Pulmonary nodule overview
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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
Solitary pulmonary nodule (SPN) is defined as a relatively well defined round or oval pulmonary parenchymal lesion equal or smaller than 30 mm in diameter. Solitary pulmonary nodule is usually surrounded by pulmonary parenchyma and/or visceral pleura an d is not associated with lymphadenopathy, atelectasis, or pneumonia. According to the Fleischner Society, solitary pulmonary nodule may be classified according to size, morphology, and distribution (multiple or single). Causes of solitary pulmonary nodule may be classified into 5 categories: infectious, neoplastic, inflammatory, immunological, vascular, and miscellaneous. Common causes of solitary pulmonary nodule, include: tuberculosis, primary lung cancer, granulomas, and rheumatic disease. In the majority of the cases, solitary pulmonary nodule can be encountered as a incidental finding.[1][2] The nodule most commonly represents a benign tumor, such as a granuloma or hamartoma, but in around 20% of cases it represents a malignant cancer.[2] Approximately 10 to 20% of patients with lung cancer are initially diagnosed with solitary pulmonary nodule.[2] Conventional radiography is the initial method of choice for the diagnosis of solitary pulmonary nodule. The risk assessment of solitary pulmonary nodule will depend on several characteristics, such as: size, growth, shape, margin, air bronchogram sign, and attenuation. The solitary pulmonary nodule risk assessment is useful to determine the likelihood for malignancy and treatment. Further evaluation of solitary pulmonary lung nodule, should include an enhanced CT scan. Other imaging studies, include PET scanning, which may be useful as a staging modality, detection of occult disease, and malignancy assessment. The possibility of cancer needs to be ruled out through further radiological studies and interventions. The optimal management approach of solitary pulmonary nodule will mainly depend on the nodule size and growth. Other parameters, such as: location, and distribution may also be helpful for the therapeutical management of solitary pulmonary nodule. Surgical resection is often recommended among patients with the malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance. The prognosis of solitary pulmonary nodule depends on the underlying condition.[3]
Classification
According to the Fleischner Society, solitary pulmonary nodules may be classified into 5 categories: solid nodules measuring >8 mm in diameter, solid nodules measuring ≤8 mm in diameter, pure subsolid nodules, part-solid nodules, and multiple nodules.[1]
Causes
Causes of solitary pulmonary nodule may be classified into 5 categories: infectious, neoplastic, inflammatory, immunological, vascular, and miscellaneous. Common causes of solitary pulmonary nodule, include: tuberculosis, primary lung cancer, granulomas, and rheumatic disease.[1]
Differentiating Solitary Pulmonary Nodule from Other Diseases
Solitary pulmonary nodule may be differentiated according to imaging (size, border characteristics, and attenuation), histological, and clinical features, from other diseases that demonstrate similar imaging findings. Common differential diagnosis of solitary pulmonary nodule, include: hamartoma, granulomas, rheumatoid nodule, and single metastasis.[1][4]
Epidemiology and Demographics
Solitary pulmonary nodules are common.[4] The estimated prevalence of incidental solitary pulmonary nodule ranges between 0.09% to 7% in general population.[4] The incidence rate of solitary pulmonary nodule increases with age, tobacco use, and prior cancer; the median age at diagnosis is between 35 to 70 years. The prevalence of malignancy among solitary pulmonary nodules ranges between 0.2% to 50%. Males are more commonly affected with solitary pulmonary nodule than females. The male to female ratio is approximately 2 to 1. There is no racial predilection of solitary pulmonary nodule.[1]
Screening
According to the U.S. Preventive Services Task Force (USPSTF), screening for suspected lung cancer by low-dose computed tomography is recommended every year among smokers who are between 55 to 80 years old and who have history of smoke 30 pack-years or more and either continue to smoke or have quit within the past 15 years (grade B recommendation).[5][6][7][4][8]
Diagnosis
Evaluation of Solitary Pulmonary Nodule
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.[2]
History and Symptoms
Solitary pulmonary nodules are generally asymptomatic. In some cases, patients may develop non-specific symptoms, such as: dyspnea, hemoptysis, chronic coughing, wheezing, and chest pain. Obtaining the detailed history can be an important aspect of making a diagnosis of solitary pulmonary nodule, specific areas of focus when obtaining the history, include: previous infection of tuberculosis, previous or current smoking history, history of immunological conditions, high occupational risk profession, or recent traveling.[2]
