The most appropriate management is to refer for thoracic surgery. One year ago this patient had a 3-mm pulmonary nodule. As a cigarette smoker, she is at high risk for lung cancer and was managed appropriately with repeat imaging in 12 months. On repeat imaging, the nodule has enlarged. The pretest probability that this nodule represents a primary lung cancer is high. Not only is this patient an active and long-time smoker, but her nodule has more than doubled in size over the previous year. Therefore, tissue diagnosis is warranted. An enlarging pulmonary nodule warrants more aggressive evaluation with tissue diagnosis or excision depending on the nodule's pretest probability of malignancy. Provided she is an appropriate candidate, surgical resection may be the best management. It would confirm the suspected diagnosis of primary lung cancer and would also be curative in this patient with likely stage I non–small cell lung cancer (based on the small size and absence of lymphadenopathy or other evidence of metastatic disease).

Although bronchoscopy could potentially provide a diagnosis, resection is the treatment of choice in a patient with stage IA lung cancer. Since she has no evidence of lymphadenopathy or other nodules, surgical resection may provide both diagnosis and cure. If the bronchoscopy is negative, the pretest probability of a primary lung cancer is high enough that the patient would still require further tissue diagnosis as well.

Similarly, a negative transthoracic needle aspiration would not be reassuring since it only obtains a small number of cells; therefore, if the needle aspiration were negative for malignancy the patient would still require a second diagnostic procedure. If the transthoracic needle aspiration confirmed malignancy, surgical resection would be indicated in the absence of any evidence of additional foci of malignancy.

This patient's pulmonary nodule has already significantly increased in size. Therefore, further surveillance imaging, even if obtained sooner, is not indicated at this time. At this point, the clinician should focus on the diagnosis, staging, and treatment.