A solitary pulmonary nodule is discovered in an asymptomatic 55-year-old smoker with no evidence of extrathoracic dissemination. The most appropriate management would be to:

D. Proceed with pulmonary resection after ascertaining that the patient would tolerate removal of the requisite amount of lung.

DISCUSSION: A patient with a solitary pulmonary nodule—a single spherical lesion within the lung— represents an important and challenging diagnostic problem in thoracic oncology. A solitary pulmonary nodule is assumed to be primary lung cancer until proved otherwise; the differential diagnosis includes metastatic carcinoma, granuloma, and benign pulmonary tumors. In most cases, solitary pulmonary nodules should be resected after thorough investigation to establish that systemic dissemination has not already occurred. CT of the chest, liver, and adrenals is performed to confirm the location of the tumor, to evaluate the mediastinum, and to assess the abdomen for systemic disease. If there is no evidence of metastases on CT, the patient should undergo bronchoscopy, which may establish the histologic diagnosis and determine resectability if an endobronchial lesion exists.

Pulmonary function studies are obtained preoperatively to assess the potential for pulmonary resection. A thorough review of systems is undertaken to rule out medical contraindications to thoracotomy. TTNA is not performed routinely and should be reserved for patients with marginal pulmonary function, for whom thoracotomy would be performed only after verification of a malignant histologic diagnosis.