Lung mass resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:

Overview

Lung mass (also known as "Pulmonary mass") is defined as any area of pulmonary opacification that measures more than 30 mm (3 cms) in the lung. Lung mass are abnormal growths found in the lung which can be either be benign or malignant. The most common cause of a pulmonary mass is lung cancer. Other causes of lung mass include granuloma, lipoma, tuberculosis, and aspergillosis.

Classification

Lung mass may be classified on the basis of histopathology into benign lung mass and malignant lung mass. In addition, lung mass can be sub-classified according to the location, imaging features, size, and distribution.

Lung mass

Location

Histology

Imaging Features

•Pleural •Endobronchial •Parenchymal

•Malignant mass •Benign mass

•Hyperdense pulmonary mass •Cavitating pulmonary mass

Causes

The common causes of lung mass include:

• Lung cancer
• Hamartomas
• Hodgkin's lymphoma
• Pleural malignant mesothelioma
• Metastasis
• Fibroma
• Lymphoma
• Asbestos
• Lung abscess
• Lipomas
• Rheumatoid arthritis
• Silica
• Smoking
• Tuberculosis

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients of lung mass.

Identify cardinal findings that increase the pretest probability of lung mass ❑ Dyspnea ❑ Chronic cough ❑ Hemoptysis ❑ Wheezing ❑ Chest pain ❑Cachexia ❑Fatigue ❑Loss of appetite ❑Dysphonia

Advise chest x ray (CXR)

Lung opacity on Chest X ray (CXR)

Size >3 cms; classified as lung mass

Size <3 cms; classified as pulmonary nodule

High resolution chest CT scan

Check previous CXR

Imaging features

Previous CXR normal; suggesting new growth

Previous CXR shows opacity but stable in size since then

Hyperdense pulmonary mass ❑Internal/eccentric calcification

Cavitating pulmonary mass ❑ Gas-filled area ❑ Thick/spiculated wall (must be greater than 2-5 mm)

Follow up every 2-3 yrs

Other diagnostic studies ❑ Sputum cytology ❑ Endobronchial ultrasound ❑ Endoscopic ultrasound ❑ Bronchoscopy ❑ Mediastinoscopy

High resolution chest CT scan

Highly suspicious for malignancy •Age >60yrs •Current smoker •Size >2cms

Suspicious for malignancy •Age 40-60yrs •Current smoker •Size 0.8-2cms

Benign features •Age <40yrs •Non smoker •Size <0.8cm

PET or biopsy

Serial CT scans

PET with biopsy

Malignancy

No evidence of malignancy

Surgical excision/Chemo depending upon histopathology

No growth over time

Lesion grows over time

Surgical excision/Chemo depending upon histopathology

Serial CT scans

No further workup

PET with or biopsy

Surgical excision/Chemo depending upon histopathology

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

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Characterize the symptoms: ❑ Low grade fever ❑ Cough ❑ Chest pain ❑ Dyspnea ❑ At rest ❑ Exertional ❑ Wheezing ❑ Hemoptysis ❑ Anorexia ❑ Cyanosis ❑ Hoarseness ❑ Fatigue ❑ Syncope Obtain a detailed history: Past medical history ❑Personal history of cancer ❑Family history of cancer ❑Positive history of active/passive smoking ❑Number of cigarettes/year ❑Number of years/months of active smoking ❑Number of years/months of second-hand smoking ❑Number of years/months of smoking cessation ❑Previous primary infection of tuberculosis ❑Onset of pulmonary symptoms ❑Acute (< 6 weeks) ❑Chronic (> 6 weeks) ❑Previous or current lung disease, such as: ❑Chronic obstructive pulmonary disease ❑Interstitial lung disease ❑ Medication history ❑ Intake of the following drugs: ❑ Alcohol ❑ Chemotherapy drugs

Examine the patient: General appearance: ❑Older age in relation to chronological age ❑Lethargic ❑Confused Vitals: ❑Low-grade fever ❑Decreased SPO2 ❑Tachypnea ❑Tachycardia Weight: ❑ Measure weight daily at the same time after the first void Skin ❑ Pallor ❑ Cool and clammy (suggestive of hypoperfusion) ❑ Cyanosis (suggestive of severe hypoxemia) ❑ Anasarca HEENT examination: ❑ Jugular vein distention (suggestive of Pulmonary HTN) ❑ Positive hepatojugular reflux ❑ Lymphadenopathy Respiratory examination Inspection ❑ Hoarseness ❑ Rapid rate of breathing Auscultation ❑ Wheeze ❑Pleural friction rub ❑Egophony ❑Crackling or bubbling noises ❑Whispered pectoriloquy ❑Decreased/absent breath sounds ❑ Dullness at lung bases (suggestive of pleural effusion ❑ Crackles/crepitations/rales (suggestive of pleural effusion) ❑ Cheyne-stokes respiration Percussion ❑Hyporesonance ❑Dull percussion ❑Tactile fremitus ❑Reduced chest expansion Abdominal examination ❑ Hepatomegaly Musculoskeletal ❑Palpable soft-tissue mass Extremity examination ❑ Pedal edema ❑ Clubbing of fingers ❑ Swelling of hands and feet ❑ Weakness Neurological examination ❑ Altered mental status ❑ Slurred speech