The problem of solitary pulmonary nodule.

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the lecture approaches the problem of solitary pulmonary nodule in terms of variable imaging findings,differential diagnosis and algorithm of follow up .

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The problem of solitary pulmonary nodule.

  1. 1. The problem of Solitary pulmonary nodule Dr/Ahmed A. Bahnassy Consultant radiologist (MBCHB-MD-FRCR (London –UK
  2. 2. DD of Solitary pulmonary nodule
  3. 3. SPN Ii is defined as a focal opacity ,visible on chest radiograph or CT ,with the following criteria :1.Relatively well defined .2.Surrounded-at least partially - by lung .3.Roughly spherical in shape.4.3 cm or less in diameter (more than 3 cm is termed mass )
  4. 4. Clinical evaluation Hx of smoking. Age over 40. Occupational exposure. Lung fibrosis. COPD. Family Hx of Lung cancer. Travel History TB skin test. Other diseases (Rheumatoid arthritis ) Malignancy .(solitary metastasis or increased likelihood of 1ry bronchogenic Ca for H & N breast ,bile ducts ,oes. ,cervix ,bladder ,prostate ,etc up to 3 folds )
  5. 5. Radiographic evaluation Morphological Characteristics. Density. Growth rate .
  6. 6. I-Morphological Characteristics Size : Diameter Malignancy The likelihood of rate malignancy is directly 1cm> 35% related to size reaching more than 85 % for SPN more than 2 cm . cm 1-2 50% cm 2-3 80%
  7. 7.  Location : 2/3 of lung cancers occur in upper lobes. 60% seen in lung periphery . Only 10 % seen in medial third . Mets tend to be subpleural or outer 1/3 of lung. 2/3 of mets are in lower lobes.
  8. 8.  Edge Appearance :90% of lesions with irregular or spiculated edges are malignant.20% only of well defined lesions are malignant (e.g.: Mets or carcinoid tumor )Corona Maligna or radiata represent either desmoplastic reaction around the tumor or actual invasion of surrounding lung …common with BAC and adenocarcinoma
  9. 9. CarcinomaFocal scarringBrncioalveolar cell carcinoma
  10. 10. Pleural tail in adenocarcinomaPleural tag refers to linear density (fibrosis) extending to pleural surface .
  11. 11. Pleural tag in adenocarcinoma
  12. 12. GranulomaHamartoma.Metastasis
  13. 13. Benign lesion-smooth edges
  14. 14. Mets
  15. 15. Hamartoma
  16. 16. Halo sign Halo of ground glass opacity surrounding a nodule .Commonly present in Leukemic patient with invasive aspergillosis (represent hemorrhagic infarction )Can occur with any other infections .Can be seen with BAC and adenocarcinoma (representing lepidic growth )
  17. 17. Causes of Halo signInvasive aspegillosis.Wegener Granulomatosis.BAC.Kaposi sarcoma.Mets.TB, nocardiosis.CMV infectionPCPBOOP
  18. 18. Invasive aspergillosis
  19. 19. BAC
  20. 20.  Shape :Lung Ca tends to be irregular , lobulated or notched.Granuloma are rounded.Hamartoma and metastasis are round ,oval or lobulated.Scars , atelectasis may appear linear .AVM and mucous plugs are particular in shape
  21. 21.  Air bronchogram and pseudocavitation.
  22. 22.  Cavitation
  23. 23.  Air crescent sign
  24. 24.  Air-Fluid level
  25. 25.  Satellite nodules ..GALAXY sign
  26. 26. Feeding vessel signShowing a vessel ending into and feeding a lesionAssociated with infarction ,AVM , metastasis ,septic emboli .
  27. 27. II-Density Ground Glass opacity
  28. 28. CalcificationCauses
  29. 29.  Benign Vs malignant patterns of calcifications
  30. 30.  Bull eye calcification
  31. 31. Target calcification -Histoplasmoma
  32. 32. POP corn calcification -hamartoma
  33. 33. Eccentric calcification in adenoCa
  34. 34.  Water density
  35. 35.  Fat density
  36. 36. Contrast enhancementHRCT –Malignant looking  Increase 40 HU (>15 ) mass post contrast. .typical of malignancy (77% accuracy)
  37. 37.  Contrast opacificationAVMPulmonary vein varix.Pulmonary artery aneurysm
  38. 38. III-Growth Doubling time is the time required for a lesion to double its volume . 26% increase in nodule diameter is one doubling Doubling of diameter is 3 volume doublings. Range of doubling time of carcinomas is 1 week to 16 months. Doubling time <1 month or >200 days is likely to be benign . No growth over 2 years most likely benign.
  39. 39. ?How to evaluate.See prior examinationsIf not availableSmall lesions follow up is at 3,6 months ,1 and 2.yearVery small lesions (3mm)..yearly follow up
  40. 40. SPECT & PET Scan additions Using FDG high activity in PET is associated with malignancy
  41. 41. .Biopsy taking FOB =fiber optic bronchoscopy..for central lesions. TNB =Trans thoracic needle biopsy ..For peripheral lesions.
  42. 42. Strategy for nodule evaluation

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