https://www.youtube.com/watch?v=RWFpbQp5IQ8 YouTube link for the Powerpoint presentation How to approach a case of Solitary Pulmonary Nodule

1. Thomas Kurian
SOLITARY
PULMONARY
NODULE

3.  <= 3cm in diameter.
 Surrounded by lung
 No associated atelectasis, lymph nodes and post obstructive
pneumonia.
 coin lesion.
DEFINITION

4. Solitary
Pulmonary
Nodule
Benign Malignant

5.  Infectious granulomas
 Vascular
 Congenital
 Inflammatory
 Benign tumors
 Miscellaneous
BENIGN SOLITARY PULMONARY NODULES

6.  Tuberculosis
 Histoplasmosis
 Coccidioidomycosis
 Mycetoma
 Ascaris
 Echinococcal cyst
 Dirofilariasis (dog heartworm)
INFECTIOUS GRANULOMAS

7.  Rheumatoid arthritis
 Wegener’s granulomatosis
 Sarcoidosis
 Paraffinoma
NONINFECTIOUS GRANULOMAS

8.  BOOP
 Abscess
 Silicosis
 Fibrosis/scar
 Hematoma
 Pseudotumor
 Spherical pneumonia
 Pulmonary infarction
 Arteriovenous malformation
 Bronchogenic cyst
 Amyloidoma
MISCELLANEOUS CAUSES

9.  Bronchogenic carcinoma
 Carcinoid
 Pulmonary lymphoma
 Pulmonary sarcoma
 Plasmacytoma
 Solitary metastases
MALIGNANT TUMORS

10.  History and physical exam
The emphasis should be on risk factors for
malignancy
HISTORY :-
smoking
Prior extra pulmonary malignancy
Weight loss
Hemoptysis
Change in nature of cough or hoarseness of voice
Chest pain
Hoarseness of voice
Joint pains
HOW SHOULD THE WORK-UP OF THE
SPN BEGIN?

11.  Other risk factors include exposures to asbestos, second hand
smoke, radon, arsenic, ionizing radiation, haloethers, nickel,
and polycyclic aromatic hydrocarbons.
 Prior travel history, places of residence, occupation, and pets
(benign disease)

12. A 24 year old male,
non smoker, got an
X ray done for dry
cough(no other
complaints like fever
or chest pain) found
have a SPN
????
A 62 year smoker
women, got x ray
done for her
hemoptysis found a
SPN
????
Benign malignant

13. AGE
•important risk factor.
•>50 yrs- a solitary pulmonary nodule has a 65% chance of
being cancer, whereas in patients <50 yrs, the chance is
33%.

14.  A Solitary Pulmonary Nodule in a patient who has Head and
Neck Cancer is more likely to be:
 A. Metastasis
 B. Primary lung cancer
QUESTION

15.  the malignant SPNs are equally or more likely to represent
primary lung cancer rather than metastasis from the
extrapulmonary malignancy
 Exceptions: sarcoma, melanoma, and testicular carcinoma.

16.  Interstitial lung diseases, such as idiopathic pulmonary
fibrosis
 Asbestosis
 Scleroderma
WHICH LUNG DISEASES PREDISPOSE TO
CANCER?

17.  Lymphadenopathy
 Hepatomegaly
PHYSICAL EXAMINATION

18. +
Radiographic Characteristics
1mm thin section
Lung window and mediastinal window

19. +
CHEST X RAY
 NODULE SIZE
 SHAPE – regular or irregular
 LOCATION- central or peripherally placed
 CALCIFICATION

20. +
SIZE INTERPRETATION
< 3mm 99.8% benign
4-7mm 99.1%benign
8-20mm 82%benign
>20mm 50%benign
>30mm 7%benign

21. +
Adenocarcinomas – Peripheral
Small cell carcinomas- Central
Metastasis- Peripheral/sub pleural
Associated with fibrosis- Lower lobe

22. +
Case
A 51 year old smoker male came with history of chest pain,
hemoptysis. His examination yielded nothing
On enquiry patient had similar complaints 3 months back. Also
patient was investigated with X ray- which shown a SPN in right
mid zone measuring 2 cm diameter
We had got another X ray now, which shows the similar lesion
with diameter of 2.6cm.

