For a patient with a 9 mm pulmonary nodule and a smoking history, what is the best management?

• A. Order a follow-up CT in three months
• B. Refer the patient for biopsy
• C. Send sputum for cytology
• D. Order positron emission tomography scan

Answer: (B)

When a solid lung nodule is 9 mm in a patient with a significant smoking history, the chance of cancer is high enough that obtaining a tissue diagnosis is the most appropriate next step. A biopsy provides a definitive histologic result, which directly guides management—whether that’s surgical planning, further oncologic treatment, or surveillance if benign. Waiting with repeat imaging delays potential treatment for cancer and can miss an opportunity for curative intervention.

Sputum cytology is unlikely to yield useful information for a solitary peripheral nodule, and while a PET scan can help assess metabolic activity and refine risk, it is not diagnostic by itself and would typically be followed by biopsy if malignancy is suspected. CT follow-up in three months could miss an early cancer in a high-risk patient. The biopsy can be performed via a CT-guided percutaneous approach or bronchoscopy with navigational guidance, depending on the nodule’s location.