Solitary pulmonary nodule CT scan: Difference between revisions
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==Overview== | ==Overview== | ||
Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule. On CT, characteristic findings of solitary pulmonary nodules | [[Computed tomography|CT scan]] is the method of choice for the [[diagnosis]] of solitary pulmonary nodule. On [[Computed tomography|CT]], characteristic findings of solitary pulmonary nodules include [[Ground glass opacification on CT|ground-glass opacity]], rounded mass, and less than 30 mm in size. The evaluation of solitary pulmonary nodule will depend on the following characteristics: [[calcification]] pattern, size, location, growth, shape, margins, [[attenuation]], and [[Contrast medium|contrast]] enhancement. | ||
==CT scan== | ==CT scan== | ||
*Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule | *[[Computed tomography|CT scan]] is the method of choice for the [[diagnosis]] of solitary pulmonary nodule. | ||
*On CT, characteristic findings of solitary pulmonary nodules | *On [[Computed tomography|CT]], characteristic findings of solitary pulmonary nodules include: | ||
:*Single intraparenchymal lesion | |||
:*Single [[Parenchyma|intraparenchymal]] [[lesion]] | |||
:*Less than 3 cm in size | :*Less than 3 cm in size | ||
:*Rounded or | :*Rounded or spiculated [[lesion]] | ||
The evaluation of solitary pulmonary nodule will depend on the following characteristics: | * The evaluation of solitary pulmonary nodule will depend on the following characteristics: | ||
'''Calcification''' | '''[[Calcification]]''' | ||
*Calcification patterns are commonly seen in granulomatous disease and hamartomas | |||
*Calcification patterns are normally a sign of benignancy | *[[Calcification]] patterns are commonly seen in [[granulomatous]] [[disease]] and [[hamartomas]]. | ||
*Characteristic benign calcification patterns of pulmonary nodule | *[[Calcification]] patterns are normally a sign of [[Benign|benignancy]] | ||
:*Diffuse | *Characteristic [[benign]] [[calcification]] patterns of pulmonary nodule include: | ||
:*[[Diffuse]] | |||
:*Central | :*Central | ||
:*Laminated | :*Laminated | ||
:*Popcorn | :*Popcorn | ||
'''Size''' | '''Size''' | ||
*Different | *Different size ranges for pulmonary nodule include: | ||
:* Nodules less than | |||
:* Nodules between | :* Nodules less than 4 mm | ||
:* Nodules between | :* Nodules between 4 mm and 7 mm | ||
:* Nodules more than | :* Nodules between 8 mm and 20 mm | ||
:* Nodules more than 20 mm | |||
'''Location''' | '''Location''' | ||
* | *Common locations of pulmonary nodule are: | ||
:* | |||
:* | :*Peri-[[lymphatic]] | ||
:*Peri-[[Fissure|fissural]] | |||
:*Centrilobular | :*Centrilobular | ||
'''Growth''' | '''Growth''' | ||
*The growth pattern of the pulmonary nodule plays an important role in the management strategy.<ref name="pmid22156993">{{cite journal |vauthors=Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H |title=Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry |journal=Radiology |volume=262 |issue=2 |pages=662–71 |year=2012 |pmid=22156993 |pmc=3267080 |doi=10.1148/radiol.11100878 |url=}}</ref> | *The growth pattern of the pulmonary nodule plays an important role in the management strategy.<ref name="pmid22156993">{{cite journal |vauthors=Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H |title=Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry |journal=Radiology |volume=262 |issue=2 |pages=662–71 |year=2012 |pmid=22156993 |pmc=3267080 |doi=10.1148/radiol.11100878 |url=}}</ref> | ||
* A 4 times growth is associated with a 50% risk of [[Cancer|malignancy]]<ref name="pmid22156993">{{cite journal |vauthors=Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H |title=Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry |journal=Radiology |volume=262 |issue=2 |pages=662–71 |year=2012 |pmid=22156993 |pmc=3267080 |doi=10.1148/radiol.11100878 |url=}}</ref> | |||
