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J Thorac Cardiovasc Surg 2005;129:1196
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Difficulty of early diagnosis in patients with solitary pulmonary nodule

D. Sortini, MD, K. Maravegias, MD, A. Sortini, MD

Department of Surgical, Radiologic, and Anesthesiologic Sciences, University of Ferrara, Ferrara, Italy

To the Editor:

We would like to express our opinion about the article by Crestanello and associates.1 First, we congratulate them for the well-performed study contributing to the early diagnosis of lung cancer. Because an early diagnosis is likely to lead to better survival, it is necessary to find a useful, easy, low-cost method to obtain better survival in patients with non–small cell lung cancer. But the results of this study seem to indicate that low-dose computed tomography (CT) screening is not the gold standard to obtain an early diagnosis. Low-dose CT screening in a well-selected group of patients detects a large number of indeterminate pulmonary nodules, but the diagnosis is not always made in the early stage; 7 patients (14.5%) had advanced lung cancer in stage IIIA or greater. These patients had a late diagnosis, despite an excellent treatment algorithm and a retrospective analysis of previous thorax CT. The percentage of patients with advanced lung cancer is very high for a well-selected group of patients, how is relatively high (39%) the percentage of benign nodules submitted to surgical operation.2 Discussants emphasized that the main problem remains in detecting nodules less than 1 cm in diameter, whereas fortunately no discussion is necessary on the detection of nodules larger than 2 cm.

What is meant by the authors’ statement, "morphologic appearance worrisome for cancer"?

Did the authors consider ground-glass opacity or other CT pattern? In their study, did the authors investigate the presence of ground-glass opacity3 in nodules less than 1 cm in diameter? Some recent studies have established a correlation between this CT pattern and the possibility of a malignant pulmonary nodule. If they studied this pattern, was the correlation observed in 37 nodules less than 1 cm in diameter in the patients enrolled in their study?

Last, what do the authors think about a computer-aided diagnosis and serial CT scan? These 2 methods have been proposed to distinguish between benign and malignant nodules.4,5 The computer-aided program can predict the histology of solitary pulmonary nodules by means of a simple chest x-ray film, whereas the serial CT scan algorithm enables volumetric modeling and may permit accurate assessment of doubling time over a relatively short period (20 days).

In conclusion, we believe that low-dose CT alone is not adequate to screen for solitary pulmonary nodules because it is possible to miss an early diagnosis and difficult to differentiate between malignant and benign nodules.

References

  1. Crestanello JA, Allen MS, Jett JR, Cassivi SD, Nichols 3rd FC, Swensen SJ, et al. Thoracic surgical operations in patients enrolled in a computed tomographic screening trial. J Thorac Cardiovasc Surg. 2004;128:254-259.[Abstract/Free Full Text]
  2. Sortini D, Feo CV, Carcoforo P, Carrella G, Pozza E, Liboni A, et al. Thoracoscopic localization’s techniques for patients with solitary pulmonary nodule and history of malignancy. A prospective study. Ann Thorac Surg. 2005;79:258-262discussion 262.[Abstract/Free Full Text]
  3. Li F, Sone S, Abe H, MacMahon H, Armato 3rd SG, Doi K. Lung cancers missed at low-dose helical CT screening in a general population. comparison of clinical, histopathologic, and imaging findings. Radiology. 2002;225:673-683.[Abstract/Free Full Text]
  4. Shiraishi J, Abe H, Engelmann R, Aoyama M, MacMahon H, Doi K. Computer-aided diagnosis to distinguish benign from malignant solitary pulmonary nodules on radiographs. ROC analysis of radiologists’ performance—initial experience. Radiology. 2003;227:469-474.[Abstract/Free Full Text]
  5. Winer-Muram HT, Jennings SG, Tarver RD, Aisen AM, Tann M, Conces DJ, et al. Volumetric growth rate of stage I lung cancer prior to treatment. serial CT scanning. Radiology. 2002;223:798-805.[Abstract/Free Full Text]




This Article
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