Pulmonary nodule differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Overview

Pulmonary nodule may be differentiated according to imaging (size, border characteristics, and attenuation), histological, and clinical features, from other diseases that demonstrate similar imaging findings. Common differential diagnosis of pulmonary nodule, include: hamartoma, granulomas, rheumatoid nodule, and single metastasis.[1][2]

Common Differential Diagnosis

  • The table below summarizes the findings that differentiate pulmonary nodule from other conditions that cause similar radiological findings on conventional radiograph.
Differential Diagnosis for Solitary Pulmonary
Adapted from Erasmus et al. [3]
Differential Diagnosis Causes
Malignant neoplasms
  • Bronchogenic carcinoma
  • Carcinoid tumor
  • Pulmonary lymphoma
  • Pulmonary sarcoma
  • Solitary metastases
Benign neoplasms
  • Hamartoma
  • Adenoma
  • Lipoma
Infectious inflammatory
  • Granuloma (tuberculous/fungal)
  • Nocardia infection
  • Round pneumonia
  • Abscess
Non-infectious inflammatory
  • Rheumatoid arthritis
  • Wegener's granulomatosis
  • Sarcoidosis
Vascular
  • Arteriovenous malformation
  • Infarction
  • Hematoma
Congenital
  • Bronchial atresia
Miscellaneous
  • External object
  • Pseudotumor
  • Pleural thickening

Differential Diagnosis

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical exam
Lab Findings CT scan Histopathology
Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Nodule content Other findings
Pulmonary Nodule(benign)

[4]

- - - - -
  • N/A
  • Normal
Normal Fat

Calcification

Types:

  • Central dense nidus
  • Diffuse solid
  • Laminated
  • Popcorn
  • well-defined smooth border
  • Growth rate > 18 months
  • Cavity wall thickness of 1 mm
  • N/A
N/A ↓ O2 Sat
Pulmonary Nodule (malignant)

[4][5]

++ ++ ++ + -
  • Normal
Tumor cells
  • Single or multiple
  • Small or > 2 cm of size
Calcification
  • Amorphous
  • Punctate
  • Reticular
  • Stippled or eccentric

Cavity

Ulceration

  • Spiculated border
  • Rapid growth rate (Doubling time 1-18 months)
  • Cavity wall thickness over 15 mm
Biopsy and histopathology ↓ O2 Sat
Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Abscess

[6]

++ - - + ++ Causative agents
  • Vary in size
  • Round in shape
. Histopathology Clubbing of finger
Septic pulmonary

emboli

[7]

- - - ++ ++ N/A
  • Multiple peripheral nodules
  • Size 0.5– 3.5 cm
  • Variable shapes
  • Central low attenuation
  • Feeding vessels
  • Pleura based wedge-shaped lesions
  • Air bronchogram
  • Abscess or infection related changes at the primary focus
  • N/A
Culture and sensitivity N/A
Fungal

infection

[8]

+/- + - + + KOH stain: Fungi
  • Multiple nodules
  • Size 0.5– 3 cm
  • nodules surrounded by ground-glass opacity/halo
  • Causative agent
Culture and sensitivity N/A
Parasites

[9]

+/- +/- +/- _ + N/A Cyst:

Coin lesion:

Visualization of parasite, egg or larvae N/A
Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Mycobacterial infections

[10][11]

+ + + ++ +/- AFB+
  • Micronodules in the subpleural region and peribronchovascular interstitium
  • Fluffy upper zone shadowing
  • Cavity
  • Fluffy upper zone shadowing
  • Interlobular septal thickening
  • Homogeneous and dense consolidation
Culture and sensitivity N/A
Chronic inflammatory conditions

(Granulomatosis with polyangiitis)

[12]

+/- + - + - N/A
  • Multiple round lesions
  • Size 0.5 to 10 cm
  • Patchy or diffuse ground-glass opacities, or both
Biopsy c-ANCA

p-ANCA

Diseases Productive cough Hemoptysis Weight loss SOB Fever Other Auscultation Sputum analysis Nodule Content Other findings Histopathology Gold standard Additional findings
Pulmonary AVMs