* A | |||
'''Shape''' | '''Shape''' | ||
* | *Pulmonary nodule can occur in the following shapes: | ||
:*Polygonal | :*Polygonal | ||
:*Spherical | :*Spherical | ||
'''Margins''' | '''Margins''' | ||
* [[Lobule|Lobulated]] or scalloped margins | |||
** Associated with an intermediate [[Cancer|malignancy]] risk | |||
* Smooth margins | |||
** Associated with nodule [[Benign|benignancy]] | |||
'''Attenuation''' | '''Attenuation''' | ||
*Different types of | *Different types of pulmonary nodule attenuation are: | ||
*Solid pulmonary nodules | *Solid pulmonary nodules | ||
:*Malignancy rate of | |||
*Calcified pulmonary nodules | :*[[Cancer|Malignancy]] rate of 7% | ||
*[[Calcification|Calcified]] pulmonary nodules | |||
*Partly solid pulmonary nodules | *Partly solid pulmonary nodules | ||
:*Malignancy rate of 63% | |||
:*[[Cancer|Malignancy]] rate of 63% | |||
*Ground glass pulmonary nodules | *Ground glass pulmonary nodules | ||
'''Contrast | :*[[Cancer|Malignancy]] rate of 18% | ||
* Contrast enhancement of pulmonary nodules may be useful to determine benign or malignant features | |||
* Benign pulmonary nodules usually have | '''Contrast Enhancement''' | ||
* Contrast enhancement of pulmonary nodules may be useful to determine [[benign]] or [[malignant]] features. | |||
*[[Benign]] pulmonary nodules usually have < 15 [[Hounsfield units|Hounsfield units (HU)]] [[Contrast medium|contrast]] enhancement. | |||
=== Other Radiological Signs of Pulmonary Nodule === | |||
*'''Corona radiata sign''': Highly associated with [[Cancer|malignancy]] | |||
*'''Corona radiata sign''': | *'''Air bronchogram sign''': [[Airway]] surrounded by [[fluid]] or [[Inflammation|inflammatory]] [[exudate]] filled [[Alveoli|alveolar spaces]] | ||
*'''Air bronchogram sign''': | *'''[[Halo sign]]''': Zone of [[Ground glass opacification on CT|ground-glass]] attenuation surrounding a pulmonary nodule or mass on [[Computed tomography|CT scan]] | ||
*'''Halo sign''': | *'''Tree-in-bud sign''': [[Computed tomography|CT scan]] appearance of multiple areas of centrilobular nodules with a linear branching pattern | ||
*'''Tree-in-bud sign''': CT appearance of multiple areas of centrilobular nodules with a linear branching pattern | *'''Cheerio sign''': Pulmonary nodules with a central lucent [[cavity]] as seen on [[Computed tomography|CT scan]]. It is due to the [[proliferation]] of ([[malignant]] or non-[[malignant]]) [[Cell (biology)|cells]] around the [[airway]] | ||
*'''Cheerio sign''': | |||
==CT Surveillance== | ==CT Surveillance== | ||
The [[American College of Chest Physicians|American College of Chest Physicians (ACCP)]] recommends the following:<ref name="pmid23649456">{{cite journal| author=Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP et al.| title=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. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e93S-120S | pmid=23649456 | doi=10.1378/chest.12-2351 | pmc=PMC3749714 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649456 }} </ref> | |||
* If less than 8 mm, use guidelines by the Fleischner society (see table below). | * If less than 8 mm in size, use [[Medical guideline|guidelines]] by the Fleischner society (see table below). | ||
* For nodules greater than 8 mm in diameter, assess the | * For nodules greater than 8 mm in [[diameter]], assess the [[Patient|patient's]] risk of [[Complication (medicine)|complications]] from [[thoracic surgery]]: | ||