23. +
 What is the inference ?
 Lesion has doubled in its volume in 90 days
How doubling time will help you in
Identifying the character of lesion ?

24. +
GROWTH RATE & DOUBLING
TIME
GROWTH RATE-
 The growth rate refers to increase in volume of nodule.
 volume of a sphere = 4/3(π)r3
 A nodule originally 1 cm in diameter whose diameter is now 1.3 cm
has actually more than doubled in volume.
 When old radiographs are available, growth rate and NODULE
DOUBLING TIME can be estimated.

25. +
What is the DOUBLING TIME of
Malignant SPN?
MALIGNANT TUMORS 20 – 400 days
Squamous & large cell tumors 100 days
adenocarcinoma 500 days
Small cell carcinoma 30 days
BENIGN TUMORS < 20 - > 400 days

26. +
 Benign nodules have doubling times of less than 20 days or
more than 400 days.
 A nodule that doubles in size in less than 20 days is usually the
result of an acute infectious or inflammatory process.
 Those that grow very slowly are usually chronic granulomatous
reactions or hamartomas.

27. +
Doubling time

28. +
A solid SPN, stable in volume
over a period of 2 years can be
reliably considered benign
Exception? -

29. +
PITFALLS IN ROUTINE X RAY
 Determination of size of small nodules is not without error.
 On chest radiographs, a 3-mm enlargement may be difficult to
appreciate.
 Some SPN mimics include leads used for cardiac monitoring ,nipple
shadows, soft tissue tumors, bone shadows, pleural plaques,
pseudotumors, and round atelectases.
.

30. +
DIGITAL CHEST X RAY
 The use of digitally enhanced films may allow for more accurate
measurements of size.
 Improve the detection of nodules over normally radiopaque areas of
the thorax, such as the mediastinum and the diaphragm.

31. +
Rounded Atelectasis
Mass of atelectasis due to previous pleural effusion showing air
bronchograms within and peripheral curving and displacement of the
bronchovascular bundles

32. +
Rounded Atelectasis

33. +
Rounded Atelectasis

34. +
CT scan vs. CXR
 CT needed if CXR demonstrates
 Uncalcified nodule
 Nodule not clearly stable for 2 yrs
 Failure of symptomatic infiltrate to clear in 4-6 wks
 CXR has “miss rate” of 25-90%
 Delays diagnosis
 7% of “definitely calcified” CXR nodules aren’t
 CT may better detect change in size

35. +
 Detects cancer spread to lymph nodes
 Demonstrates chest wall involvement
 May suggest benign disease
 AVM, round atelectasis, hamartoma, infarct

36. +
CT CHARACTERISTIC
CT APPEARANCE BENIGN NODULE MALIGNANT
NODULE
MARGINS well circumscribed Irregular
APPEARENCE rounded appearance Lobulated or
spiculated
PLEURAL TAG OR
TAIL
- +
NOTCH (Rigler’s
Sign).
- +
CALCIFICATION
PATTERN
central, diffuse,
stippled ,
Laminar or concentric
Eccentric calcification
.None of these
radiographic signs is
entirely specific for
malignancy.
.

