title: A prospective study to determine the incidence of non-imaged malignant pulmonary nodules in patients who undergo metastasectomy by thoracotomy with lung palpation.
abstract: BACKGROUND
  To prospectively assess the incidence of non-imaged malignant nodules in patients who undergo thoracotomy for metastasectomy with bimanual lung palpation.
  
  
  METHODS
  This is a prospective cohort study of patients who underwent open metastasectomy by thoracotomy. All patients had metastatic lung lesions, underwent 64-slice helical computed tomographic (CT) scan with intravenous contrast using 5-mm collimated cuts, and most had integrated PET (positron emission tomography)-CT. Unsuspected malignant pulmonary nodules that were palpated and removed, and that were not imaged preoperatively, were recorded.
  
  
  RESULTS
  From January 2006 to March 2010, 152 patients underwent metastasectomy by rib-sparing, nerve-sparing thoracotomy by 1 surgeon. Fifty-one (34%) patients had 57 pulmonary nodules that were not imaged preoperatively and 32 of the 57 (56%) nodules were malignant. Thirty patients had non-imaged malignant nodules that were palpated and removed. There were 15 malignant nodules that were in different lobes than the imaged nodules. The 3 most commonly missed malignant nodules occurred in patients with colorectal cancer, renal cell, and sarcoma.
  
  
  CONCLUSIONS
  Metastasectomy by thoracotomy, which affords bimanual palpation of the entire lung, discovers ipsilateral non-imaged malignant pulmonary metastases in 1 of 5 patients who had at least 1 imaged metastatic pulmonary lesion. This is true despite preoperative, fine cut chest CT scan with contrast, and integrated 18F-fluorodeoxyglucose-PET-CT scanning. The clinical significance of these non-imaged, resected malignant nodules is unknown, nor is the added morbidity of resecting benign nodules.
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA. robert.cerfolio@ccc.uab.edu
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Cerfolio
authors.forename: Ayesha S
authors.initials: AS
authors.lastname: Bryant
authors.forename: Todd P
authors.initials: TP
authors.lastname: McCarty
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Minnich
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008175:Lung Neoplasms / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010173:Palpation; D011446:Prospective Studies; D003074:Solitary Pulmonary Nodule / Q000453:epidemiology*; D020775:Thoracic Surgery, Video-Assisted; D013908:Thoracotomy / Q000379:methods*