** | ** In low - moderate risk, assess the probability of [[cancer]] by a validated calculator and follow up with [[Computed tomography|CT scan]] surveillance. A model developed at the [[Mayo Clinic]] has been the most extensively validated. An open-source version is [https://openrules.ocpu.io/home/www/pulmnodule.html available online]. | ||
** | ** In high risk, assess the probability of [[cancer]] by a validated calculator and obtain non-surgical biopsy.<ref name="pmid9129544">{{cite journal| author=Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES| title=The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. | journal=Arch Intern Med | year= 1997 | volume= 157 | issue= 8 | pages= 849-55 | pmid=9129544 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9129544 }} </ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
|+Fleischner Society | |+Fleischner Society Guidelines for Follow-up and Management of Pulmonary Modules < 8 mm <br>Detected Incidentally at Non-screening CT<ref name="pmid16244247">{{cite journal| author=MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP et al.| title=Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. | journal=Radiology | year= 2005 | volume= 237 | issue= 2 | pages= 395-400 | pmid=16244247 | doi=10.1148/radiol.2372041887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16244247 }} </ref> | ||
! Nodule Size (mm) | ! Nodule Size (mm) | ||
! Low risk patients† | ! Low risk patients† | ||
! High risk patients‡ | ! High risk patients‡ | ||
|- | |- | ||
| | | ≤ 4 | ||
| No follow-up needed | | | ||
| Follow-up at 12 months | * No follow-up needed | ||
| | |||
* Follow-up at 12 months | |||
* If no change, no further [[imaging]] needed | |||
|- | |- | ||
| > 4 - 6 | | > 4 - 6 | ||
| Follow-up at 12 months | | | ||
| Initial follow-up CT at 6 -12 months | * Follow-up at 12 months | ||
* If no change, no further [[imaging]] needed | |||
| | |||
* Initial follow-up [[Computed tomography|CT]] at 6 -12 months | |||
* If no change, follow-up [[Computed tomography|CT]] at 18 - 24 months | |||
|- | |- | ||
| > 6 - 8 | | > 6 - 8 | ||
| Initial follow-up CT at 6 -12 months | | | ||
| Initial follow-up CT at 3 - 6 months<br> | * Initial follow-up [[Computed tomography|CT]] at 6 -12 months | ||
* If no change, follow-up [[Computed tomography|CT]] at 18 - 24 months | |||
| | |||
* Initial follow-up CT at 3 - 6 months<br> | |||
* If no change, follow-up [[Computed tomography|CT]] at 9 -12 and 24 months | |||
|- | |- | ||
| > 8 | | > 8 | ||
| Follow-up CT at around 3, 9, and 24 months | | | ||
| Same at for low risk patients | * Follow-up [[Computed tomography|CT]] at around 3, 9, and 24 months | ||
* Dynamic contrast enhanced [[Computed tomography|CT]], [[Positron emission tomography|PET]], and/or [[biopsy]] | |||
| | |||
* Same at for low risk [[Patient|patients]] | |||
|- | |- | ||
| colspan="3" |† Low risk patients: Minimal or absent history of smoking and | | colspan="3" |† Low risk [[Patient|patients]]: Minimal or absent history of [[smoking]] and other known [[Risk factor|risk factors]].<br />‡ High risk [[Patient|patients]]: History of [[smoking]] and/or other known [[Risk factor|risk factors]] | ||
|} | |} | ||
==Images== | ==Images== | ||
Latest revision as of 19:41, 1 July 2019
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Solitary pulmonary nodule CT scan On the Web |
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Risk calculators and risk factors for Solitary pulmonary nodule CT scan |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]Sabawoon Mirwais, M.B.B.S, M.D.[3]
Overview
CT scan is the method of choice for the diagnosis of solitary pulmonary nodule. On CT, characteristic findings of solitary pulmonary nodules include ground-glass opacity, rounded mass, and less than 30 mm in size. The evaluation of solitary pulmonary nodule will depend on the following characteristics: calcification pattern, size, location, growth, shape, margins, attenuation, and contrast enhancement.