37. +
Riglers notch

38. +
PATTERNS OF MARGINS

39. +

40. +

41. +

42. +
PLEURAL TAG OR TAIL

43. +
Corona radiata sign
Fine linear strands extending 4-5 mm outward
Spiculated on CXRs
88– 94% are malignant

44. +
PATTERS OF MARGINS
Exceptions: lipoid pneumonia, focal atelectasis,
tuberculoma,PMF

45. +
Adenocarcinoma. HRCT shows an irregular, spiculated nodule with multiple
pleural tails. Air bronchograms are visible within the nodule

46. +
CT **** SIGN

47. +
CT HALO SIGN
Represents hemorrhage,inflammation,infiltration
 Invasive aspergillosis
 Wegener's granulomatosis
 Metastatic angiosarcoma
 Kaposi's sarcoma

48. +
Halo sign
a) invasive aspergillosis.
b) bronchioloalveolar carcinoma

49. +ATOLL SIGN
• Reverse halo sign-central area of ground glass attenuation
surrounded by a halo or crescent of consolidation
• Seen in CRYPTOGENIC ORGANIZING PNEUMONIA
Tuberculosis,
• Lymphomatoid granulomatosis,
• Wegener granulomatosis,
• Sarcoidosis
• Lung cancer after radiotherapy

50. +

51. + PATTERNS OF CALCIFICATION
Eccentric calcification
central
diffuse
Laminar or
concentric
Popcorn
calcification

52. +
Calcification

53. +
What is the type of calcification?

54. +
What is the type of calcification?

55. +
Hamartoma

56. +
Calcification
Stippled or
eccentric
patterns
Have been
associated
with cancer

57. +
Eccentric Calcification

58. +
a)Homogeneous calcification b)Concentric or “target” calcification

59. +
a)Dense central or “bull's-eye”
(arrows) .This is typical of
histoplasmoma or hamartoma
b)Multiple confluent nodular foci of
calcification (“popcorn” calcification; arrow)
This appearance is typical of hamartoma
and corresponds to calcification of cartilage
nodules

60. +
Feeding Vessel Sign

61. +
FEEDIFEEDING VESSEL SIGN SIGN
• Small pulmonary artery is seen leading directly to a nodule
• Most common with metastasis, infarct, and arteriovenous
fistula.
•

62. +
Air bronchograms and pseudocavitation more
commonly malignant

63. +AIR BRONCHOGRAM &
PSEUDOCAVITATION
• Presence implies malignancy.
• Most typical of adenocarcinoma or bronchioloalveolar carcinoma.
• Small air-filled cystic areas in the tumor (so-called pseudocavitation), or small
cavities have the same significance as air bronchograms.

64. +
Ground Glass Opacity

65. +
Which is more likely malignant?

66. +
Cavitation
Small Cell Carcinoma
Benign causes : abscesses, infectious granulomas,vasculitis, LCH
Wall Thickness <5mm and >15mm

67. +
Benign or Malignant ?
a
c

68. +Name the Sign

69. +

70. +
Fungal Ball
Crescent sign in relation to the right upper lobe
SPN due to a fungal ball in a cavity

71. +

72. +
Air Fluid Level
• Benign disease
• Any infected cystic or cavitary lesion may be associated with an air-fluid
level.
• uncommon in a cavitary carcinoma
CT scan of a lung abscess

73. +
Name the sign

74. +
SATELLITE NODULE
• Small nodules seen adjacent to a larger nodule or
mass & predict benign lesion
• Most common with granulomatous diseases &
infections such as TB
• Only a small percentage of carcinomas are
associated with satellite nodules.
• Galaxy sign in sarcoidosis

75. +
Fat attenuation

76. +
Hamartomas containing fat in three patients. Focal areas of low-
attenuation fat are visible within the nodules. The nodules are
rounded and sharply defined

77. +
Fat attenuation
 HAMARTOMA
 LIPOMA
 LIPOID PNEUMONIA
 TERATOMA
 LIPOSARCOMA
 RCC

78. +
WATER DENSITY
Benign cystic lesions, such as pulmonary bronchogenic cyst,
sequestration, congenital cystic adenomatoid malformation
(CCAM), or a fluid-filled cyst or bulla , occasionally may be
diagnosed on CT by their water attenuation (0 HU)
Pulmonary bronchogenic cyst. A sharply marginated
round nodular opacity (arrow) is visible in the right lower
lobe. This measured 0 HU in attenuation. This
appearance is typical of a fluid-filled bronchogenic cyst

