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| {{Infobox_Disease | | __NOTOC__ |
| | Name = Solitary pulmonary nodule
| | {{Solitary pulmonary nodule}} |
| | Image = Malignant solitary pulmonary nodule 1.jpg
| | '''For the WikiPatient page for this topic, click [[Pulmonary nodule (patient information)|here]]''' |
| | Caption = Malignant solitary pulmonary nodule: The patient is a 67 year old woman with a solitary pulmonary nodule on a recent chest x-ray. A retrospective review of prior chest x-rays suggests that this is nodule is of recent origin. This lesion was felt to be too peripheral for reliable bronchial wash findings.
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| | DiseasesDB = 29456
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| | ICD10 =
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| | OMIM =
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| | MedlinePlus = 000071
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| | eMedicineSubj = RADIO
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| | eMedicineTopic = 782
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| | MeshID = D003074
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| }}
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| {{Search infobox}}
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| '''For the WikiPatient page for this topic, click [[Solitary pulmonary nodule (patient information)|here]]''' | |
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| {{CMG}} | | {{CMG}}{{AE}}{{MV}} {{JE}} |
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| {{Editor Help}} | | {{SK}} SPN; Coin lesion; Pulmonary nodules; Solitary pulmonary nodules; Pulmonary nodule |
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| {{SK}} SPN, coin lesion
| | ==[[Pulmonary nodule overview|Overview]]== |
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| ==Overview== | | ==[[Pulmonary nodule historical perspective|Historical Perspective]]== |
| A '''solitary pulmonary nodule''' ('''SPN''') or '''coin lesion''' is a [[tumor|mass]] in the [[lung]] smaller than 3 centimeters in diameter. It can be an [[incidentaloma|incidental finding]] found in up to 0.2% of [[chest X-ray]]s<ref name="NEJM-cp">{{cite journal |author=Ost D, Fein AM, Feinsilver SH |title=Clinical practice. The solitary pulmonary nodule |journal=N. Engl. J. Med. |volume=348 |issue=25 |pages=2535–42 |year=2003 |month=June |pmid=12815140 |doi=10.1056/NEJMcp012290 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12815140&promo=ONFLNS19}}</ref> and around 1% of [[CT scan]]s.<ref name="pmid18402653">{{cite journal |author=Alzahouri K, Velten M, Arveux P, Woronoff-Lemsi MC, Jolly D, Guillemin F |title=Management of SPN in France. Pathways for definitive diagnosis of solitary pulmonary nodule: a multicentre study in 18 French districts |journal=BMC Cancer |volume=8 |issue= |pages=93 |year=2008 |pmid=18402653 |pmc=2373300 |doi=10.1186/1471-2407-8-93 |url=http://www.biomedcentral.com/1471-2407/8/93}}</ref>
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| The nodule most commonly represents a [[benign]] tumor such as a [[granuloma]] or [[hamartoma]], but in around 20% of cases it represents a [[malignant]] [[cancer]],<ref name="pmid18402653">{{cite journal |author=Alzahouri K, Velten M, Arveux P, Woronoff-Lemsi MC, Jolly D, Guillemin F |title=Management of SPN in France. Pathways for definitive diagnosis of solitary pulmonary nodule: a multicentre study in 18 French districts |journal=BMC Cancer |volume=8 |issue= |pages=93 |year=2008 |pmid=18402653 |pmc=2373300 |doi=10.1186/1471-2407-8-93 |url=http://www.biomedcentral.com/1471-2407/8/93}}</ref> especially in [[elderly|older adults]] and [[tobacco smoking|smokers]]. Conversely, 10 to 20% of patients with [[lung cancer]] are diagnosed in this way.<ref name="pmid18402653"/> Thus, the possibility of cancer needs to be excluded through further radiological studies and interventions, possibly including surgical resection. The [[prognosis]] depends on the underlying condition.
| | ==[[Pulmonary nodule classification|Classification]]== |
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| ==Definition== | | ==[[Pulmonary nodule pathophysiology|Pathophysiology]]== |
| A solitary pulmonary nodulus needs to be separated from larger lung tumors, smaller infiltrates or masses with other accompanying characteristics. An often used formal radiological definition is the following: a single lesion in the lung completely surrounded by lung [[parenchyma]] (functional tissue) with a diameter less than 3 cm and without associated [[pneumonia]], [[atelectasis]] (lung collaps) or [[lymphadenopathy|lymphadenopathies]] (swollen lymph nodes).<ref name="pmid12527568">{{cite journal |author=Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD |title=The solitary pulmonary nodule |journal=Chest |volume=123 |issue=1 Suppl |pages=89S–96S |year=2003 |month=January |pmid=12527568 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=12527568}}</ref><ref name="Radiology2006">{{cite journal |author=Winer-Muram HT |title=The solitary pulmonary nodule |journal=Radiology |volume=239 |issue=1 |pages=34–49 |year=2006 |month=April |pmid=16567482 |doi=10.1148/radiol.2391050343 |url=http://radiology.rsnajnls.org/cgi/pmidlookup?view=long&pmid=16567482}}</ref>
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| ==Differential diagnosis of causes of pulmonary nodule== | | ==[[Pulmonary nodule causes|Causes]]== |
| ===Common Causes===
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| Not every round spot on a radiological image is a coin lesion: it should not be confused with the projection of a structure of the [[chest wall]] or [[skin]], such as a nipple, a healing [[rib fracture]] or [[electrocardiography|electrocardiographic]] monitoring.
