Malignancy yield after resection of incidentally detected solid solitary pulmonary nodules according to lung cancer screening eligibility

Abstract

Solid solitary pulmonary nodules (SPNs) detected incidentally may represent a primary pulmonary malignancy, metastatic disease, or benign pathology, and accurate preoperative differentiation remains challenging. The study assessed malignancy yield after surgical resection based on retrospectively determined lung cancer screening eligibility and identified factors associated with malignant pathology in a predefined high-risk surgical cohort. The retrospective single-center study included adults who underwent lung resection for incidentally detected solid SPNs measuring 8–30 mm with no preoperative tissue diagnosis or previous lung cancer between January 2016 and January 2026. The cohort consisted of patients who either fulfilled the study-specific lung cancer screening definition (age and smoking history) or had a first-degree family history of cancer or previous extrathoracic malignancy. Malignancy yield was compared between screening-eligible and non-eligible patients. Factors associated with malignant pathology were explored using multivariable logistic regression. A sensitivity analysis excluding pulmonary metastases evaluated associations with primary pulmonary malignancy. Among 112 patients, 78 cases (69.6%) had malignant pathology and 34 (30.4%) had benign lesions. Malignant nodules consisted of 58 primary pulmonary malignancies and 20 pulmonary metastases. Seventy-four patients met the screening eligibility criteria, having a higher malignancy yield than non-eligible patients (81.1% vs. 47.4%; P < 0.001). The initial multivariable analysis demonstrated that male sex and previous extrathoracic malignancy were independently associated with malignancy. Increasing age, male sex, and previous extrathoracic malignancy remained associated with primary pulmonary malignancy after exclusion of pulmonary metastases. Screening eligibility was associated with higher malignancy yield among patients who had already undergone multidisciplinary selection for surgery. These findings apply to a predefined at-risk surgical cohort and do not estimate screening performance or malignancy prevalence among unselected patients with incidental SPNs. Benign pathology in nearly one-third of resections highlights the limitations of preoperative differentiation.