79. +
Contrast Enhancement

80. + CONTRAST ENHANCEMENT
• Cancers have a greater tendency to opacify following contrast infusion
than do some types of benign nodules
• scans at 1 minute intervals for 4 minutes following the start of the
injection of iodine

81. +
 <15 HU - strongly indicative of benignity (positive predictive
value,approximately99%).
 >15 HU is more likely to represent malignancy, only 58% of nodules are
malignant
 Enhancing nodules should still be considered indeterminate and require
further workup.
 Sensitive , not specific

82. +
CONTRAST OPACIFICATION
 Some solitary (or multiple) lesions opacify following contrast
injection, thus representing vascular structures .
Arteriovenous malformation
Pulmonary vein varix
Pulmonary artery aneurysm

83. 11 a. Coned-down CT image of the chest with coronal reformation shows a 1.2-cm
subsolid nodule (arrow) in the left upper lobe. (b) Follow-up CT image obtained 1 year
later shows the nodule (arrow), which demonstrates increased attenuation, in addition
to an increase in the overall size.
12 . (a) Contrast-enhanced CT image shows a 1.8-cm nodule with pure ground-glass
attenuation (arrow) in the left upper lobe. (b) Follow-up CT image obtained 3 months
later shows the nodule (arrow), with a new solid component posteriorly (arrowhead).
Biopsy was performed, and results of histologic analysis revealed adenocarcinoma.

84. +
Lung cancer manifesting with increased wall thickness of a cystic airspace in a 77-
year-old man with a history of right upper lobectomy for adenocarcinoma. (a)
Contrast-enhanced CT image shows a cystic airspace (*) in the right lower lobe. (b)
Follow-up CT image obtained 6 months later shows a new soft-tissue component
(arrows) along the wall of the cystic airspace. Results of histologic analysis of the
soft-tissue component revealed adenocarcinoma.

85. +
Transient decrease in size of a lung cancer. (a) CT image obtained at the patient’s
initial presentation shows a nodule (arrow) in the left lower lobe. (b) Follow-up CT
image obtained 1 year later shows the nodule (arrow), which decreased in size. (c)
CT image obtained 2 years after the initial presentation shows the nodule (arrow),
which increased in size and lobularity.

86. MRI
 Better imaging for pleural, diaphragm, and chest
wall disease .
 less useful in assessing the lung parenchyma
(especially assessing pulmonary nodules) because of
poorer spatial resolution.
 High cost.
 Tumors that are difficult to assess on CT (eg.
Pancoast tumors).

87. Ultrasound
 Ultrasound is not commonly used in the evaluation of
an SPN.
 Ultrasound has a limited role in percutaneous biopsy
of larger peripherally based lesions.

88. NUCLEAR IMAGING
 Recently, nuclear medicine imaging has been studied
for use in evaluation of SPNs.
 Positron emission tomography (PET).
 SPECT

90. Positron emission tomography
 PRINCIPLE
 18-flurodeoxyglucose
 Taken up by cells in glycolysis but is bound within cells
and cannot enter normal glycolytic pathway
 Most tumors have greater uptake of FDG than normal
tissue
 Due to increased metabolic activity

91. Positron emission tomography
 quantified using the standardized uptake ratio (SUR)
 This allows comparison of uptake between different
lesions and patients.
 better detection of mediastinal metastases

92. Positron emission tomography
 Sensitivity for identifying a malignancy is 96%
and specificity 79%
 False negatives can occur;
 Bronchoalveolar carcinoma
 Carcinoids
 Tumors < 1 cm in diameter

93. Positron emission tomography
 False positives
 Infectious (tuberculosis or endemic fungi)
 Inflammatory processes (rheumatoid arthritis
and sarcoidosis)
 Uncontrolled hyperglycemia

94. Positron emission tomography
 Resolution is currently 7 – 8 mm
 Imaging of nodules < 1 cm unreliable

95. PET IMAGES

96. SPECT imaging
 Depreotide is a somatostatin analog labelled with
technetium Tc 99m, which has been shown to bind to
somatostatin receptors expressed on non small cell
carcinomas.
 Use of SPECT scanning has not been evaluated in a
larger series.