| | ==[[Pulmonary nodule differential diagnosis|Differentiating Pulmonary Nodule from Other Diseases]]== |
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| The most important cause to exclude is a form of lung cancer, including rare forms such as primary pulmonary [[lymphoma]], [[carcinoid tumor]] and a solitary [[metastasis]] to the lung (common unrecognised primary tumor sites are [[melanoma]]s, [[sarcoma]]s or [[testicular cancer]]). Benign tumors in the lung include [[hamartoma]]s and [[chondroma]]s.
| | ==[[Pulmonary nodule epidemiology and demographics|Epidemiology and Demographics]]== |
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| The most common benign coin lesion is a [[granuloma]] (inflammatory nodule), for example due to [[tuberculosis]] or a [[fungal infection]]. Other infectious causes include a pulmonary abscess, [[pneumonia]] (including [[Pneumocystis carinii pneumonia]]) or rarely [[Nocardia]]l infection or worm infection (such as dirofilariasis or dog heartworm infestation). Lung nodules can also occur in [[immune disorder]]s such as [[rheumatoid arthritis]] or [[Wegener's granulomatosis]].
| | ==[[Pulmonary nodule risk Factors|Risk Factors]]== |
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| An SPN can be found to be an [[arteriovenous malformation]], a [[hematoma]] or an [[infarction]] zone. It may also be caused by [[bronchial atresia]], sequestration, an inhaled [[foreign body]] or [[pleural plaque]].
| | ==[[Pulmonary nodule screening|Screening]]== |
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| === Complete Differential Diagnosis === | | ==[[Pulmonary nodule Natural History, Complications and Prognosis|Natural History, Complications and Prognosis]]== |
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| In alphabetical order <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002: 306-307 ISBN 1591032016 </ref>
| | ==[[Pulmonary nodule screening diagnosis|Diagnosis]]== |
| | | [[Solitary pulmonary nodule evaluation of solitary pulmonary nodule|Evaluation of solitary pulmonary nodule]] | [[Pulmonary module diagnostic study of choice|Diagnostic study of choice]] | [[Pulmonary nodule history and symptoms|History and Symptoms ]] | [[ Pulmonary nodule physical examination|Physical Examination]] | [[Pulmonary nodule laboratory studies|Laboratory Findings]]| | [[Pulmonary nodule Electrocardiogram|Electrocardiogram]] | [[Pulmonary nodule X-Ray Findings|X-Ray Findings]] | [[Pulmonary nodule Echocardiography and Ultrasound|Echocardiography and Ultrasound]] | [[Pulmonary nodule CT|CT]] | [[Pulmonary nodule MRI|MRI]] | [[Pulmonary nodule Other Imaging Findings|Other Imaging Findings]] | [[Pulmonary nodule other diagnostic studies|Other Diagnostic Studies]] |
| *[[Amyloid]]
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| *[[Arteriovenous malformation]]
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| *[[Aneurysm]] of the [[pulmonary artery]]
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| *Benign tumors
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| *[[Breast Cancer]]
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| *[[Bronchial atresia]]
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| *[[Bronchial carcinomas]]
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| *[[Bronchogenic cyst]]
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| *[[Cancer]]s
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| *[[Chondroma]]
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| *[[Endometriosis]]
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| *[[Fungal infection]]s
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| *[[Gastric Cancer]]
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| *[[Granulomas]]
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| *[[Hamartoma]]
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| *[[Hemangioma]]
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| *[[Hypernephroma]]
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| *[[Hystiocytosis X]]
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| *[[Lipoid pneumonia]]
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| *Localized [[pleural effusion]]
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| *Localized scar
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| *[[Lymphoma]]
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| *[[Metastases]]
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| *Mucoid impaction
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| *[[Multiple Myeloma]]
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| *[[Neurogenic tumor]]
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| *[[Nocardia]]
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| *Parasites
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| *[[Pneumonia]]
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| *[[Pulmonary infarction]]
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| *[[Pulmonary sequestration]]
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| *[[Prostate Cancer]]
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| *[[Rheumatoid nodule]]
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| *[[Sarcoma]]
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| *[[Seminoma]]
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| *[[Thyroid Cancer]]
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| *[[Tuberculosis]]
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| *Varicose [[pulmonary vein]]
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| ===Radiological features=== | |
| Several features help to distinguish benign conditions from possible lung cancer. The first parameter is the size of the lesion: the smaller, the less risk for malignant cancer.<ref name="Radiology2006"/> Benign causes tend to have a well defined border, whereas lobulated lesions or those with an irregular margin extending into the neighbouring tissue tend to be malignant.<ref name="Radiology2006"/>
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| If there is a central cavity, then a thin wall points to a benign cause whereas a thick wall is associated with malignancy (especially 4mm or less versus 16mm or more).<ref name="Radiology2006"/> In lung cancer, cavitation can represent central tumor [[necrosis]] (tissue death) or secondary abces formation. If the walls of an airway are visible (air bronchogram), [[bronchioloalveolar carcinoma]] is a possibility.
