Research Article|Articles in Press

Lung Cancer resection in the absence of pre-operative histology: The Accuracy of Multidisciplinary Team Consensus

Published:April 15, 2023DOI:



      Lung resection remains the gold-standard of treatment for non-small cell lung cancer (NSCLC). British Thoracic Society (BTS) guidelines recommends the pursuit of pre-operative histological diagnosis and staging where possible. In the absence of pre-operative histology, surgical treatment can be offered in conjunction with multidisciplinary team (MDT) and patient consensus. We undertook a single-centre analysis of the accuracy of the lung cancer MDT in recommending surgical resection for those with suspected lung malignancy in the absence of pre-operative histological diagnosis over a six-year period.


      A retrospective review was performed of patients undergoing any pulmonary oncological resection with therapeutic intent without pre-operative histological diagnosis at the recommendation of the lung cancer MDT in our unit between May 2016 and July 2022.


      270 consecutive patients underwent lung resection for a lung nodule of indeterminate significance. This accounted for 45% of the oncological resections performed over this period. The mean age of the cohort was 67.9 years, and 47.4% were male. Overall, 10% of resected specimens (n = 27) were benign on final histopathology. 93% of those undergoing a lobectomy received a malignant diagnosis. Across the study cohort, surgical resection was well tolerated with a low complication rate.


      Lung cancer resection in the absence of pre-operative histological diagnosis is feasible in a select patient cohort. This approach requires an experienced multi-disciplinary team and careful patient counselling. Our study demonstrates this adapted approach to be a pragmatic solution to the management of indeterminate pulmonary nodules in centres where biopsy is not routinely available due to existing constraints on the health system.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Callister M.E.
        • Baldwin D.R.
        • Akram A.R.
        • et al.
        British Thoracic Society guidelines for the investigation and management of pulmonary nodules.
        Thorax. 2015; 70 (ii1-ii54)
        • Ettinger
        • et al.
        National comprehensive cancer network clinical practice guidelines in oncology - non-small cell lung cancer version 3.
        2020 - February 11 (2020)
        • Howington J.A.
        • Blum M.G.
        • Chang A.C.
        • et al.
        Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines.
        Chest. 2013; 143: e278S-e313S
        • Postmus P.E.
        • Kerr K.M.
        • Oudkerk M.
        • et al.
        Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
        Ann Oncol. 2017; 28: iv1-iv21
        • Ghamati M.R.
        • Li W.W.L.
        • van der Heijden E.H.F.M.
        • Verhagen A.F.T.M.
        • Damhuis R.A.
        Surgery without preoperative histological confirmation of lung cancer: what is the current clinical practice?.
        J Thorac Dis. 2021 Oct; 13 (PMID: 34795925; PMCID: PMC8575862): 5765-5775
        • Gould M.K.
        • Donington J.
        • Lynch W.R.
        • et al.
        Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2013; 143: e93S-e120S
        • Madariaga M.L.
        • Lennes I.T.
        • Best T.
        • et al.
        Multidisciplinary selection of pulmonary nodules for surgical resection: diagnostic results and long-term outcomes.
        J Thorac Cardiovasc Surg. 2020; 159 (e3): 1558-1566
        • Cho J.
        • Ko S.J.
        • Kim S.J.
        • et al.
        Surgical resection of nodular ground-glass opacities without percutaneous needle aspiration or biopsy.
        BMC Cancer. 2014; 14: 838
        • Sihoe A.D.
        • Hiranandani R.
        • Wong H.
        • et al.
        Operating on a suspicious lung mass without a preoperative tissue diagnosis: pros and cons.
        Eur J Cardio Thorac Surg. 2013; 44 (; discussion 237. 10.1093/ejcts/ezs671): 231-237
        • Heo E.Y.
        • Lee K.W.
        • Jheon S.
        • et al.
        Surgical resection of highly suspicious pulmonary nodules without a tissue diagnosis.
        Jpn J Clin Oncol. 2011; 41: 1017-1022
        • de Koning H.J.
        • et al.
        Reduced lung-cancer mortality with volume CT screening in a randomized trial.
        N Engl J Med. 2020; 382: 503-513
      1. Field, John K, et al., Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis. .The Lancet Regional Health – Europe, Volume 10, 100179.