97. +
How to approach

98. +

99. +
Probability of malignancy
 Based history, physical, and CT imaging characteristics.
 low probability (less than 10 percent) malignant disease -
 stable on serial CXR for 2 years or more.
 characteristic benign calcification pattern, or are present in
patients less than 35 years of age.
 absence of other risk factors.
 observed with serial CT scans depending on their size.

100. +
 High probability of malignant disease:
 who are surgical candidates should be considered for staging
followed by VATS/thoracotomy.
 Moderate probability (10–60 percent) of cancer:
 Indeterminate 75 percent of nodules that remain indeterminate
are malignant.

101. +

102. +

103. +

104. +

105. +
Biopsy TECHNIQUES
 BRONCHOSCOPY.
 Limited usefulness in the evaluation of solitary pulmonary nodules.
 INDICATIONS
 Nodules larger than 2 cm in diameter, a sensitivity as high as 68
percent.
 Nodules located in the inner or middle one-third of the lung fields
have the best diagnostic yield.
 Nodule’s relation to neighboring bronchi.
Tuberculosis or fungal infections .

106. +
COMPLICATIONS
 Relatively low risk
 Overall complication rate 5%
 3% risk of pneumothorax
 1% risk of hemorrhage
 0.24% risk of death

107. +
Percutaneous Needle Aspiration
 Fluoroscopic or CT guidance
 INDICATIONS
 peripheral lesions, in the outer third of the lung .
 lesions under 2 cm in diameter.
 It can establish the diagnosis of malignancy in up to 95 percent
of cases .
 specific benign diagnosis (granuloma, hamartoma, infarct) in up
to 68 percent of patients.

108. +
Complications of FNAC
 Pneumothorax is seen in as many as 30% of these patients
and approximately 5% require a chest tube.
 Hemoptysis is seen in 5-10% of these patients and usually is
minor and resolves spontaneously.
 Fatal hemorrhage and air embolism are rare.

109. +
Contraindications of FNAC
 Limited pulmonary reserve (FEV1 under 1 L)
 Those with bullous emphysema or blebs in the needle path .
 postpneumonectomy patients.
 Bleeding diathesis
 Inability to hold breath
 Severe pulmonary hypertension.

110. +
MANAGEMENT
Surgical biopsy.
 “Only curative procedure”
 VATS with option to convert to …
 Thoracotomy
 Lobectomy
 Segmentectomy (23% local recurrence)

111. +
VATS
 VATS uses fiberoptic telescopes and miniaturized video
cameras to facilitate biopsies and resection.
 Does not require a full thoracotomy incision or spreading of the
ribs.
 Removal of peripheral nodules with a wedge resection.
 If at the time of VATS the frozen section is positive for
malignancy, an open thoracotomy can be performed for proper
anatomic resection.
 If a benign lesion is found, the procedure saves the patient
from the invasiveness of a full thoracotomy and lobectomy.

