The Solitary Pulmonary Nodule

doi:10.1378/chest.123.1_suppl.89S

Chest

Volume 123, Issue 1, Supplement, January 2003, Pages 89S-96S

https://doi.org/10.1378/chest.123.1_suppl.89S Get rights and content

More than 150,00 patients a year present to their physicians with the diagnostic dilemma of a solitary pulmonary nodule (SPN) found either on chest radiography or chest CT. A thoughtful and timely workup of this finding is essential if lung cancer is to be recognized early and the chance for cure optimized. Based on the literature to date, recommendations are made for appropriate imaging modalities and diagnostic testing, as well as indications for obtaining preoperative tissue diagnosis for the patient with an SPN.

Section snippets

Differential Diagnosis

The differential diagnosis of an SPN includes neoplastic, infectious, inflammatory, vascular, traumatic, and congenital lesions.² Other benign etiologies for SPNs are rheumatoid nodules, intrapulmonary lymph nodes, plasma cell granulomas, and sarcoidosis. Although most SPNs are benign,²⁵ primary malignancy may be found in approximately 35% of SPNs, and solitary metastases can account for another 23%.⁶⁷⁸ Clinical characteristics such as older age, a history of cigarette smoking, and a previous

Radiologic Diagnostics: CXRs

Since the SPN is by definition a radiographic finding, radiologic imaging is intrinsic to the diagnostic workup. Essentially all SPN are found on CXRs or incidentally on CT. The CXR is an excellent initial imaging study for patients with symptoms, or as routine follow-up for patients with known pulmonary lesions. The indications and efficacy of CXRs for routine cancer surveillance are beyond the scope of this chapter and are discussed in the chapter on “Follow-up and Surveillance” in these

Radiographic Diagnostics: Chest CT

Spiral CT with IV contrast enhancement is the imaging modality of choice for the SPN and should be obtained on all newly diagnosed SPNs. CT provides ideal imaging for characterizing the nodule and its location. The CT scan can also be used to identify synchronous lung lesions or metastatic liver or adrenal lesions or mediastinal lymph nodes. Chest CT is also helpful for assessment of chest wall, mediastinal, or diaphragmatic invasion or for evaluation of superior sulcus (Pancoast) tumors. Of

Radiologic Diagnostics: MRI

MRI has a very limited role in the evaluation of the SPN. It may be beneficial in the patient who cannot tolerate IV contrast. MRI may also allow better anatomic evaluation of the lung apices, thoracic inlet, chest wall, or diaphragm due to its ability to provide sagittal, coronal, and oblique images. In general, the cost of MRI is not worth the lower risk of contrast-induced toxicity for most patients, as the imaging accuracy of CT is as good for most locations of SPNs. With the exception of

Tissue Diagnosis: TTNA

Obtaining a tissue diagnosis via TTNA is somewhat less invasive than bronchoscopy and Wang needle biopsy and does not require IV sedation. Certainly, it is much less invasive than surgery, but a nonmalignant diagnosis may not be believed and TTNA and bronchoscopy can at best only be diagnostic, not therapeutic. The sensitivity for malignancy is 64 to 100%.³⁹⁴⁰ Unfortunately, the sensitivity of TTNA for a specific benign diagnosis is 12 to 68% but only 12% in a number of studies.⁴¹ Adding

Tissue Diagnosis: Bronchoscopy

Bronchoscopy may be an good approach for obtaining a tissue diagnosis in the large, central lung mass or in those with endobronchial encroachment, as diagnostic yield is 70% and 90%, respectively.⁴⁵⁴⁶⁴⁷⁴⁸⁴⁹ The best application of bronchoscopy and TBNA is for staging of NSCLC by aspirating enlarged mediastinal lymph nodes. The discovery of metastatic disease will change patient management and obviates any further surgical staging. However, for the patient with a peripheral lung nodule, there is

