Situation

A patient is referred with two nodules on CXR. What do you do ?

Opinion

Opinion

Firstly is the patient fit for any operation, if not stop. Are the nodules:

Contralateral 

    non primary lung cancer metastasis M1 or two primaries TXNXM0 or 

Ipsilateral

    same lobe (primary lung cancer metastasis T4 or two primaries TXNXM0) or 

    different lobe (non primary lung cancer metastasis M1, primary lung cancer metastasis T4 or two primaries TXNXM0).

Previous CXRs can be invaluable in this setting as one of the nodules may have been present for years. the presence of calcium in the nodules reduces the likelihood of carcinoma.

Needle biopsy, or bronchoscopy and washings of both lesions is preferable, but if on lesion is calcified biopsy the non calcified lesion even if it is the most difficult.

If you think the patient has two separate primaries are they fit enough to undergo both resections? if not don't even do one resection.

The primary to operate on first is the one that you think has the most chance of been unresectable.