Physical Examination
Patients with solitary pulmonary nodule usually are well-appearing. Physical examination of patients with solitary pulmonary nodule usually has no remarkable findings. In some cases, solitary pulmonary nodule may show findings associated with the underlying condition.[3]
Laboratory Findings
There are no diagnostic laboratory findings associated with solitary pulmonary nodule.[3]
Imaging
Conventional radiography is the initial method of choice for the diagnosis of solitary pulmonary nodule. The evaluation and risk assessment of solitary pulmonary nodule will depend on several characteristics, such as: size, growth, shape, margin, air bronchogram sign, and attenuation. Further evaluation of solitary pulmonary lung nodule, should include enhanced CT scan or MRI imaging. Other imaging studies include PET scanning, which may be useful as a staging modality, detection of occult disease, and malignancy assessment.[3]
Other Diagnostic Studies
Other diagnostic studies for solitary pulmonary nodule, include: transthoracic percutaneous fine needle aspiration, bronchoscopy, and mediastinoscopy.[9][10]
Biopsy
Biopsy for pulmonary nodule may be classified into 2 categories: non-surgical biopsy and surgical biopsy. Biopsy findings associated with pulmonary nodule will depend on tumor histology. Common types of lung tissue biopsy for solitary pulmonary nodule, include: conventional bronchoscopic-guided transbronchial biopsy, bronchoscopic-transbronchial needle aspiration, endobronchial ultrasound-guided sheath transbronchial biopsy, and endobronchial ultrasound-guided transbronchial needle aspiration. Common indications for biopsy in pulmonary nodule, include: high risk nodule (> 65%), intermediate risk nodule with a high risk patient profile, intermediate risk nodule with a positive positive positron emission tomography scan.
Treatment
Therapeutic Management
The optimal management approach of solitary pulmonary nodule will mainly depend on the nodule size and growth.[2] Other parameters, such as: location, and distribution may also be helpful for the therapeutical management of solitary pulmonary nodule. Moreover, the solitary pulmonary nodule risk assessment is useful to determine the likelihood for malignancy and treatment. Surgical resection is often recommended among patients with the malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.
Prevention
Prevention of solitary pulmonary nodule, includes: avoidance of smoking, smoking exposure, exposure to asbestos, and other high risk occupational jobs.[11]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Ost D, Fein AM, Feinsilver SH (2003). "Clinical practice. The solitary pulmonary nodule". N. Engl. J. Med. 348 (25): 2535–42. doi:10.1056/NEJMcp012290. PMID 12815140. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Alzahouri K, Velten M, Arveux P, Woronoff-Lemsi MC, Jolly D, Guillemin F (2008). "Management of SPN in France. Pathways for definitive diagnosis of solitary pulmonary nodule: a multicentre study in 18 French districts". BMC Cancer. 8: 93. doi:10.1186/1471-2407-8-93. PMC 2373300. PMID 18402653.
- ↑ 3.0 3.1 3.2 3.3 Lillington GA (1991). "Management of solitary pulmonary nodules". Dis Mon. 37 (5): 271–318. PMID 2019220.
- ↑ 4.0 4.1 4.2 4.3 McWilliams A, Tammemagi MC, Mayo JR, et. al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013 Sep 5;369(10):910-9. doi:10.1056/NEJMoa1214726.
- ↑ Lung Cancer: Screening http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening. Accessed on February 3, 2016
- ↑ Davis AM, Cifu AS. Lung Cancer Screening. JAMA. 2014;312(12):1248-1249. doi:10.1001/jama.2014.12272.
- ↑ National Lung Screening Trial. Wikipedia. https://en.wikipedia.org/wiki/National_Lung_Screening_Trial Accessed on February 4,2016
- ↑ Recommendations. US preventive services task force(2016) http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=solitary_pulmonary_nodule Accessed on March, 15th 2016
- ↑ Kinsey CM, Arenberg DA (2014). "Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging". Am. J. Respir. Crit. Care Med. 189 (6): 640–9. doi:10.1164/rccm.201311-2007CI. PMID 24484269.
- ↑ Mosmann MP, Borba MA, de Macedo FP, Liguori Ade A, Villarim Neto A, de Lima KC (2016). "Solitary pulmonary nodule and (18)F-FDG PET/CT. Part 1: epidemiology, morphological evaluation and cancer probability". Radiol Bras. 49 (1): 35–42. doi:10.1590/0100-3984.2014.0012. PMC 4770395. PMID 26929459.
- ↑ Khuri FR (2003). "Primary and secondary prevention of non-small-cell lung cancer: the SPORE Trials of Lung Cancer Prevention". Clin Lung Cancer. 5 Suppl 1: S36–40. PMID 14641993.