Solitary pulmonary nodule evaluation of solitary pulmonary nodule

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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 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.

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 of pulmonary nodule, can be categorized into 3 groups:

Low probability

• Usually less than <5 percent
• The nodule size is less than or equal to 4 mm
• The nodule size is between 4-6 mm

Intermediate probability

• Between 5 to 65 percent

High probability

• More than >65 percent

The patient risk assessment of pulmonary nodule, can be categorized into 2 groups:

• High risk patients

• Patient age is > 35
• Positive smoking history
• Male patients
• Positive for prior malignancy
• Other risk factors:

• Low risk patients

• Patient age < 35
• Smoking history:
• No smoking history
• Female patients
• Negative for prior malignancy
• No associated risk factors