Solitary pulmonary nodule (SPN)

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A radiology and imaging approach to solitary pulmonary (lung) nodule (SPN)

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Solitary pulmonary nodule (SPN)

  1. 1. Solitary Pulmonary Nodule Dr. Bhavin JankhariaRadiologist, Jankharia Imaging, Mumbai, India
  2. 2. Algorithm using a typical case
  3. 3. 52-years old lady went for a health check-up
  4. 4. Please identify the lesion
  5. 5. SPN Lesion Detection• Pickup - this is a variable factor depending on the radiology’s experience• Experience & Expertise – The “Ten-Thousand” hours rule• Overreading / underreading• High kV - better rate of detection• Digital radiograph - these allow manipulation on a computer monitor and a higher rate of detection
  6. 6. She has a 2.2 cm sized nodule in the right mid-zone
  7. 7. Next Steps• A – Do nothing - old granuloma• B – Aggressive - suspected malignancy• C – Give antibiotics or AKT• D – Investigate further
  8. 8. Confirm intra pulmonary location
  9. 9. This lesion is intra-pulmonary – seen on both frontal and lateral radiographs in the lung
  10. 10. This lesion is pleural – in the minor fissure and ovoid and calcified and hence not significant
  11. 11. This lesion also pleural – probably an old calcified hematoma and hence not an SPN
  12. 12. This patient had neurofibromatosis 1 and camefor a CT guided biopsy of a left upper lobe mass
  13. 13. Classic example of “hyposkilia” – the patient had never been examined
  14. 14. This lady also came for a CT guided biopsy of a left mid-zone lesion
  15. 15. Rib fracture callus
  16. 16. In our 52-years old lady, a CT scan show the lesion to be in the right upper lobe – intra-pulmonary
  17. 17. Next Steps• A – Do nothing - old granuloma• B – Aggressive - suspected malignancy• C – Give antibiotics or AKT
  18. 18. Is this benign or malignant?
  19. 19. Criteria for benignity• A - Calcification• B - Absence of enhancement• C - No growth in 2 years
  20. 20. Completely calcified - benign Engulfed calcific focus by a malignant lesion
  21. 21. April 06 June 08A B C Completely calcified and no growth in 2 years - benign
  22. 22. plain post-contrastNo enhancement whatsoever - benign
  23. 23. JulyOur 52-years old lady
  24. 24. May July She shows a significant increase in size over 2 ½ months
  25. 25. Plain Post-contrast Contrast-enhanced study shows enhancement
  26. 26. Possible etiology• A - Granuloma• B - Malignancy• C - Other
  27. 27. This does not show any criteria of benignity and hence is of indeterminate etiology
  28. 28. Next steps• A - Trial of therapy• B - CT guided biopsy• C - Bronchoscopy guided biopsy• D - Lobectomy
  29. 29. CT – guided biopsy
  30. 30. Tips during biopsy• Biopsy not FNAC• At least 5 cores• Material for EGFR mutation studies
  31. 31. Gun-cannula technique – stylet in cannula and gun
  32. 32. Gun-cannula technique – stylet outside cannula and gun
  33. 33. Gun-cannula technique – gun in cannula – allowing multiplebiopsies to be obtained with a single puncture of the cannula
  34. 34. Foot pedal and in-room monitor allow accurate control along with CT fluoroscopy
  35. 35. DiagnosisAdenocarcinoma
  36. 36. Next steps• A - Lobectomy• B - PET/CT• C - Chemotherapy• D - Radiotherapy
  37. 37. PET/CT and Contrast-MRI of Brain for Staging
  38. 38. Lung CancerStaging• Nodes• Metastases• Local staging
  39. 39. A 52-year old with bronchogenic carcinoma – operable (T2N0M0)
  40. 40. A 68-year old with bronchogenic carcinoma – operable (N1M0)
  41. 41. A 57-year old with bronchogenic carcinoma – non-operable (N2M0)
  42. 42. A 52-year old doctor with bronchogenic carcinoma and solitary focus of uptake in the left humeral head
  43. 43. A 52-year old doctor with bronchogenic carcinoma – nonoperable (N0M1)
  44. 44. The fundamental idea when dealing with a solitary pulmonary nodule > 8mm is to not miss malignancy
  45. 45. If a lesion has definite criteria for benignity (no growth over 2 years, diffuse calcification and/or noenhancement whatsoever), then you can forget about it
  46. 46. Else, the lesion should be assumed to be malignant unless proved otherwise and should be biopsied
  47. 47. SPN PA radiographBENIGN INDETERMINATECalcification Old X-raysLesion external or extra-pulmonary BENIGN INDETERMINATE No change over 2 years CT scan / PET/CT BENIGN No enhancement or uptake INDETERMINATE Calcification BIOPSY
  48. 48. Sometimes, some lesions are characteristic
  49. 49. Fungal BallCrescent sign in relation to the right upper lobeSPN due to a fungal ball in a cavity
  50. 50. AVMNodule showingcurvilinear vesseldensity on the lateralradiograph (red arrow).The CT shows thetypical appearance
  51. 51. Rounded AtelectasisMass of atelectasis due to previous pleural effusion (documented)showing air bronchograms within and peripheral curving anddisplacement of the bronchovascular bundles (red arrow)
  52. 52. Rounded AtelectasisMass of atelectasis due to previous pleural effusion (documented)showing air bronchograms within and peripheral curving anddisplacement of the bronchovascular bundles (red arrow)
  53. 53. Email: bhavin@jankharia.com Twitter: @bhavinjFB: www.facebook.com/bhavinjankharia

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