Evaluation of a mediastinal mass Mediastinal Masses Mediastinal masses are caused by a variety of cysts and tumors; likely causes differ by patient age and location of the mass (anterior, middle, or posterior mediastinum). They may be asymptomatic... read more is discussed elsewhere.
Solitary pulmonary nodules are most often detected incidentally when a CT or chest x-ray is taken for other reasons, or during lung cancer screening. Nonpulmonary soft-tissue densities caused by nipple shadows, warts, cutaneous nodules, and bone abnormalities are often confused for a nodule on chest x-ray.
Etiology of Solitary Pulmonary Nodule
Although cancer is usually the primary concern, solitary pulmonary nodules have many causes (see table ). Of these, the most common vary by age and risk factors, but typically include
Evaluation of Solitary Pulmonary Nodule
The primary goal of evaluation is to detect cancer and active infection.
History may reveal information that suggests malignant and nonmalignant causes of a solitary pulmonary nodule and includes
Current or past cigarette smoking
History of cancer or an autoimmune disorder
Occupational risk factors for cancer (eg, exposure to asbestos, vinyl chloride, radon)
Travel to, or living in, areas with endemic mycosis or a high prevalence of tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more (TB)
Risk factors for opportunistic infections (eg, HIV, immune deficiency)
Older age, cigarette smoking, and history of cancer all increase the probability of cancer and are used along with the nodule diameter to estimate likelihood ratios for cancer.
A thorough physical examination may uncover findings that suggest an etiology (eg, a breast lump or skin lesion suggestive of cancer) for a pulmonary nodule but cannot definitely establish the cause.
The goal of initial testing is to estimate the malignant potential of the solitary pulmonary nodule. The first step is a review of plain x-rays and then usually CT.
Radiographic characteristics help define the malignant potential of a solitary pulmonary nodule:
Growth rate is determined by comparison with previous chest x-ray or CT, if available. A lesion that has not enlarged in ≥ 2 years suggests a benign etiology. Tumors that have volume doubling times from 21 to 400 days are likely to be malignant.
Calcification suggests nonmalignant disease, particularly if it is central (tuberculoma, histoplasmoma), concentric (healed histoplasmosis), or in a popcorn configuration (hamartoma).
Margins that are spiculated or irregular (scalloped) are more indicative of cancer.
Diameter< 1.5 cm strongly suggests a benign etiology; diameter > 5.3 cm strongly suggests cancer. However, nonmalignant exceptions include lung abscess Lung Abscess Lung abscess is a necrotizing lung infection characterized by a pus-filled cavitary lesion. It is most commonly caused by aspiration of oral secretions by patients who have impaired consciousness... read more , granulomatosis with polyangiitis Granulomatosis with Polyangiitis (GPA) Granulomatosis with polyangiitis is characterized by necrotizing granulomatous inflammation, small- and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent... read more , and hydatid cyst Echinococcosis Echinococcosis is infection with larvae of the tapeworm Echinococcus granulosus (cystic echinococcosis, hydatid disease) or Echinococcus multilocularis (alveolar disease). Symptoms... read more .
Location in the upper lobe carries a higher risk of malignancy.
These characteristics are sometimes evident on the original plain film but usually require CT. CT can also distinguish pulmonary from pleural radiopacities. CT has a sensitivity of 70% and a specificity of 60% for detecting cancer.
The mainstay of diagnosis of solitary pulmonary nodules is interval imaging. Specific imaging recommendations depend on the size of the nodule and whether the nodule is ground-glass, semi-solid, or solid, and individual risk factors (history of heavy smoking, exposure to asbestos, family history of lung cancer, older age [ 1 Evaluation reference A solitary pulmonary nodule is a discrete lesion < 3 cm in diameter that is completely surrounded by lung parenchyma (ie, does not touch the hilum, mediastinum, or pleura) and is without... read more ]).
Positron emission tomography (PET) imaging Positron Emission Tomography (PET) Positron emission tomography (PET), a type of radionuclide scanning, uses compounds containing radionuclides that decay by releasing a positron (the positively charged antimatter equivalent... read more can help differentiate cancerous and benign nodules. PET is most often used to image nodules whose probability of being cancerous is intermediate or high. It has a sensitivity > 90% and a specificity of about 78% for detecting cancer. PET activity is quantified by the standardized uptake value (SUV) of (18)F-2-deoxy-2-fluoro-D-glucose (FDG). SUV >2.5 suggests cancer, while nodules with SUV < 2.5 are more likely to be benign. False-negative results are more likely if nodules are < 8 mm. False-negative PET scans can result from metabolically inactive tumors, and false-positive results can occur in various infectious and inflammatory conditions.
Cultures may be useful when historical information suggests an infectious cause (eg, TB, coccidioidomycosis Coccidioidomycosis Coccidioidomycosis is caused by the fungi Coccidioides immitis and C. posadasii; it usually occurs as an acute, benign, asymptomatic or self-limited respiratory infection. The... read more ) as a possible diagnosis.
Invasive testing options include
CT- or ultrasound-guided transthoracic needle aspiration
Although cancers can be diagnosed by biopsy, definitive treatment is resection, and so patients with a high likelihood of cancer with a resectable lesion should proceed to surgical resection. However, bronchoscopic endobronchial ultrasound-guided mediastinal lymph node biopsy is being used increasingly and is recommended by some experts as a less invasive way to diagnose and stage lung cancers before nodules are surgically resected.
Transthoracic needle aspiration Transthoracic Needle Biopsy Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis. Transthoracic needle biopsy is done to evaluate... read more is best for peripheral lesions and is particularly useful if infectious etiologies are strongly considered because using the transthoracic approach, as opposed to bronchoscopy, avoids the possibility of contamination of the specimen with upper airway organisms. The main disadvantage of transthoracic needle aspiration is the risk of pneumothorax, which is about 10%.
Flexible bronchoscopy allows for endobronchial washing, brushing, needle aspiration, and transbronchial biopsy. Yield is higher for larger, more centrally located lesions, but very experienced operators using specially designed thin scopes can successfully biopsy peripheral lesions that are < 1 cm in diameter.
In cases in which nodules are not accessible from these less invasive approaches, open surgical biopsy is necessary.
1. MacMahon H , Naidich DP, Goo JM: Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. Radiology 284(1): Supplement, 2017. https://doi.org/10.1148/radiol.2017161659
Treatment of Solitary Pulmonary Nodule
If the suspicion of cancer is very low, the lesions are very small (< 1 cm), or the patient refuses or is not a candidate for surgical intervention, observation using serial CT scanning is reasonable. The timing and duration of follow-up CT scans are based mostly on the size and morphology of the nodule (1 Treatment reference A solitary pulmonary nodule is a discrete lesion < 3 cm in diameter that is completely surrounded by lung parenchyma (ie, does not touch the hilum, mediastinum, or pleura) and is without... read more ). Other factors that influence monitoring frequency include the location of the nodule, presence of emphysema or fibrosis on CT scan, age, sex, race, family history, and history of tobacco use (1 Treatment reference A solitary pulmonary nodule is a discrete lesion < 3 cm in diameter that is completely surrounded by lung parenchyma (ie, does not touch the hilum, mediastinum, or pleura) and is without... read more ).
When cancer is the most likely cause or when nonmalignant causes are unlikely, patients should undergo resection unless surgery is contraindicated due to poor pulmonary function, comorbidities, or withholding of consent.
1. MacMahon H, Naidich DP, Goo JM, et al: Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 284(1): Supplement, 2017. https://doi.org/10.1148/radiol.2017161659