How do you approach a lung malignancy with a single pleural nodule near a primary?

This is a relatively rare scenario. For example, in a Korean series of almost 4,000 patients undergoing surgery for NSCLC, 78 (2%) were found to have unexpected pleural seeding intra-operatively (Thorac Cardiovasc Surg 2018;66:142). A small number of surgical reports suggest, that when limited seeding is identified intra-operatively, proceeding with the planned lung resection and resecting the pleural nodule(s) seems to be associated with improved outcomes compared with abandoning the surgery. Of course, there is likely a selection bias that occurs based on the extent of pleural seeding and the stage of the known disease.

There is much less data in the literature to shed light on the clinical scenario when a pleural nodule is identified clinically with initial staging. There is surely a false positive rate with both CT and PET-CT that is not well described in the literature. If the patient is otherwise a surgical candidate, then VATS exploration of the pleura to confirm involvement would seem appropriate before planned resection. If the patient would otherwise be treated with definitive radiation therapy, and the primary tumor is in close proximity, I would probably proceed with definitive treatment (giving the patient the benefit of the doubt), but would hedge my bets by including the pleural nodule in the CTV (again, if in close proximity). I am not aware of any robust data demonstrating outcomes with this approach.