Solitary pulmonary nodule evaluation of solitary pulmonary nodule: Difference between revisions

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VisualWikitext

Latest revision as of 17:03, 28 June 2019

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

Imaging evaluation

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

Cancer

Extrathoracic cancer more than 5 years prior

Nodule diameter
Spiculation

Yes
No

Upper lobe

Yes
No

The risk calculator is not validated for patients with history of cancer in the past 5 years.^[1]

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.

[calculator-1] 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.

[pmid19835344-2] 2.0 ^2.1 Albert RH, Russell JJ (2009). "Evaluation of the solitary pulmonary nodule". Am Fam Physician. 80 (8): 827–31. PMID 19835344.

[1]

[2]

@@ Line 5: / Line 5: @@
 ==Overview==
-A hallmark feature in the evaluation of solitary pulmonary nodule is the malignancy risk assessment. The evaluation approach of solitary 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 for the risk assessment, therapeutical management, surveillance, and follow-up of solitary pulmonary nodule. Solitary pulmonary nodule can be divided into 4 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.
+A [[hallmark]] feature in the evaluation of pulmonary nodule is the [[Cancer|malignancy]] risk assessment. The evaluation approach for pulmonary nodule will mainly depend in the initial [[Morphology|morphological]] evaluation of the [[Nodule (medicine)|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 [[Diagnosis|diagnostic]] studies and management include: [[Positron emission tomography|PET]]/[[Computed tomography|CT scan]], [[Computed tomography|CT scan]], non-surgical [[biopsy]], and [[Resection|surgical resection]].
 ==Evaluation of Solitary Pulmonary Nodule==
@@ Line 21: / Line 21: @@
 {{familytree | | | C01 | | | | C02 | | | | C01=<div style="width: 17em; padding:1em;text-align:center">'''Step 2A'''<br>'''[[Solitary pulmonary nodule CT|'''Enhanced Computed Tomography''']] </div>|C02=<div style="width: 15em; padding:1em;">'''Step 2B'''<br>'''Surveillance'''</div>}}
 {{familytree | | | |!| | | | | | | | | | | |}}
-{{familytree | | | C03 | | | | | | | | | | | |C03=<div style="width: 10em; padding:0.2em;">'''Imaging evaluation'''</div>}}
+{{familytree | | | C03 | | | | | | | | | | | |C03=<div style="width: 10em; padding:0.2em;">[[Solitary pulmonary nodule imaging|'''Imaging evaluation''']]</div>}}
 {{familytree|boxstyle= border-top: 0px;| | | C04 | | | | | | | | | | | C04=<div style="width: 17em; padding:1em;text-align:left">'''Location'''<br> ❑ Upper lobe <br> ❑ Lower lobe  <br> ❑ Middle lobe <br>'''Size'''<br> ❑ < 8mm <br> ❑ > 8mm <br>'''Lesion characteristics'''<br>  ❑ Margins (irregular/regular)<br>  ❑ Shape (spiculated/rounded)<br>  ❑ Attenuation </div>}}
 {{familytree | | | |!| | | | | | | | | | | |}}
@@ Line 34: / Line 34: @@
 {{familytree | | | | | | F01 | | | | | | | F01=<div style="width: 15em; padding:1em;">'''Step 3: [[Solitary pulmonary nodule medical therapy|'''Treatment and Follow-up''']]''' </div>}}
 {{familytree/end}}
+==Malignancy Risk Assessment==
+The [[Cancer|malignancy]] risk assessment for pulmonary nodule considers the following factors:<ref name="calculator">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.</ref>
+*Age
+*[[Smoking]]
+:*Current
+:*Never smoker
+*[[Cancer]]
+:*[[Thoracic|Extrathoracic]] [[cancer]] more than 5 years prior
+*[[Nodule (medicine)|Nodule]] diameter
+*Spiculation
+:*Yes
+:*No
+*Upper [[Lobe (anatomy)|lobe]]
+:*Yes
+:*No
+*The risk calculator is not validated for [[Patient|patients]] with history of [[cancer]] in the past 5 years.<ref name="calculator">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.</ref>
+The [[Cancer|malignancy]] of pulmonary nodule can be categorized into 3 groups:<ref name="pmid19835344">{{cite journal |vauthors=Albert RH, Russell JJ |title=Evaluation of the solitary pulmonary nodule |journal=Am Fam Physician |volume=80 |issue=8 |pages=827–31 |year=2009 |pmid=19835344 |doi= |url=}}</ref>
+'''Low Probability'''
+* Usually less than < 5 percent
+* The [[Nodule (medicine)|nodule]] size is less than or equal to 4 mm
+* The [[Nodule (medicine)|nodule]] size may also be between  4 - 6 mm, with no associated [[Risk factor|risk factors]]
+* Observation is suggested
+* Observation usually involves [[Radiological|radiologic]] surveillance with serial [[Computed tomography|CT scans]]
+'''Intermediate Probability'''
+* Between 5 to 65 percent
+* The [[Nodule (medicine)|nodule]] size is between 6 - 8 mm
+* The [[Nodule (medicine)|nodule]] size is more than > 8 mm with associated [[Risk factor|risk factors]]
+*[[Diagnosis|Diagnostic]] testing is indicated: [[Positron emission tomography|Positron emission tomography (PET)]], [[Computed tomography|CT]]-[[Needle aspiration biopsy|FNA]], and [[bronchoscopy]]
+'''High Probability'''
+* More than > 65 percent
+* The [[Nodule (medicine)|nodule]] size is more than > 8 mm with associated [[Risk factor|risk factors]]
+*[[Diagnosis|Diagnostic]] testing is indicated: [[Positron emission tomography|Positron emission tomography (PET)]], [[Computed tomography|CT]]-[[Needle aspiration biopsy|FNA]], and [[bronchoscopy]]
+*[[Surgery|Surgical]] [[excision]]
+The [[patient]] risk assessment of pulmonary nodule can be categorized into 2 groups:<ref name="pmid19835344">{{cite journal |vauthors=Albert RH, Russell JJ |title=Evaluation of the solitary pulmonary nodule |journal=Am Fam Physician |volume=80 |issue=8 |pages=827–31 |year=2009 |pmid=19835344 |doi= |url=}}</ref>
+*'''High Risk Patients'''
+:*[[Patient]] age is > 35
+:* Positive [[smoking]] history
+:*[[Male]] [[Patient|patients]]
+:* Positive for prior [[Cancer|malignancy]]
+:* Other associated [[Risk factor|risk factors]].
+*'''Low Risk Patients'''
+:*[[Patient]] age < 35
+:*No [[smoking]] history
+:*[[Female]] [[Patient|patients]]
+:*Negative for prior [[Cancer|malignancy]]
+:*No associated [[Risk factor|risk factors]]
 ==References==
 {{reflist|2}}