ABSTRACT
Indeterminate and likely malignant nodules require further diagnostic studies. Prior to further diagnostic testing, complete pulmonary function tests and a helical CT scan of the entire chest, liver, and adrenal glands using intravenous contrast should be obtained. Evidence of potential disease elsewhere may indicate a more appropriate biopsy site and significantly influence patient management, particularly with regard to surgical treatment options. In asymptomatic individuals with non-small-cell lung cancer, metastatic lesions to the brain are uncommon and a head CT scan is not routinely performed. After a complete noninvasive evaluation, indeterminate SPNs should be referred for TTNA biopsy. A satis factory biopsy that is negative for malignancy but without a definite benign diagnosis should be considered for surgical resection. In the absence of a clinical suspicion for malignancy, some authors advocate a watch-and-wait strategy using serial chest radio graphs or CT scans. In patients who are elderly or are otherwise poor surgical candidates, this is probably a justifiable approach. For the SPN that is likely to be malignant and in the absence of detectable metastatic disease, direct surgical referral is indicated. Some centers advocate TTNA biopsy for definitive diagnosis prior to surgery. There are no substantive data to support or refute this position.