        • Adams A.M.
        • et al.
        • National Lung Screening Trial Research Team Aberle DR
        Reduced lung-cancer mortality with low-dose computed tomographic screening.
        N Engl J Med. 2011; 365: 395-409
        • Saghir Z.
        • Dirksen A.
        • Ashraf H.
        • et al.
        CT screening for lung cancer brings forward early disease. The randomised Danish Lung Cancer Screening Trial: status after five annual screening rounds with low-dose CT.
        Thorax. 2012; 67: 296-301
        • Pedersen J.H.
        • Ashraf H.
        • Dirksen A.
        • et al.
        The Danish randomized lung cancer CT screening trial – overall design and results of the prevalence round.
        J Thorac Oncol. 2009; 4: 608-614
        • Kuo E.
        • Bharat A.
        • Bontumasi N.
        • et al.
        Impact of video-assisted thoracoscopic surgery on benign resections for solitary pulmonary nodules.
        Ann Thorac Surg. 2012; 93: 266-273
        • Smith M.A.
        • Battafarano R.J.
        • Meyers B.F.
        • Zoole J.B.
        • Cooper J.D.
        • Patterson G.A.
        Preva- lence of benign disease in patients undergoing resection for suspected lung cancer.
        Ann Thorac Surg. 2006; 81: 1824-1829
        • Heo E.Y.
        • Lee K.W.
        • Jheon S.
        • Lee J.-H.
        • Lee C.-T.
        • Il Yoon H.
        Surgical resection of highly suspicious pulmonary nodules without a tissue diagnosis.
        Jpn J Clin Oncol. 2011; 41: 1017-1022
      2. Andrew E. Giles et al, Lung Resection Without Tissue Diagnosis: A Pragmatic Perspective on the Indeterminate Pulmonary Nodule, Clin Lung Cancer,

        • Lowe V.J.
        • Fletcher J.W.
        Prospective investigation of positron emission tomography in lung nodules.
        J Clin Oncol. 1998; 16: 1075-1084
        • Bastarrika G.
        • Garcia-Velloso M.J.
        • Lozano M.D.
        Early lung cancer detection using spiral computed tomography and positron emission tomography.
        Am J Respir Crit Care Med. 2005; 171: 1378-1383
        • Imdahl A.
        • Jenkner S.
        • Brink I.
        Validation of FDG PET for differentietion of unknown pulmonary lesions.
        Eur J Cardio Thorac Surg. 2001; 20: 324-329
        • Yilmaz F.
        • Tastekin G.
        Sensitivity of (18)F-FDG PET in evaluation of solitary pulmonary nodules.
        Int J Clin Exp Med. 2015 Jan 15; 8: 45-51
        • Chang J.M.
        • Lee H.J.
        • Goo J.M.
        • Lee H.Y.
        • Lee J.J.
        • Chung J.K.
        • et al.
        False positive and false negative FDG-PET scans in various thoracic diseases.
        Korean J Radiol. 2006 Jan-Mar; 7: 57-69
        • Al-Ameri Ali
        • Malhotra Puneet
        • Thygesen Helene
        • et al.
        Risk of malignancy in pulmonary nodules: a validation study of four prediction models.
        Lung Cancer. 2015; 89: 27-30
        • Susam S.
        • et al.
        Comparison of Brock University, Mayo Clinic and Herder models for pretest probability of cancer in solid pulmonary nodules.
        Clin Res J. 2022 Nov; 16: 740-749
        • MacMahon H.
        • Naidich D.
        • Goo J.
        • et al.
        Guidelines for management of incidental pulmonary nodules detected on CT images: from the fleischner society 2017.
        Radiology. 2017; 284: 228-243