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| An SPN often contains calcifications. Certain patterns of calcification are reassuring, such as the popcorn-like appearance of hamartoma.<ref name="NEJM-cp"/> An SPN with a density below 15 Hounsfield units on [[computed tomography]] tends to be benign, whereas malignant tumors often measure more than 20 Hounsfield units. Fatty tissue inside hamartomas will have a strongly negative value on the Hounsfield scale.
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| The growth velocity of a lesion is also informative: very fast or very slow growing tumors are rarely malignant, in contrary to inflammatory or congenital conditions.<ref name="pmid10682770">{{cite journal |author=Erasmus JJ, Connolly JE, McAdams HP, Roggli VL |title=Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions |journal=Radiographics |volume=20 |issue=1 |pages=43–58 |year=2000 |pmid=10682770 |doi= |url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=10682770}}</ref> It is therefore important to retrieve previous imaging studies to see if a lesion was presented and how fast its volume is increasing. This is more difficult for nodules smaller than 1 centimeter. Moreover, the predictive value of stable lesion over a period of 2 years has been found to be rather low and unreliable.<ref name="pmid10682770"/>
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| [http://www.peir.net Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <div align="left">
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| <gallery heights="200" widths="200">
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| Image:Malignant solitary pulmonary nodule 1.jpg|Malignant solitary pulmonary nodule: The patient is a 67 year old woman with a solitary pulmonary nodule on a recent chest x-ray. A retrospective review of prior chest x-rays suggests that this is nodule is of recent origin. This lesion was felt to be too peripheral for reliable bronchial wash findings. Concern over potential sampling error associated with needle biopsy prompted a referral for PET imaging to rule out a malignant process.
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| Image:Malignant solitary pulmonary nodule 2.PET.jpg|After a 4 hour fast, the patient was injected with 10 mCi of 18-FDG IV and after allowing one hour for localization, transmission and emission PET data were acquired. A hypermetabolic focus can be seen in the left upper lobe corresponding to the chest x-ray abnormality. No other abnormalities are seen. The hypermetabolic nodule suggests a malignant process without metastasis. Lesions with only slight tracer uptake can be evaluated quantitatively for significance. A significant uptake value (SUV) can be calculated by dividing the mean activity in the suspicious area (mCi/ml) by the injected dose (mCi) per kilograms of body weight. Using a (SUV) of 2.5 or greater to define a malignancy, the sensitivity and specificity of 18-FDG-PET for detecting cancer in solitary pulmonary nodules greater than 1.2 cm approaches 90% with a nearly 100% specificity (1). False positives have included infectious etiologies, and sarcoid.
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| </gallery>
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| </div>
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| <gallery heights="200" widths="200">
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| Image:Pulmonary AVM as nodule 1.jpg|Chest x-ray: A 32 year old woman. 1. Two pulmonary arteriovenous malformations consistent with the nodules seen on the recent chest film. There is breathing artifact on several of the images and other tiny AVMs cannot be excluded. 2. Cardiomegaly with right atrial and left atrial enlargement and hepatic congestion.
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| Image:Pulmonary AVM as nodule 2.jpg|Thorax CT
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="200" widths="200">
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| Image:Pulmonary AVM as nodule 3.jpg|Thorax CT
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| Image:Pulmonary AVM as nodule 4.jpg|Thorax CT
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="200" widths="200">
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| Image:Pulmonary AVM as nodule 5.jpg|Thorax CT
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| Image:Pulmonary AVM as nodule 6.jpg|Thorax CT
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| </gallery>
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| </div>
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| <div align="left">
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| <gallery heights="200" widths="200">
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| Image:Pulmonary AVM as nodule 7.jpg|Thorax CT
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| Image:Pulmonary AVM as nodule 8.jpg|Thorax CT
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| </gallery>
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| </div>
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| ====Halo Sign====
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| *The halo sign refers to a zone of ground-glass attenuation surrounding a pulmonary nodule or mass on CT images.
