Lung mass evaluation

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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 lung mass is the malignancy assessment. The evaluation approach of lung mass will mainly depend on the initial morphological evaluation of the mass (size, margins, contours, calcification pattern, and growth). Other characteristics, such as location, clinical features, and distribution, may be helpful for the therapeutic management, surveillance, and follow-up of lung mass. Lung mass can be divided into 2 categories: benign pulmonary mass and malignant lung mass. Based upon these categories, complementary diagnostic studies and management, include: PET/CT scan, CT scan, non-surgical biopsy, and surgical resection.

Lung Mass Evaluation

• The algorithm below summarizes the initial lung mass evaluation according to imaging features.

Lung Mass Detected

Step 1: Assess likelihood of cancer ❑ Request enhanced CT scan

Step 2: What are the imaging features?

Hyperdense pulmonary mass ❑ Internal calcification

Cavitating pulmonary mass ❑ Gas-filled area ❑ Thick wall (must be greater than 2-5 mm)

Other diagnostic studies ❑ Sputum cytology ❑ Endobronchial ultrasound ❑ Endoscopic ultrasound ❑ Bronchoscopy ❑ Mediastinoscopy ❑ PET/CT

Biopsy

Lung opacity on Chest X ray (CXR)

Size >3 cms; classified as lung mass

Size <3 cms; classified as pulmonary nodule

High resolution chest CT scan

Check previous CXR

Imaging features

Previous CXR normal; suggesting new growth

Previous CXR shows opacity but stable in size since then

Hyperdense pulmonary mass ❑Internal/eccentric calcification

Cavitating pulmonary mass ❑ Gas-filled area ❑ Thick/spiculated wall (must be greater than 2-5 mm)

Follow up every 2-3 yrs

Other diagnostic studies ❑ Sputum cytology ❑ Endobronchial ultrasound ❑ Endoscopic ultrasound ❑ Bronchoscopy ❑ Mediastinoscopy

High resolution chest CT scan

Highly suspicious for malignancy •Age >60yrs •Current smoker •Size >2cms

Suspicious for malignancy •Age 40-60yrs •Current smoker •Size 0.8-2cms

Benign features •Age <40yrs •Non smoker •Size <0.8cm

PET or biopsy

Serial CT scans

PET with biopsy

Malignancy

No evidence of malignancy

Surgical excision/Chemo depending upon histopathology

No growth over time

Lesion grows over time

Surgical excision/Chemo depending upon histopathology

Serial CT scans

No further workup

PET with or biopsy

Surgical excision/Chemo depending upon histopathology

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