Surgery

The patient with an SPN that is new and does not have benign appearing calcifications should be considered to have a malignancy until proven otherwise. Surgical resection is the ideal approach, as it is both diagnostic and therapeutic. If it is believed that based on patient history that the SPN may not be NSCLC but rather metastatic disease, then thoracoscopy and wedge resection is an accepted initial surgical approach. The specimen should be sent for frozen section, so that conversion to a

Follow-up

The patient with an SPN who does not have a tissue diagnosis and who is deemed acceptable for observation should be followed up closely for a minimum of 2 years. This should include an initial CXR, and CT scanning at 3, 6, 12, and 24 months for best monitoring for nodule growth. There is very little objective evidence for frequency of surveillance monitoring.

Summary of Recommendations

1.
For patients with an SPN that is visible on CXR, all previous CXRs should be reviewed. Level of evidence, poor; benefit, substantial; grade of recommendation, C
2.
For all patients with previous CXRs, an SPN that is unchanged for > 2 years does not require further diagnostic evaluation. Level of evidence, fair; benefit, substantial; grade of recommendation, B
3.
For patients with an SPN visible on CXR in which benign central calcification is present, no further diagnostic evaluation is necessary. Level

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Detection of pulmonary nodules on chest x-rays is an important task for radiologists. Previous studies have shown improved detection rates using gray-scale inversion. The purpose of our study was to compare the efficacy of gray-scale inversion in improving the detection of pulmonary nodules on chest x-rays for radiologists and machine learning models (ML). We created a mixed dataset consisting of 60, 2-view (posteroanterior view – PA and lateral view) chest x-rays with computed tomography confirmed nodule(s) and 62 normal chest x-rays. Twenty percent of the cases were separated for a testing dataset (24 total images). Data augmentation through mirroring and transfer learning was used for the remaining cases (784 total images) for supervised training of 4 ML models (grayscale PA, grayscale lateral, gray-scale inversion PA, and gray-scale inversion lateral) on Google's cloud-based AutoML platform. Three cardiothoracic radiologists analyzed the complete 2-view dataset (n=120) and, for comparison to the ML, the single-view testing subsets (12 images each). Gray-scale inversion (area under the curve (AUC) 0.80, 95% confidence interval (CI) 0.75-0.85) did not improve diagnostic performance for radiologists compared to grayscale (AUC 0.84, 95% CI 0.79-0.88). Gray-scale inversion also did not improve diagnostic performance for the ML. The ML did demonstrate higher sensitivity and negative predictive value for grayscale PA (72.7% and 75.0%), grayscale lateral (63.6% and 66.6%), and gray-scale inversion lateral views (72.7% and 76.9%), comparing favorably to the radiologists (63.9% and 72.3%, 27.8% and 58.3%, 19.5% and 50.5% respectively). In the limited testing dataset, the ML did demonstrate higher sensitivity and negative predictive value for grayscale PA (72.7% and 75.0%), grayscale lateral (63.6% and 66.6%), and gray-scale inversion lateral views (72.7% and 76.9%), comparing favorably to the radiologists (63.9% and 72.3%, 27.8% and 58.3%, 19.5% and 50.5%, respectively). Further investigation of other post-processing algorithms to improve diagnostic performance of ML is warranted.
Predicting lung nodules malignancy
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It is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting.
The authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy.
From a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573.
The prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.
Bronchoscopy
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Bronchoscopy is an endoscopic technique used to visualize the tracheobronchial tree for diagnostic and therapeutic purposes. Using a cytology brush or transbronchial needle aspiration, samples of bronchoalveolar fluid or lung tissue may be obtained from the upper and lower respiratory tract and help diagnose respiratory tract infections, lung cancer or other cancer types that metastasize to the lungs, and diffuse parenchymal lung diseases. Depending on the situation, a pulmonologist, intensivist, anesthesiologist, or surgeon may perform the procedure. Procedure-related mortality is extremely rare (0.01%), and reported complication rates are 0.08%–6.8%. Medication implications focus on: 1) minimizing bleeding by withholding P2Y₁₂ inhibitors, warfarin, and/or direct oral anticoagulants; 2) ensuring appropriate blood glucose control by adjusting oral hypoglycemic agents and insulin therapy; and 3) optimizing blood pressure control by adjusting antihypertensive therapy periprocedurally.
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Las fracturas por insuficiencia o fracturas patológicas son aquellas que se producen tras un mínimo traumatismo o sin traumatismo previo y que asientan sobre huesos normalmente patológicos. Las fracturas que aparecen con patrones anormales o la presencia de varias fracturas que aparecen en un corto periodo de tiempo o sin traumatismo aparente o importante deben hacer sospechar su presencia.
Ante la confirmación de una fractura patológica, se debe hacer diagnóstico diferencial con las fracturas tumorales o por metástasis, si existe antecedente de neoplasia primaria de base.
El cáncer de pulmón ha variado su epidemiologia debido al ingreso de la mujer en el hábito tabáquico. En mujeres, el tipo de cáncer pulmonar más frecuente es el adenocarcinoma de pulmón, el cual es menos agresivo y presenta menor mortalidad, con una sobrevida a los 5 años del 9,5%. Este hecho hace que en España hasta un 44% de los nódulos pulmonares se deban a adenocarcinomas. Por lo tanto, todo nódulo pulmonar solitario debe ser monitorizado por lo menos durante 5 años.
El antecedente de nódulo pulmonar solitario es un hallazgo que se da en una de cada 1.000 radiografías. Sin embargo, en menores de 35 años solo el 1% es maligno. El antecedente de malignidad y una edad mayor de 35 años eleva la malignidad al 68%. Un tamaño mayor de 3 cm eleva el porcentaje de malignidad hasta un 93%. Por lo tanto, ante el antecedente de un nódulo pulmonar solitario en una mujer, fumadora y mayor de 50 años, este nódulo debe considerarse como maligno mientras no se demuestre lo contrario.
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Insufficiency fractures, or pathological fractures, are produced after minimal trauma or no prior trauma and normally affect weakened bone. Their presence should be suspected in fractures showing abnormal patterns, when several fractures occur in a short period of time and in those with no apparent or only minimal trauma.
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Chest

