golding RP, et al. Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography. Chest 2005;128:2490-6. doi:10.1378/chest.128.4.2490.
• Al-Ameri A, Malhotra P, Thygesen H, et al. Risk of malignancy in pulmonary nodules: a validation study of four prediction models. Lung Cancer 2015;89:27-30. doi:10.1016/j. lungcan.2015.03.018.
• Ost DE, Gould MK. Decision making in patients with pulmonary nodules. Am J Respir Crit Care Med 2012;185:363- 72. doi:10.1164/rccm.201.104.0679CI.
• Radswiki T, Sergev O, Khalighinejad P, et al. Fleischner Society pulmonary nodule recommendations. Reference article. Radiopaedia.org Accessed on: 17 March, 2025. doi:10.53347/ rID-13541.
• Charlson ME, Carrozzino D, Guidi J, Patierno C, Fava GA. Charlson Comorbidity Index: a critical review of clinimetric properties. Psychother Psychosom 2022;9:8-35. doi:10.1159/000521288.
• Zhao H, Knipe H, Rasuli B, et al. Brock model for pulmonary nodules. Reference article. Radiopaedia.org Accessed on 17 March, 2025. doi:10.53347/rID-50917.
• Little D, Campos A, Knipe H. Herder risk model. Reference article. Radiopaedia.org Accessed on: 17 March, 202. doi:10.53347/rID-78064.
• Massion PP, Antic S, Ather S, et al. Assessing the accuracy of a deep learning method to risk stratify indeterminate pulmonary nodules. Am J Respir Crit Care Med 2020;202:241- 9. doi:10.1164/rccm.201.903.0505OC.
• Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc 1999;74:319-29. doi:10.4065/74.4.319.
• Yang X, Wisselink HJ, Vliegenthart R, et al. Association between chest CT–defined emphysema and lung cancer: a systematic review and meta-analysis. Radiology 2022;304:322- 30. doi:10.1148/radiol.212904.
• Schultz EM, Sanders GD, Trotter PR, P et al. Validation of two models to estimate the probability of malignancy in patients with solitary pulmonary nodules. Thorax 2008;63:335-41. doi:10.1136/thx.2007.084731.
• Perandini S, Soardi GA, Larici AR, et al. Multicenter external validation of two malignancy risk prediction models in patients undergoing 18F-FDG-PET for solitary pulmonary nodule evaluation. Eur Radiol 2017;27:2042-6. doi:10.1007/ s00330.016.4580-3.
• Alberts WM, American College of Chest Physicians. Diagnosis and management of lung cancer executive summary: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132(3 Suppl):1S-19S. doi:10.1378/chest.07-1860.
• Evangelista L, Panunzio A, Polverosi R, Pomerri F, Rubello D. Indeterminate lung nodules in cancer patients: pretest probability of malignancy and the role of 18F-FDG PET/ CT. AJR Am J Roentgenol 2014;202:507-14. doi:10.2214/ AJR.13.11728.
• Imperatori A, Rotolo N, Gatti M, et al. Peri-operative complications of video-assisted thoracoscopic surgery (VATS). Int J Surg 2008;6 Suppl 1:S78-81. doi:10.1016/j. ijsu.2008.12.014.
• Lillington GA. Management of solitary pulmonary nodules. Postgrad Med 1997;101:145-50. doi:10.3810/pgm.1997.03.177.
• Jancovici R, Lang-Lazdunski L, Pons F, et al. Complications of video-assisted thoracic surgery: a five-year experience. Ann Thorac Surg 1996;61:533-7. doi:10.1016/0003-4975(95)01060-2.
• Downey RJ. Complications after video-assisted thoracic surgery. Chest Surg Clin N Am 1998;8:907-17.
• Yim AP, Liu HP. Complications and failures of videoassisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61:538-41. doi:10.1016/0003- 4975(95)01097-1.
• Allen MS, Deschamps C, Jones DM, Trastek VF, Pairolero PC. Video-assisted thoracic surgical procedures: the Mayo experience. Mayo Clin Proc 1996;71:351-9. doi:10.4065/71.4.351.
• Inderbitzi RG, Grillet MP. Risk and hazards of videothoracoscopic surgery: a collective review. Eur J Cardiothorac Surg 1996;10:483-9. doi:10.1016/s1010-7940(96)80412-x.
• Mazzone PJ, Lam L. Evaluating the patient with a pulmonary nodule: a review. JAMA 2022;327:264-73. doi:10.1001/ jama.2021.24287.
• Kakinuma R, Muramatsu Y, Kusumoto M, et al. Solitary pure ground-glass nodules 5 mm or smaller: frequency of growth. Radiology 2015;276:873-82. doi:10.1148/radiol.201.514.1071.
• Sawada S, Yamashita N, Sugimoto R, Ueno T, Yamashita M. Long-term outcomes of patients with ground-glass opacities detected using CT scanning. Chest 2017;151:308-15. doi:10.1016/j.chest.2016.07.007.
• Ginsberg MS, Griff SK, Go BD, Yoo HH, Schwartz LH, Panicek DM. Pulmonary nodules resected at video-assisted thoracoscopic surgery: etiology in 426 patients. Radiology 1999;213:277-82. doi:10.1148/radiology.213.1.r99oc08277.