112. 52-years old lady went for a health check-up

113. PLEASE IDENTIFY THE LESION

114. • Pickup - this is a variable factor depending on
the radiology’s experience
• Experience & Expertise
• Overreading / underreading
• High kV - better rate of detection
• Digital radiograph - these allow manipulation
on a computer monitor and a higher rate of
detection
SPN
LESION DETECTION

115. She has a 2.2 cm sized nodule in the right mid-
zone

116. • A – Do nothing - old granuloma
• B – Aggressive - suspected malignancy
• C – Give antibiotics or AKT
• D – Investigate further
NEXT STEPS

117. CONFIRM INTRA PULMONARY
LOCATION

118. This lesion is intra-pulmonary – seen on both
frontal and lateral radiographs in the lung

119. This lesion is pleural – in the minor fissure and
ovoid and calcified and hence not significant

120. This lesion also pleural – probably an old
calcified hematoma and hence not an SPN

121. This patient had neurofibromatosis 1 and came
for a CT guided biopsy of a left upper lobe mass

122. the patient had never been examined

123. This lady also came for a CT guided biopsy of a
left mid-zone lesion

124. Rib fracture callus

125. In our 52-years old lady, a CT scan show the lesion to
be in the right upper lobe – intra-pulmonary

126. • A – Do nothing - old granuloma
• B – Aggressive - suspected malignancy
• C – Give antibiotics or AKT
NEXT STEPS

127. IS THIS BENIGN OR MALIGNANT?

128. • A - Calcification
• B - Absence of enhancement
• C - No growth in 2 years
CRITERIA FOR BENIGNITY

129. Completely calcified - benign Engulfed calcific focus by a malignant
lesion

130. A B C
April 06 June 08
Completely calcified and no growth in 2
years - benign

131. plain post-contrast
No enhancement whatsoever - benign

132. July
Our 52-years old lady

133. May July
She shows a significant increase in size
over 2 ½ months

134. Plain Post-contrast
Contrast-enhanced study shows
enhancement

135. • A - Granuloma
• B - Malignancy
• C - Other
POSSIBLE ETIOLOGY

136. THIS DOES NOT SHOW ANY
CRITERIA OF BENIGNITY AND
HENCE IS OF INDETERMINATE
ETIOLOGY

137. • A - Trial of therapy
• B - CT guided biopsy
• C - Bronchoscopy guided biopsy
• D - Lobectomy
NEXT STEPS

138. CT – guided biopsy

139. • Biopsy not FNAC
• At least 5 cores
• Material for EGFR mutation studies
TIPS DURING BIOPSY

140. Gun-cannula technique – stylet in cannula and gun

141. Gun-cannula technique – stylet outside cannula and gun

142. Gun-cannula technique – gun in cannula – allowing multiple
biopsies to be obtained with a single puncture of the cannula

143. Foot pedal and in-room monitor allow accurate control along with
CT fluoroscopy

144. DIAGNOSIS
ADENOCARCINOMA

145. • A - Lobectomy
• B - PET/CT
• C - Chemotherapy
• D - Radiotherapy
NEXT STEPS

146. PET/CT AND CONTRAST-MRI OF
BRAIN FOR STAGING

147. Staging
• Nodes
• Metastases
• Local staging
LUNG CANCER

148. A 52-year old with bronchogenic carcinoma – operable (T2N0M0)

149. A 68-year old with bronchogenic carcinoma – operable (N1M0)

150. A 57-year old with bronchogenic carcinoma – non-operable

151. A 52-year old doctor with bronchogenic carcinoma and solitary
focus of uptake in the left humeral head

152. A 52-year old doctor with bronchogenic carcinoma – nonoperable
(N0M1)

154. THE FUNDAMENTAL IDEA WHEN
DEALING WITH A SOLITARY
PULMONARY NODULE > 8MM IS TO
NOT MISS MALIGNANCY

155. IF A LESION HAS DEFINITE
CRITERIA FOR BENIGNITY (NO
GROWTH OVER 2 YEARS, DIFFUSE
CALCIFICATION AND/OR NO
ENHANCEMENT WHATSOEVER),
THEN YOU CAN FORGET ABOUT IT

156. ELSE, THE LESION SHOULD BE
ASSUMED TO BE MALIGNANT
UNLESS PROVED OTHERWISE
AND SHOULD BE BIOPSIED

157. THANKS