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| *The presence of a halo of ground-glass opacity or ground-glass attenuation is usually associated with hemorrhagic nodules.
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| *In severely neutropenic patients, the halo sign is highly suggestive of infection by an angioinvasive fungus, most commonly [[Aspergillosis | Aspergillus]].
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| *Vascular invasion by this fungus results in thrombosis of small- to medium-sized vessels, which causes ischemic necrosis.
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| *At pathologic examination, the nodules represent foci of infarction, and the halo of ground-glass attenuation results from alveolar hemorrhage.
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| *Although it is less common, the halo sign may also be observed in nonhemorrhagic nodules, in which case either tumor cells or inflammatory infiltrate account for the halo of ground-glass attenuation.
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| ===Patient features===
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| Several patient factors may influence the likelihood of a benign versus a malignant condition: these include previous exposure to smoke or other [[carcinogen]]s such as [[asbestos]], and previously diagnosed cancer or [[respiratory infection]]s. A patient with airway symptoms, especially coughing up blood ([[hemoptysis]]), is more likely to have cancer compared to a patient with no respiratory symptoms.
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| ==Treatment== | | ==Treatment== |
| | [[Pulmonary nodule medical therapy|Medical Therapy]] | [[Pulmonary nodule Interventions |Interventions ]] | [[Pulmonary nodule surgery |Surgery]] | [[Pulmonary nodule primary prevention|Primary Prevention]] | [[Pulmonary nodule secondary prevention|Secondary Prevention]] | [[Pulmonary nodule cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Pulmonary nodule future or investigational therapies|Future or Investigational Therapies]] |
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| ===Recommendations for Follow-up and Management of Nodules <8 mm Detected Incidentally at Non-screening CT=== | | ==Case Studies== |
| | | [[Solitary pulmonary nodule case study one|Case #1]] |
| {| border="2" cellpadding="20" cellspacing="0"
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| !Nodule Size (mm)
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| !'''Low risk''' patients
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| !'''High risk''' patients
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| |-
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| |Less than or equal to 4
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| |No follow-up needed.
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| |Follow-up at 12 months. If no change, no further imaging needed.
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| |-
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| |>4 - 6
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| |Follow-up at 12 months. If no change, no further imaging needed.
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| |Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change.
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| |-
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| |>6 - 8
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| |Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change.
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| |Initial follow-up CT at 3 - 6 months and then at 9 -12 and 24 months if no change.
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| |-
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| |>8
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| |Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy
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| |Same at for low risk patients
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| |}
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| Note: Newly detected indeterminate nodule in persons 35 years of age or older.<ref>Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. [http://radiology.rsnajnls.org/cgi/content/abstract/237/2/395 Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society.] Radiology 2005 237: 395-400.</ref>
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| * '''Low risk patients''': Minimal or absent history of smoking and of other known risk factors.
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| * '''High risk patients''': History of smoking or of other known risk factors.
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| ==References==
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| <references/>
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| ==External Links== | | ==External Links== |
| * [http://www.fleischner.org/ Fleischner Society for Thoracic Imaging] | | *[https://www.youtube.com/watch?v=LKCAVaUONes Cleveland Clinic: Epidemiology and Management of the Solitary Pulmonary Nodule (Interactive Video)] |
| | *[https://www.youtube.com/watch?v=JUhlj2_w_i8 NEJM: Risk of Cancer in a CT-Discovered Nodule] |
| | *[http://www.chestx-ray.com/index.php/calculators/spn-calculator Solitary Pulmonary Nodule Malignancy Risk Calculator (Mayo Clinic model)] |
| | *[http://eradiology.bidmc.harvard.edu/LearningLab/respiratory/Said.pdf Summary: Solitary Pulmonary Nodule] |
| | *[http://www.aafp.org/afp/2009/1015/p827.html Evaluation of the Solitary Pulmonary Nodule] |
| | *[http://www.radiologyassistant.nl/en/p460f9fcd50637/solitary-pulmonary-nodule-benign-versus-malignant.html Solitary Pulmonary Nodule: benign versus malignant] |
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| {{Respiratory pathology}} | | {{Respiratory pathology}} |
| {{SIB}}
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| [[Category:Radiology]] | | [[Category:Radiology]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| [[Category:Signs and symptoms]] | | [[Category:Disease]] |
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