[13]

- +/- - + - RBCs
  • Solitary or multiple nodules
  • Round, oval, or polycyclic
  • Size 1 to 5 cm
  • Not done
Pulmonary angiography N/A
Pneumoconiosis + - + + - Inorganic particle
  • Solitary or multiple nodules
  • Size 1 - 10 cm
  • In the upper lobes
  • N/A
CT scan N/A

ABBREVIATIONS:

N/A: Not available , SOB: Shortness of breath, M/C: Most common

References

  1. Ost D, Fein AM, Feinsilver SH (2003). "Clinical practice. The solitary pulmonary nodule". N. Engl. J. Med. 348 (25): 2535–42. doi:10.1056/NEJMcp012290. PMID 12815140. Unknown parameter |month= ignored (help)
  2. 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 5;369(10):910-9. doi:10.1056/NEJMoa1214726.
  3. Solitary Pulmonary Nodule: Morphological Evaluation. http://pubs.rsna.org/doi/pdf/10.1148/radiographics.20.1.g00ja0343 Accessed on March 15, 2016
  4. 4.0 4.1 Khan AN, Al-Jahdali HH, Irion KL, Arabi M, Koteyar SS (October 2011). "Solitary pulmonary nodule: A diagnostic algorithm in the light of current imaging technique". Avicenna J Med. 1 (2): 39–51. doi:10.4103/2231-0770.90915. PMC 3507065. PMID 23210008.
  5. Li J, Xia T, Yang X, Dong X, Liang J, Zhong N, Guan Y (April 2018). "Malignant solitary pulmonary nodules: assessment of mass growth rate and doubling time at follow-up CT". J Thorac Dis. 10 (Suppl 7): S797–S806. doi:10.21037/jtd.2018.04.25. PMC 5945695. PMID 29780626.
  6. Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D (August 2015). "Lung abscess-etiology, diagnostic and treatment options". Ann Transl Med. 3 (13): 183. doi:10.3978/j.issn.2305-5839.2015.07.08. PMC 4543327. PMID 26366400.
  7. Chang E, Lee KH, Yang KY, Lee YC, Perng RP (2009). "Septic pulmonary embolism associated with a peri-proctal abscess in an immunocompetent host". BMJ Case Rep. 2009. doi:10.1136/bcr.07.2008.0592. PMC 3029652. PMID 21686732.
  8. Chong, Semin; Lee, Kyung Soo; Yi, Chin A; Chung, Myung Jin; Kim, Tae Sung; Han, Joungho (2006). "Pulmonary fungal infection: Imaging findings in immunocompetent and immunocompromised patients". European Journal of Radiology. 59 (3): 371–383. doi:10.1016/j.ejrad.2006.04.017. ISSN 0720-048X.
  9. Kunst H, Mack D, Kon OM, Banerjee AK, Chiodini P, Grant A (June 2011). "Parasitic infections of the lung: a guide for the respiratory physician". Thorax. 66 (6): 528–36. doi:10.1136/thx.2009.132217. PMID 20880867.
  10. Ryu YJ (April 2015). "Diagnosis of pulmonary tuberculosis: recent advances and diagnostic algorithms". Tuberc Respir Dis (Seoul). 78 (2): 64–71. doi:10.4046/trd.2015.78.2.64. PMC 4388902. PMID 25861338.
  11. Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  12. Kubaisi B, Abu Samra K, Foster CS (May 2016). "Granulomatosis with polyangiitis (Wegener's disease): An updated review of ocular disease manifestations". Intractable Rare Dis Res. 5 (2): 61–9. doi:10.5582/irdr.2016.01014. PMC 4869584. PMID 27195187.
  13. Khurshid I, Downie GH (April 2002). "Pulmonary arteriovenous malformation". Postgrad Med J. 78 (918): 191–7. PMC 1742331. PMID 11930021.