How to choose a treatment plan for lung nodules?

Author: Gao Xuehan Peking Union Medical College Hospital

Zhou Mengxin Peking Union Medical College Hospital

Reviewer: Guo Chao, deputy chief physician, Peking Union Medical College Hospital

Li Danqing, Chief Physician, Peking Union Medical College Hospital

Pulmonary nodules refer to abnormal lesions (<3 cm) in the lungs found by CT scans. They may be benign or malignant. When faced with pulmonary nodules, doctors will develop personalized treatment plans based on the nature of the nodules and the specific conditions of the patient. This article will introduce several treatment options for pulmonary nodules.

Figure 1 Copyright image, no permission to reprint

1. Treatment of benign nodules

Benign nodules in the lungs mainly include infectious lesions and benign tumors.

1. Treatment of infectious lesions

For infectious lesions, further diagnosis and targeted anti-infective treatment are usually required in the respiratory department. Old infections may only require regular observation, while special infections such as fungal infections or tuberculosis may require surgical treatment if anti-infective treatment is limited.

2. Treatment of benign tumors

For benign lung tumors, regular observation is usually an option. However, if the tumor grows larger, affects lung function, or shows signs of malignancy, it is necessary to choose diagnosis and treatment options such as surgery depending on the situation.

2. Treatment of nodules with malignant tendencies

Malignant nodules mainly include primary lung malignant tumors and lung metastatic cancer.

1. Treatment of primary lung malignant tumors

For primary lung cancer, treatment options include regular observation, surgery, medication, and other treatments.

(1) Regular observation: For nodules that are considered to have a malignant tendency and grow slowly, i.e., indolent nodules, they can be temporarily observed and treated. For nodules with indolent growth characteristics that are discovered for the first time, it is recommended to review the chest CT after 3 months; if there is no change, the review cycle can be extended to 6 months or longer. The advantage of regular observation is that the patient does not need to undergo surgical trauma for the time being; and if the nodule shrinks or disappears during the follow-up process, the nodule is very likely to be a benign lesion. However, regular observation may become a psychological burden for some patients, and in severe cases it may even affect the normal work and life of some patients.

(2) Surgery: According to the doctor's judgment, surgical treatment should be considered for resectable solid nodules with malignant signs, or partially solid nodules and pure ground glass nodules with growth signs (clinical stage I to IIIa). Surgery has both diagnostic and therapeutic effects and is effective for resectable lung malignancies.

The preferred surgical method is usually video-assisted thoracic surgery (VATS) or robot-assisted thoracic surgery (RATS), which is often called "minimally invasive" surgery. However, "minimally invasive" here only refers to a small surgical incision and a shortened operation time (both the surgical incision and the operation time are compared with traditional thoracotomy), while the surgical scope in the chest cavity will not be reduced. Therefore, surgical risks and postoperative damage to lung function are objectively present, and minimally invasive surgery is not equal to "minor surgery."

The standard surgical procedure for malignant lung tumors is to remove the lobes where the tumor is located, and to simultaneously clear the hilar and mediastinal lymph nodes on the same side. However, with the advancement of technology and the increase in the detection rate of early lung cancer and precancerous lesions, sublobar resection (i.e., only part of the lobe is removed instead of the entire lobe, such as wedge resection, segmentectomy, and subsegmentectomy) is becoming more and more widely used. The specific surgical plan needs to be decided by the thoracic surgeon after a comprehensive assessment of the patient's condition. Aspects that need to be considered in determining the surgical method include, but are not limited to: the nature of the nodules, the number of nodules, the location of the nodules, the patient's health condition, etc. For some complex or high-risk surgeries, thoracotomy can be selected.

After surgery, the entire treatment process is not complete. If postoperative pathological examination confirms that the nodule is malignant, subsequent treatment or follow-up is required based on the type and severity (i.e., stage) of the tumor.

Figure 2 Video-assisted thoracic surgery (VATS), robot-assisted thoracic surgery (RATS), open chest surgery and electromagnetic navigation bronchoscopy-assisted surgery (copyrighted images are not authorized for reproduction)

(3) Drugs and other treatment options: In addition to surgical treatment, there are a variety of treatment options for lung malignancies, such as chemotherapy, radiotherapy, targeted therapy, immunotherapy, radiofrequency ablation, and proton therapy. These treatment options are usually suitable for patients with advanced or locally advanced disease who are unable to undergo surgery (or refuse surgery), and as perioperative adjuvant therapy.

Conditions that cannot be operated on include:

a. Consider advanced lesions: If the doctor determines that the patient has lost the opportunity for surgery (such as distant metastasis, nodules invading surrounding large blood vessels or other organs) based on imaging features and various auxiliary examinations, surgical treatment will not be considered for the time being. The reason is that surgery only increases the patient's trauma and cannot achieve the ideal treatment effect. The next step is to obtain tumor tissue for pathological examination by puncture and other methods, and determine the treatment plan based on the pathological results. If these treatment plans are effective and the tumor shrinks, the thoracic surgeon can evaluate the difficulty, risks and benefits of the operation and decide whether to perform surgical treatment.

b. The patient's general condition does not allow surgery: For patients with severe systemic diseases, such as severe coronary heart disease, chronic obstructive pulmonary disease, etc., surgery may cause these diseases to worsen, and in severe cases may endanger the patient's life. In this case, surgery is not considered for the time being. The next step is to visit the corresponding department to actively control the systemic disease and decide whether to undergo surgery through re-evaluation. However, if the patient's systemic disease cannot be well controlled, it is also necessary to clarify the pathology and decide on the next treatment plan based on the pathological results.

2. Treatment of lung metastases

Another type of malignant lung nodules is lung metastasis, which is the metastasis of malignant tumors in other parts of the body. The treatment of this type of nodules is mainly to treat the primary tumor.

Summarize

Depending on the nature of the nodule, the doctor will give a recommended treatment plan, including regular observation, surgery, drug therapy, etc. The specific plan should be a personalized comprehensive treatment based on the patient's specific situation.

References

[1]FREIMAN MR, CLARK JA, SLATORE CG, et al. Patients' knowledge, beliefs, and distress associated with detection and evaluation of incidental pulmonary nodules for cancer: results from a multicenter survey[J]. J Thorac Oncol, 2016, 11:700-708.

[2]GOLDSTRAW P, CHANSKY K, CROWLEY J, et al. The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. J Thorac Oncol, 2016, 11:39-51.