Relationship Between a History of Antecedent Cancer and the Probability of Malignancy for a Solitary Pulmonary Nodule

doi:10.1378/chest.125.6.2175

Chest

Volume 125, Issue 6, June 2004, Pages 2175-2181

https://doi.org/10.1378/chest.125.6.2175 Get rights and content

Study objectives

To determine the probability of malignancy for a solitary pulmonary nodule (SPN) as a function of cancer history.

Setting and design

Patients who had undergone resection of SPNs at Brigham and Women's Hospital between August 1989 and October 1998 were analyzed. The cohort was split into the following three groups: no history of cancer; history of lung cancer; and history of extrapulmonary malignancy. The histology of the SPN was determined after excision. Logistic regression was used to evaluate the effect of covariates on the probability of malignancy.

Measurements and results

A total of 1,104 patients (55% women; median age, 64 years; age range, 17 to 88 years) underwent removal of 353 benign lesions (32%), 638 non-small cell lung cancers (NSCLCs) [58%], and 113 metastases (10%). Antecedent cancer history was significantly associated with final diagnosis (p < 0.0001), with SPNs being malignant in 63% of patients with no previous cancer, 82% of those with a history of lung cancer (NSCLC, 80%; metastases, 2%), and 79% of patients with history of extrapulmonary cancer (NSCLC, 41%; metastases, 38%). There was no difference in the cause of SPNs between patients with a history of a single cancer and those with a history of multiple cancers. The probability of a benign cause ranged between 62% for nodules < 1 cm to 17% when nodules were > 3 cm, if the patient had no history of cancer (p < 0.0001). The probability of an SPN being benign was cut in half if there was a history of cancer. Among patients with previous extrapulmonary malignancy, age, smoking history, and histology were predictors of diagnosis (p < 0.0001). These variables were used to construct a clinical score to predict the probability of an SPN being a NSCLC or metastasis in these patients.

Conclusions

A history of cancer is an important predictor of the probability of malignancy in new SPNs. Metastases from previous cancer account for almost half of SPNs seen among patients in this subgroup. Diagnosis depends on the histology of previous malignancies, smoking history, age, and size of the SPN.

Section snippets

PATIENTS AND METHODS

The base population for this study was composed of 1,112 patients who underwent resection of an SPN at Brigham and Women's Hospital between August 1989 and October 1998. Patients without a complete clinical history (six patients) or who had previously undergone resection of pulmonary metastases (two patients) were excluded. Therefore, 1,104 patients with an SPN undergoing an initial excisional biopsy were included in the analysis.

Preoperative information was collected prospectively for each

RESULTS

One thousand one hundred four patients (women, 55%; men, 45%; median age, 64 years; age range, 17 to 88 years) were included in the study. The cohort was composed of 767 patients (69%) without a history of cancer, 49 patients (4%) with previous lung cancer; and 288 patients (26%) with a history of extrapulmonary malignancies. Of the 49 patients with a history of lung cancer, 13 also had a history of extrapulmonary neoplasms.

DISCUSSION

An SPN in this highly selected cohort was found to be from a malignant cause in at least 63% of cases, even with no history of cancer. A history of extrapulmonary neoplasms increased the overall risk of cancer in an SPN from 63 to 79%. Primary lung cancer remained the most important cause of malignancy (52%) in this subgroup of patients, although there was roughly an even chance that a malignant nodule within this group represented a metastasis (48%). Nodules were also malignant in 82% of

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Dr. Mery was partly supported by scholarships from the Mexican Council for Science and Technology (CONACyT) and the Fundación México en Harvard, AC.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

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Chest

Clinical InvestigationsSurgeryRelationship Between a History of Antecedent Cancer and the Probability of Malignancy for a Solitary Pulmonary Nodule

Study objectives

Setting and design

Measurements and results

Conclusions

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Am J Surg

J Thorac Cardiovasc Surg

Surg Clin North Am

Lancet

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Solitary pulmonary nodule

Cleve Clin J Med

Estimating the probability of malignancy in solitary pulmonary nodules: a Bayesian approach

Am Rev Respir Dis

A pattern classification approach to characterizing solitary pulmonary nodules imaged on high resolution CT: preliminary results

Med Phys

Management of solitary pulmonary nodules

Dis Mon

Multiple primary malignant tumors: a survey of the literature and a statistical study

Am J Cancer

Clinical Investigations
Surgery
Relationship Between a History of Antecedent Cancer and the Probability of Malignancy for a Solitary Pulmonary Nodule