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A classic solitary pulmonary nodule (SPN) is a single, spherical, well- circumscribed, radiographic opacity measuring less than or equal to 3. The SPN is a coined term that in the past described solitary nodules detected incidentally by chest radiography (CXR). Today, most nodules are detected by computed tomography (CT). The detailed CT images frequently identify more than one nodule, or enlarged lymph nodes. Masses have a high probability of being malignant. Subcentimeter nodules are less than 1. Subsolid nodules include pure ground- glass nodules (GGNs) and part- solid nodules. GGNs are defined as focal nodular areas of increased lung attenuation through which normal parenchyma structures such as airways, vessels, and interlobular septa can be visualized. Since first reported in 1. GGNs frequently represent adenocarcinomas or their precursors. The widespread use of chest imaging has led to the detection of many pulmonary lesions. The American College of Chest Physicians (ACCP) does not recommend distinguishing between nodules detected by CXR versus CT. The goal in managing patients with pulmonary nodules is to distinguish between benign and malignant nodules, expediting diagnosis for malignant nodules while minimizing testing of those that are benign. Back to Top. Prevalance. The prevalence of pulmonary nodules varies significantly across studies. This variation stems from the inconsistency among studies in method, enrolled population, and reporting results. Most lung nodules are detected incidentally on CXR or CT scans obtained for other purposes. It is estimated that 0. CXR scans will incidentally detect pulmonary nodules. In CT angiograms obtained to diagnose pulmonary embolism, a study reports 1. In another cohort study, 3. CT scans for coronary calcium scoring have incidental findings of pulmonary nodules. In lung cancer screening trials, 7% of CXR scans obtained from previously healthy individuals contain pulmonary nodules. CT scans to screen for lung cancer detect nodules in 8% to 5. Given the findings from the National Lung Screening Trial, the use of low- dose CT scanning as a screening tool for lung cancer is expected to increase, leading to the discovery of many pulmonary nodules. Back to Top. Differential Diagnoses. The primary concern when evaluating someone with a pulmonary nodule is that it could represent bronchogenic carcinoma. The differential diagnosis of lung nodules includes many benign diseases. Benign etiologies of pulmonary nodules include healed or nonspecific granulomas and active granulomatous infections, which account for 2. Active granulomatous infections include tuberculosis, coccidioidomycosis, histoplasmosis, cryptococcus, and aspergillosis. Hamartomas comprise an additional 1. Other benign causes include nonspecific inflammation and fibrosis, lung abscesses, round atelectasis, bronchogenic cysts, healed pulmonary infarcts, focal hemorrhage, hemangiomas, and arteriovenous malformations. The prevalence of malignancy in patients with pulmonary nodules ranges from 1. This rate depends on the nodule characteristics and the population at risk. Most malignant pulmonary nodules are adenocarcinoma (4. Other less common causes of malignant lung nodules include: large cell carcinoma, carcinoid tumors, lymphomas, adenosquamous carcinoma, adenoid cystic carcinoma, and malignant teratomas (Table 1). Table 1: Differential Diagnosis for a Pulmonary Nodule. Benign. Malignant (1. Nonspecific granuloma (1. Adenocarcinoma (4. Harmatoma (1. 5%)Squamous cell carcinoma (2. Infectious granuloma (1. Aspergillosis. Coccidioidomycosis. Cryptococcosis. Histoplasmosis. Tuberculosis. Metastatic (8%)Small cell lung carcinoma (4%)Others: lung abscess, round pneumonia, bronchogenic cysts, focal hemorrhage, hemangiomas, AVMs. Others: large cell carcinoma, carcinoid tumors, lymphomas, malignant teratomas. Back to Top. Estimating the Probability of Malignancy. Traditionally, established historical and radiographic criteria are used to estimate the probability that a pulmonary nodule is malignant. If this probability is quite low, observation is chosen as the course to follow. If this probability is quite high, immediate surgical resection is indicated. Most pulmonary nodules lie somewhere between these extremes and are said to be indeterminate, requiring further evaluation. Traditional nodule evaluation is most relevant for solid nodules 1 cm or larger in size. The evaluation of subcentimeter and semi- solid nodules has evolved more recently. In considering these issues, this chapter will review the established clinical and radiographic criteria used to estimate the probability of malignancy in solid pulmonary nodules, current invasive and noninvasive methods of evaluating them, their respective test characteristics, and how test results influence the probability of malignancy. Separately, we will discuss some of the unique considerations in the evaluation of subcentimeter and semi- solid nodules. Finally, management guidelines for pulmonary nodules