Solitary pulmonary nodule evaluation of solitary pulmonary nodule
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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
A hallmark feature in the evaluation of pulmonary nodule is the malignancy risk assessment. The evaluation approach for pulmonary nodule will mainly depend in the initial morphological evaluation of the nodule (size, margins, contours, and growth). Other characteristics, such as location, clinical features, and distribution may be helpful in the risk assessment, management, surveillance, and follow-up of pulmonary nodule. Pulmonary nodule can be divided into 3 risk categories: low risk, intermediate/moderate, and high risk. Based upon these risk categories, complementary diagnostic studies and management include: PET/CT scan, CT scan, non-surgical biopsy, and surgical resection.
Evaluation of Solitary Pulmonary Nodule
Initial Evaluation Algorithm
Solitary Pulmonary Nodule Detected | |||||||||||||||||||||||||||||||||
Step 1: Assess likelihood of cancer ❑ Mayo Clinic Malignancy Risk Calculator | |||||||||||||||||||||||||||||||||
| Step 2: Review prior films Is there a growth? | No previous films *Refer to step 2A | ||||||||||||||||||||||||||||||||
| Yes, growing | No, stable | ||||||||||||||||||||||||||||||||
Step 2A Enhanced Computed Tomography | Step 2B Surveillance | ||||||||||||||||||||||||||||||||
Location ❑ Upper lobe ❑ Lower lobe ❑ Middle lobe Size ❑ < 8mm ❑ > 8mm Lesion characteristics ❑ Margins (irregular/regular) ❑ Shape (spiculated/rounded) ❑ Attenuation | |||||||||||||||||||||||||||||||||
Other Diagnostic Studies ❑ PET/CT scan | |||||||||||||||||||||||||||||||||
| Low risk ❑ < 5% | Intermediate risk ❑ 5-65% | High risk ❑ > 65% | |||||||||||||||||||||||||||||||
| Serial CT scans | Non-surgical biopsy *Refer to Step 3: Treatment and Follow-up | Surgical resection *Refer to Step 3: Treatment and Follow-up | |||||||||||||||||||||||||||||||
Step 3: Treatment and Follow-up | |||||||||||||||||||||||||||||||||
Malignancy Risk Assessment
The malignancy risk assessment for pulmonary nodule considers the following factors:[1]
- Age
- Smoking
- Current
- Never smoker
- Extrathoracic cancer more than 5 years prior
- Nodule diameter
- Spiculation
- Yes
- No
- Upper lobe
- Yes
- No
The malignancy of pulmonary nodule can be categorized into 3 groups:[2]
Low Probability
- Usually less than < 5 percent
- The nodule size is less than or equal to 4 mm
- The nodule size may also be between 4 - 6 mm, with no associated risk factors
- Observation is suggested
- Observation usually involves radiologic surveillance with serial CT scans
Intermediate Probability
- Between 5 to 65 percent
- The nodule size is between 6 - 8 mm
- The nodule size is more than > 8 mm with associated risk factors
- Diagnostic testing is indicated: Positron emission tomography (PET), CT-FNA, and bronchoscopy
High Probability
- More than > 65 percent
- The nodule size is more than > 8 mm with associated risk factors
- Diagnostic testing is indicated: Positron emission tomography (PET), CT-FNA, and bronchoscopy
- Surgical excision
The patient risk assessment of pulmonary nodule can be categorized into 2 groups:[2]
- High Risk Patients
- Patient age is > 35
- Positive smoking history
- Male patients
- Positive for prior malignancy
- Other associated risk factors.
- Low Risk Patients
- Patient age < 35
- No smoking history
- Female patients
- Negative for prior malignancy
- No associated risk factors
References
- ↑ 1.0 1.1 Swensen SJ, Silverstein MD, Ilstrup DM, et. al. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. 1997 Apr 28;157(8):849-55.
- ↑ 2.0 2.1 Albert RH, Russell JJ (2009). "Evaluation of the solitary pulmonary nodule". Am Fam Physician. 80 (8): 827–31. PMID 19835344.