CT scan
- CT scan is the method of choice for the diagnosis of solitary pulmonary nodule.
- On CT, characteristic findings of solitary pulmonary nodules include:
- Single intraparenchymal lesion
- Less than 3 cm in size
- Rounded or spiculated lesion
- The evaluation of solitary pulmonary nodule will depend on the following characteristics:
- Calcification patterns are commonly seen in granulomatous disease and hamartomas.
- Calcification patterns are normally a sign of benignancy
- Characteristic benign calcification patterns of pulmonary nodule include:
- Diffuse
- Central
- Laminated
- Popcorn
Size
- Different size ranges for pulmonary nodule include:
- Nodules less than 4 mm
- Nodules between 4 mm and 7 mm
- Nodules between 8 mm and 20 mm
- Nodules more than 20 mm
Location
- Common locations of pulmonary nodule are:
Growth
- The growth pattern of the pulmonary nodule plays an important role in the management strategy.[1]
- A 4 times growth is associated with a 50% risk of malignancy[1]
Shape
- Pulmonary nodule can occur in the following shapes:
- Polygonal
- Spherical
Margins
- Lobulated or scalloped margins
- Associated with an intermediate malignancy risk
- Smooth margins
- Associated with nodule benignancy
Attenuation
- Different types of pulmonary nodule attenuation are:
- Solid pulmonary nodules
- Malignancy rate of 7%
- Calcified pulmonary nodules
- Partly solid pulmonary nodules
- Malignancy rate of 63%
- Ground glass pulmonary nodules
- Malignancy rate of 18%
Contrast Enhancement
- Contrast enhancement of pulmonary nodules may be useful to determine benign or malignant features.
- Benign pulmonary nodules usually have < 15 Hounsfield units (HU) contrast enhancement.
Other Radiological Signs of Pulmonary Nodule
- Corona radiata sign: Highly associated with malignancy
- Air bronchogram sign: Airway surrounded by fluid or inflammatory exudate filled alveolar spaces
- Halo sign: Zone of ground-glass attenuation surrounding a pulmonary nodule or mass on CT scan
- Tree-in-bud sign: CT scan appearance of multiple areas of centrilobular nodules with a linear branching pattern
- Cheerio sign: Pulmonary nodules with a central lucent cavity as seen on CT scan. It is due to the proliferation of (malignant or non-malignant) cells around the airway
CT Surveillance
The American College of Chest Physicians (ACCP) recommends the following:[2]
- If less than 8 mm in size, use guidelines by the Fleischner society (see table below).
- For nodules greater than 8 mm in diameter, assess the patient's risk of complications from thoracic surgery:
- In low - moderate risk, assess the probability of cancer by a validated calculator and follow up with CT scan surveillance. A model developed at the Mayo Clinic has been the most extensively validated. An open-source version is available online.
- In high risk, assess the probability of cancer by a validated calculator and obtain non-surgical biopsy.[3]
| Nodule Size (mm) | Low risk patients† | High risk patients‡ |
|---|---|---|
| ≤ 4 |
|
|
| > 4 - 6 |
|
|
| > 6 - 8 |
| |
| > 8 |
| |
| † Low risk patients: Minimal or absent history of smoking and other known risk factors. ‡ High risk patients: History of smoking and/or other known risk factors | ||
Images
References
- ↑ 1.0 1.1 Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H (2012). "Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry". Radiology. 262 (2): 662–71. doi:10.1148/radiol.11100878. PMC 3267080. PMID 22156993.
- ↑ Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP; et al. (2013). "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. 143 (5 Suppl): e93S–120S. doi:10.1378/chest.12-2351. PMC 3749714. PMID 23649456.
- ↑ Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES (1997). "The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules". Arch Intern Med. 157 (8): 849–55. PMID 9129544.
- ↑ MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP; et al. (2005). "Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society". Radiology. 237 (2): 395–400. doi:10.1148/radiol.2372041887. PMID 16244247.