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solitary pulmonary nodule; pulmonary coin lesion

A single rounded density seen on radiographs, 1-5 cm in diameter (> 4-6 mm, < 3 cm [3]), located in lung parenchyma, usually well circumscribed, without satellite lesions. A larger density is considered a pulmonary mass. Etiology: 1) common a) granuloma - tuberculosis, coccidioidomycosis, histoplasmosis, cryptococcosis b) hamartoma of the lung c) primary lung carcinoma, - bronchogenic carcinoma (35%) [3] - lung adenocarcinoma tends to be peripheral d) solitary metastasis to the lung e) resolving pneumonia 2) uncommon a) carcinoid b) bronchogenic cyst c) resolving infarction d) rheumatoid nodule e) vasculitic nodule f) arteriovenous malformation History: - age, smoking, previous malignancy, exposure to tuberculosis, travel, recent respiratory tract infection, recent pulmonary infarction, recent trauma to chest, asthma, ENT symptoms, use of mineral oil or oily nose drops, immune status, CHF, connective tissue disease, family history (AV malformation) Laboratory: 1) complete blood count (CBC) 2) comprehensive chemistry profile 3) rheumatology workup a) erythrocyte sedimentation rate (ESR) b) serum C-reactive protein c) rheumatoid factor (if indicated) d) reflex anti-nuclear antibody (ANA) panel (if indicated) e) serum complement (if indicated) Special laboratory: 1) bronchoscopy a) 60% diagnostic yield in lung cancer b) provides sufficient information in 30% of cases [3] 2) transthoracic needle biopsy a) CT or fluoroscopic guided b) 85% diagnostic yield for lung cancer c) 20% risk of pneumothorax 3) a non-specific negative result does not exclude malignancy [3] 4) see lung carcinoma for suspected lung cancer - needle aspiration of suspicious peripheral lymph node [3] Radiology: 1) previous chest X-ray 2) computed tomography (CT) a) contrast enhancement suggests malignancy b) spiculated borders suggests malignancy c) helpful for assessing calcification - central calcification suggests granuloma - off-center calcification may be benign or malignant - calcification in rings or arcs suggests benign disease - diffuse calcification suggests benign disease [2,5] d) smooth borders suggests granuloma e) subsolid or ground-glass nodules through which normal parenchymal structures are visible are often slow-growing adenocarcinomas f) useful for staging of lung cancer 3) PET scan - may be falsely negative with alveolar cell carcinoma - may be falsely positive with inflammation [3] 4) compare current with previous imaging prior to additional testing [3] * see Fleisher criteria for imaging of solitary pulmonary nodule Complications: - more intensive diagnostic evaluation associated with greater procedural complications, radiation exposure, & costs [16] Management: 1) if > 8 mm, assess risk factors for lung cancer 2) if nodule remains unchanged for 2 years, no follow-up is necessary, unless nodule is ground-glass appearing - such nodules may represent slow-growing lung adenocarcinoma - follow-up recommended for at least 5 years [3,9] 3) for current smokers with nodules <6 mm in size, follow-up CT at 12 months [7] - if nodule is unchanged at 12 month, no further imaging is necessary [3,5] 4) for smokers with nodules 6-8 mm, CT at 6-12 months 5) for non-smokers with nodules 6-8 mm, CT at 6-12 months [3] 6) for non-smokers & otherwise low-risk with nodules <6 mm, no follow-up needed [3] 7) for large solid nodules (>8 mm), follow-up at 3,9 & 12 months with contrast-enhanced CT, PET scan or lung biopsy [3] 8) a more complex algorithm [6] a) for small solid nodules (8 mm), follow Fleischner Society guidelines on intervals for repeat CT [7] b) for large solid nodules (>8 mm), assess the probability of malignancy according to clinical & imaging characteristics [8] c) further evaluation depends on whether calculated probability of malignancy is low (<5%), intermediate (5%-60%) or high (>60%) & is based partly on guidelines in [5] d) small pure subsolid nodule (5 mm) require no follow-up [6] 9) another algorithm [15] - low or high risk - < 6 mm: no routine followup - 6-8 mm: CT at 6-12 months; then consider CT at 18-24 months - > 8 mm: CT at 3 months, PET/CT 10) tissue diagnosis with lung biopsy or surgical resection if nodule is growing or exhibits high metabolic rate [3] - referral to thoracic surgery for resection preferable to bronchoscopy [3] - navigational bronchoscopy with better yield than conventional bronchoscopy [4] - transthoracic fine-needle aspiration inadequate [3] 11) indications for surgical removal of nodule a) solitary nodule is probably malignant - large nodule > 3 cm = pulmonary mass; >= 2.3 cm - spiculated nodule b) lack of evidence to support benign nature of nodule c) consider PET imaging for staging prior to surgical resection 12) patient refuses surgery or is poor surgical risk a) repeat chest X-ray every 3 months b) enlargement of nodule may change patient's or surgeon's decision regarding surgery 13) lesion most likely benign: - if there is not change in the size or shape of the nodule for over 2 years, repeat chest X-ray every 6-12 months - 35% of pulmonary nodules 8-20 mm surgically excised are benign [11] === Factors favoring benign etiology === , 1) age < 35 2) female sex (Brock University says female sex is a risk factor for malignancy) 3) non-smoker 4) asymptomatic 5) exposure to tuberculosis 6) recent travel to region endemic for mycosis 7) nodule size < 2 cm 8) nodule present for more than 2 years (absence of enlargement for > 2 years)* 9) doubling time of nodule < 30 days 10) smooth nodule margins 11) calcification, especially dense central calcification* 12) satellite lesions present 13) no enhancement on CT with contrast * only reliable markers of benign nature [3]

