To excise nodules directly or take in biopsy first - an issue of taking chance

In private sectors, not all patients come for treatment. They are just coming for second opinion. This is a hypothetical scenario to seek help from two soucess. If different, they would not jump on the treatment plan. If more or less the same or the reason given is the same, they can then opt for the original treatment plan. Rarely, they may accept the suggestion of treatment plan of the second doctor. And switch to the new care giver.

For me, as an experienced surgeon, the line of thinking of pursuing one investigation or other is more or less natural to me. Some nodules in the lung, I wound quickly advise surgery. Whether it is open or minimally invasive is not a major issue. The chance of missing lethal lung cancer is the main concern.
For some nodules with background of lot of disease, with chance of multiple metastases or just more likely a reactive change, I wound suggest observation or biopsy. Not always matter with the size. But to balance the chance of morbidity free surgery versus over - positive thinking.

Indeed, as advocated in my earlier blog, size if more than 9 mm should be annually re CT and excised once the possibility of benign lesion cannot be fully established.
Size less than 6 mm can be safely watched. Above 6 mm, can be watched for 3 or 4 years and left alone.
But there is always some exception. Sometime for over cautious patient, needle biopsy is essential though clinically likely Ca Lung is well suggested.

And the way to deal with negative biopsy has to be evaluated. If patient or doctors are totally insecure of leaving the nodule alone. Needle biopsy can be omitted.
For patients where non operative option is highly favorable, like bleeding tendency, very elderly, bread winner of family, needle biopsy at least clear some uncertainty in this occasion.

If patient  otherwise fit and healthy, Video assisted wedge biopsy is always justifiable if the lesion is regarded as suspicious.
For highly likely non malignant case, say with normal CEA, non smoker and calcified mass or very low PET SUV, needle biopsy is safe to document the non malignant nature in a way better than sitting on X ray comment alone.