Evaluation of solitary pulmonary nodule

Diseases

Summary

A solitary pulmonary nodule is defined as a relatively round lesion that is <3 cm in diameter and completely surrounded by lung parenchyma. It is distinct from a lung lesion >3 cm in diameter, which is considered a lung mass and is usually presumed to be malignant until proved otherwise.[1] [2]

A solitary pulmonary nodule may be detected incidentally following computed tomography (CT) imaging/chest X-ray (CXR), or may be identified via lung cancer surveillance programs which utilize low-dose CT (LDCT). Pulmonary nodules are identified in approximately 1.6 million people annually in the US.[3]

All pulmonary nodules - including solid nodules, sub-solid nodules (also known as semi-solid nodules, which have both solid and ground-glass components), and nodules with a pure ground glass appearance - require assessment for risk of malignancy, with further action to be taken as appropriate.[4] [5]

Most national guidelines make separate recommendations regarding the evaluation and management of solid pulmonary nodules, pure ground-glass nodules, and sub-solid nodules.

Management goals

Following identification of a solitary pulmonary nodule, careful diagnostic evaluation and management is required to distinguish the benign nodule from the malignant nodule and, when malignancy is either confirmed or strongly suspected, to expedite treatment.

For solitary pulmonary nodules, established clinical features (e.g., patient age, smoking status) and radiographic findings (e.g., calcification, growth rate, size) help determine a probability of malignancy. These factors can be used to inform risk calculations based on models derived from large screening studies.[6] [7] If risk is deemed to be sufficiently high, noninvasive and/or invasive testing is used to more accurately determine the probability of malignancy to a level that enables a decision to be made regarding observation or resection. Therefore, the proper use of these tests mandates knowledge about their performance characteristics.

Library

Computed tomography (CT) showing a right upper lobe posterior cavitating nodule, with biopsy confirming granulomatosis with polyangiitis
Computed tomography (CT) showing a right upper lobe apical solid nodule with a surrounding 'ground glass' halo, in a patient with seropositive rheumatoid arthritis on methotrexate. Other similar nodules were seen throughout both lungs, and remain stable for >2 years, consistent with inflammatory benign rheumatoid nodules
Computed tomography (CT) showing two areas (red circles) of mucoid impaction of the left upper lobe subsegmental bronchi, resulting in appearance that mimics a nodule
Computed tomography (CT) showing two left lower lobe peripheral nodules (one slightly spiculated and the other with smoother margins) in a patient presenting with fever, high inflammatory serum markers, and blood cultures confirming Streptococcus intermedius. Both nodules completely resolved following a course of linezolid, consistent with septic emboli
Computed tomography (CT) showing a left upper lobe peripheral elongated nodule, with contrast enhancement and a clear feeding and draining side, consistent with a small arteriovenous malformation
Computed tomography (CT) showing a right lower lobe large nodule, with contrast enhancement and a clear feeding and draining side, consistent with an arteriovenous malformation
Computed tomography (CT) showing a benign calcified granuloma in the right middle lobe, stable >10 years. The patient reported previous pneumonia on the same side
A-D: calcification patterns of benign nodules; E, F: may be seen in malignant nodules
Computed tomography (CT) showing a right upper lobe spiculated solitary nodule within emphysema, in a current smoker with previous asbestos exposure. Note the visible pleural plaque on the left side. Resection histology revealed adenocarcinoma of the lung
Computed tomography (CT) showing a left upper lobe ground-glass nodule. This was eventually resected 2 years into surveillance because of growth and the histopathology confirmed adenocarcinoma of lung with mixed mucinous-lepidic pattern
Computed tomography (CT) sections with examples of semi-solid solitary nodules
Computed tomography (CT) showing a small left upper lobe nodule with smooth margins, subsequently found to be a solitary colorectal metastasis on resection
Computed tomography (CT) sections from two cases with benign perifissural nodules. Note the smooth margins and the normal undisturbed adjacent fissure
Computed tomography (CT) showing examples of malignant perifissural nodules. Note the spiculated edge of the nodules and the evident retraction of the adjacent fissure. Both resection tissue analyses confirmed adenocarcinoma of lung
Computed tomography (CT) showing a left upper lobe spiculated nodule with a pleural 'tag'. Resection histopathology confirmed a moderately-differentiated squamous cell lung cancer
Computed tomography (CT) showing a left upper lobe peripheral nodule with several pleural 'tags' and element of retraction of the adjacent pleura. Resection histopathology confirmed a well-differentiated squamous cell lung cancer
Initial approach to solid pulmonary nodules
Solid pulmonary nodule surveillance algorithm. VDT, volume doubling time
Sub-solid pulmonary nodules algorithm. PSNs, part solid nodules; SSN, sub-solid nodules
PET CT scan with 18-fluorodeoxyglucose (18-FDG) showing a low uptake in a semi-solid right upper lobe posterior lesion. Surgical resection confirmed adenocarcinoma with primarily lepidic pattern
PET CT scan with 18-fluorodeoxyglucose (18-FDG) showing a high uptake peripheral left lung lesion. Surgical resection confirmed a moderately differentiated squamous cell lung cancer
Computed tomography (CT) section with soft tissue configuration, showing a right lung hamartoma, as incidental finding in an asymptomatic patient. Note the central calcification and several small spots of fat within the nodule. This nodule was stable over a 12 year period and no intervention required
Computed tomography (CT) showing a small peripheral triangular nodule in the right lower lobe, consistent with an intrapulmonary lymph node
Computed tomography (CT) showing a posterior left upper lobe spiculated nodule, with 'bronchus sign' in a female non-smoker. Bronchoscopic forceps biopsy and brushing assisted by radial EBUS miniprobe localisation, confirmed a non-Hodgkin's lymphoma
Computed tomography (CT) section capturing the transthoracic core biopsy needle targeting a left lower lobe lobulated nodule. Histopathology confirmed a well-differentiated squamous cell lung cancer

Citations

Key Articles

Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-54.[Full Text]
American College of Radiology. ACR appropriateness criteria: incidentally detected indeterminate pulmonary nodule. 2023 [internet publication].[Full Text]
Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e93S-120.[Abstract][Full Text]
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. 2017 Jul;284(1):228-43.[Abstract][Full Text]
Ruparel M, Quaife SL, Navani N, et al. Pulmonary nodules and CT screening: the past, present and future. Thorax. 2016 Apr;71(4):367-75.[Abstract][Full Text]

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