Managing the small pulmonary nodule discovered by CT.

Objectives: To review the Early Lung Cancer Action Project experience and the medical literature from 1993 to 2003 on detection of the small, noncalcified pulmonary nodule by CT in order to formulate a management algorithm for these nodules.

Design: Prospective noncomparative study of smokers without prior malignancy and a review of the medical literature of CT screening of lung cancer.

Interventions: Chest CT and, where appropriate, CT observation for nodule growth, antibiotics, CT-guided fine-needle aspiration (FNA) biopsy, fiberoptic bronchoscopy, and video-assisted thoracoscopic surgery (VATS).

Results: The following factors influence the probability of malignancy in a CT-detected, small, noncalcified pulmonary nodule: size, change in size, age, smoking history, density, number of nodules, gender, circumstance of the CT, spirometry, occupational history, and endemic granulomatous disease. The two diagnostic techniques most useful in evaluating the CT-detected, small, noncalcified nodule are short-term observation of nodule growth by CT and CT-guided FNA. Due to small nodule size and the frequent finding of nonsolid or part-solid nodules, positron emission tomography, fiberoptic bronchoscopy, and VATS were less useful.

Conclusions: Pulmonologists are frequently asked to evaluate the CT-detected, small, noncalcified nodule invisible on standard chest radiography. Immediate biopsy is justified if the likelihood of cancer is high, but if that likelihood is low or intermediate, a period of observation by CT is appropriate. VATS or thoracotomy are rarely necessary for a diagnosis of lung cancer in the CT-detected small pulmonary nodule.