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Invasive Diagnostic and Therapeutic Procedures

These guidelines are limited to the noninvasive management of incidentally detected nodules. The appropriate use of invasive diagnostic and therapeutic procedures is vitally important but depends greatly on available resources and expertise. As a general rule, transthoracic needle biopsy is an effective approach in experienced hands, but it has important limitations for very small nodules and ground-glass lesions due to potential problems with inadequate sampling and false-negative results (84–86).

Newer guided transbronchial tissue sampling techniques that use electromagnetic navigation and endobronchial ultrasonography-guided nodal sampling have greatly extended the role and accuracy of bronchoscopy for diagnosis and staging (87,88), while minimally invasive surgery with lung-sparing technique enables diagnosis and definitive treatment in selected patients (89–92).

Decisions regarding choice of procedure in any given case are best made in the context of a multidisciplinary conference, where the merits and limitations of each approach can be discussed (93).

Additional Considerations

Apical Scarring

Some degree of pleural and subpleural apical scarring is extremely common, and these scars may have a nodular appearance, especially when viewed on transverse images. Certain features are suggestive of a scar, including a pleural-based configuration, an elongated shape, straight or concave margins, and the presence of similar adjacent opacities. Review on coronal or sagittal reconstructed images can be helpful in the characterization of such findings. Similar considerations apply to subpleural opacities in other locations, including the costophrenic angles, where focal scarring is also common.

Perifissural Nodules

Perifissural nodule is a term used to describe small solid nodules that are commonly seen on CT images adjacent to pleural fissures and that are thought to represent intrapulmonary lymph nodes. Similar nodules can occur in other locations, usually adjacent to a pleural surface. Typically, these are triangular or oval on transverse images, and they have a flat or lentiform configuration in sagittal or coronal reconstructions and a fine linear septal extension to the pleura. When small nodules have a perifissural or other juxtapleural location and a morphology consistent with an intrapulmonary lymph node, follow-up CT is not recommended, even if the average dimension exceeds 6 mm. In one study of patients in the NELSON Lung Cancer Screening Trial, 20% of nodules were classified as perifissural, and 16% of these grew during the study; however, none were malignant (94). However, perifissural or juxtapleural location does not in itself reliably indicate benignancy, and the specific nodule morphology must be considered (95, 96