The Solitary Pulmonary Nodule*

Section snippets

Differential Diagnosis

Radiologic Diagnostics: CXRs

Radiographic Diagnostics: Chest CT

Radiologic Diagnostics: MRI

Tissue Diagnosis: TTNA

Tissue Diagnosis: Bronchoscopy

Surgery

Follow-up

Summary of Recommendations

Radiol Clin North Am

Chest

Chest

Clin Chest Med

Chest

Radiol Clin North Am

Clin Chest Med

Clin Chest Med

Chest

Chest

Chest

Chest

Glossary of terms for thoracic radiology: recommendations of the Nomenclature Committee of the Fleischner Society

Am J Roentgenol

Clinical oncology

Lung cancer: small solitary pulmonary nodules

Radiol Clin North Am

Cancer statistics, 2001

CA Cancer J Clin

Cancer statistics, 2002

CA Cancer J Clin

The probability of malignancy in solitary pulmonary nodules: application to small radiologically indeterminate nodules

Arch Intern Med

Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis: Part I. Theory

Radiology

Neural networks for the analysis of small pulmonary nodules

Clin Imaging

Computerized analysis of the likelihood of malignancy in solitary pulmonary with use of artificial neural networks

Radiology

Management of solitary pulmonary nodules: how to decide when resection is required

Postgrad Med

When is it malpractice to miss lung cancer on chest radiographs?

Radiology

Radiologic screening in the early detection of lung cancer

Radiol Clin North Am

Non-small cell lung cancer: results of the New York screening program

Radiology

Lung cancer detected during a screening program using 4-month chest radiographs

Radiology

retrospective review of survey photofluorograms of persons with lung cancer

Cancer

The Solitary Pulmonary Nodule^*