Related

Fleisher criteria for imaging of solitary pulmonary nodule; Fleischner Society guidelines

General

pulmonary nodule

References

  1. Introduction to Clinical Imaging, Radiology Syllabus, UCSF, 1993
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. van 't Westeinde SC et al The role of conventional bronchoscopy in the workup of suspicious CT scan screen-detected pulmonary nodules. Chest 2012 Aug; 142:377 PMID: 22302298d http://journal.publications.chestnet.org/article.aspx?articleid=1262329 - Wang Memoli JS et al. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest 2012 Aug; 142:385 PMID: 21980059 http://journal.publications.chestnet.org/article.aspx?articleid=1262330
  5. Gould MK, Fletcher J, Iannettoni MD et al Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). PMID: 17873164
  6. Patel VK et al. A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules. Part 1: Radiologic characteristics and imaging modalities. Chest 2013 Mar; 143:825. PMID: 23460160 - Patel VK et al. A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules. Part 2: Pretest probability and algorithm. Chest 2013 Mar; 143:840. PMID: 23460161 - Wiener RS et al. "What do you mean, a spot?" A qualitative analysis of patients' reactions to discussions with their physicians about pulmonary nodules. Chest 2013 Mar; 143:672. PMID: 22814873 http://journal.publications.chestnet.org/article.aspx?articleid=1653815
  7. MacMahon H et al Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society Radiology. November 2005 Radiology, 237, 395400. http://radiology.rsna.org/content/237/2/395
  8. Probability of Malignancy in SPN: Bayesian Analysis Online Calculator http://www.chestx-ray.com/SPN/SPNProb.html
  9. Godoy MC, Naidich DP. Subsolid pulmonary nodules and the spectrum of peripheral adenocarcinomas of the lung: recommended interim guidelines for assessment and management. Radiology. 2009 Dec;253(3):606-22. PMID: 19952025
  10. National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011 Jul 1; 365:395. PMID: 21714641
  11. Tanner NT et al. Management of pulmonary nodules by community pulmonologists: A multicenter observational study. Chest 2015 Dec; 148:1405. PMID: 26087071 http://journal.publications.chestnet.org/article.aspx?articleid=2337001 - Wiener RS et al. Pulmonologists' reported use of guidelines and shared decision-making in evaluation of pulmonary nodules: A qualitative study. Chest 2015 Dec; 148:1415 PMID: 25789979 http://journal.publications.chestnet.org/article.aspx?articleid=2209998
  12. Murrmann GB, van Vollenhoven FH, Moodley L. Approach to a solid solitary pulmonary nodule in two different settings-"Common is common, rare is rare". J Thorac Dis. 2014 Mar;6(3):237-48. Review. PMID: 24624288 Free PMC Article
  13. MacMahon H, Naidich DP, Goo JM et al. Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. Radiology 2017 Feb 23 PMID: 28240562
  14. McWilliams A, Tammemagi MC, Mayo JR et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013 Sep 6; 369:910 PMID: 24004118 Free PMC Article https://www.nejm.org/doi/full/10.1056/NEJMoa1214726
  15. NEJM Knowledge+ Question of the Week. Aug 27, 2019 https://knowledgeplus.nejm.org/question-of-week/1763/
  16. Farjah F, Monsell SE, Gould MK et al Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules. JAMA Intern Med. Published online January 19, 2021. PMID: 33464296 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2775378
  17. Mazzone PJ, Lam, L Evaluating the Patient With a Pulmonary Nodule. A Review. JAMA. 2022;327(3):264-273 PMID: 35040882 https://jamanetwork.com/journals/jama/fullarticle/2788136
  18. Lung cancer risk calculator http://www.brocku.ca/lung-cancer-risk-calculator