Multiple pulmonary nodules: a management dilemma

The management of patients with multiple pulmonary nodules is increasingly common, representing diagnostic and therapeutic challenges. The various presentations of synchronous versus metachronous appearance, ipsilateral versus contralateral manifestation, central vs. peripheral location, and separate primary etiology versus T3, T4, or M1 status contribute to the complexity of the decision-making, including the timing of resection, the extent of resection, and the use of systemic therapy. The goal of the evaluation is complete preoperative staging to determine oncologic operability; physiologic operability must also be assessed, which may guide the use of lobar vs. sub-lobar resection. Even after resection, it may not be clear whether the multiple malignancies represent separate primaries or more advanced involvement: T3, T4, or M1a. The algorithmic approach to evaluation and management supports the use of resection even in cases of T4 or M1a disease, in conjunction with systemic therapy, in the absence of other metastatic diseases. The presence of N1 or N2 nodal disease is an additional factor that further complicates decision-making, both the extent of resection and the use of systemic therapy. In this chapter we will summarize different criteria used to stage multifocal lung nodules and discuss algorithms for surgical management, including our practice at Duke Cancer Institute.