will be summarized. Solid Nodules. Clinical Risk Factors. Clinical features which are independent predictors of malignancy include age, tobacco smoking status, and the history of a prior malignancy (Table 2). The probability of malignancy in a pulmonary nodule is directly related to the individual's age. The calculated likelihood ratio (LR) for malignancy in a lung nodule in individuals under age 3. Cigarette smoking has long been recognized as a risk factor for lung cancer. In a never smoker, the LR for malignancy in a lung nodule is 0. This LR increases as the number of cigarettes smoked increases and decreases with an increased duration of smoking abstinence. Cigar smoking is also an independent risk factor for lung cancer. A history of a prior malignancy (> 5 years ago) in an individual with a pulmonary nodule is a predictor of malignancy, with LRs for malignancy ranging from 3. Table 2: Clinical and Radiographic Features of High Influence for Solid Nodules. Benign. Malignant. Age < 3. 0 years old in a lifelong nonsmoker. Benign pattern of calcification on radiographic study. Absence of an increase in nodule size for a period of 2 years. Diameter of nodule > 3 cm. The presence of moderate or severe obstructive lung disease and exposure to fine particulates or sulfur oxide- related pollution are also risk factors for lung cancer. These risk factors are less well established as independent predictors of malignancy in a lung nodule. Radiographic Features. Several radiographic criteria are used to estimate the probability of malignancy in a pulmonary nodule, including: calcification, nodule size, growth rate, and edge characteristics (Table 3). Table 3: Influence of Patient and Nodule Characteristics on Likelihood of Malignancy in Solid Nodules. Clinical/Radiographic Features. Likelihood Ratio*Age< 3. Tobacco use. Never smoker. History of other malignancy. Calcification. Benign pattern. Near 0. Growth rate. Growth < 7 days. Near 0. No growth > 4. Near 0. Edge characteristics Smooth. Lobulated. 0. 7. 3Spiculated. Size< 1 cm. 0. Cavity wall thickness< 4 mm. Location. Upper/middle lobes. Satellite nodules. The positive likelihood ratio is the ratio of the true positive fraction to the false positive fraction (sensitivity/(1 – specificity) ). It expresses the relative likelihood that a given characteristic (e. A very high LR rules in a disease, and a very low LR rules out a disease. An LR of 1 means that the posttest probability is identical to the pretest probability. Calcification in a pulmonary nodule typically indicates benign disease. Benign nodules often contain dense, central, laminated, popcorn, and punctate patterns of calcification. Malignant pulmonary nodules can also have a calcified appearance. However, these are typically small and contain central niduses with speckled patterns, or eccentric punctate foci (Figure 1 (A - D)5. Since the patterns of calcification typically do not overlap, a benign pattern is one of the few radiographic features that justify a decision that no further evaluation of the lung nodule is warranted. The calculated LR for malignancy in a pulmonary nodule with a benign pattern of calcification approaches 0. While benign patterns of calcification can be highly specific for the absence of malignancy, CXR is not a perfect tool for detecting calcification, with a sensitivity of 5. CT has a higher sensitivity for calcification compared with CXR. The size of a pulmonary nodule influences the probability of malignancy. Benign lesions are smaller overall than malignant ones. As the lesion increases in size, its probability of being malignant increases. The prevalence of malignancy is 0% to 1% for nodules < 5 mm, 6% to 2. For nodules more than 3 cm in diameter, 9. Given the high likelihood of malignancy in lesions > 3 cm (masses), they are considered malignant unless proven otherwise. The LRs for lesions less than 1 cm and more than 3 cm are 0. The growth rate of a pulmonary nodule also has predictive value for benignity and malignancy. A very rapidly growing or very slowly growing pulmonary nodule suggests a benign etiology. The calculated LR for malignancy in a pulmonary nodule approaches 0 if growth is noted in fewer than 7 days, or if no growth is noted for 4. Thus, a very rapid growth rate or stability over a 2- year time period are accepted indicators of benignity. The radiographic edge characteristics of a pulmonary nodule influence the probability of malignancy. Nodule edges can be smooth, lobulated, irregular, and spiculated based on CT appearance. Typically, benign nodules have well- defined borders while malignant nodules are irregular or elongated. However, one cannot use edge characteristics alone as an endpoint as there is much overlap. The LR for a smooth edge is 0. A spiculated edge is an independent predictor of malignancy in a lung nodule. Bootleggers is a free browser based mafia massively multiplayer online role-playing game (MMORPG). Compete with thousands of other players in this addictive strategy.
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