Clinical Pulmonology

1. Approach to Solitary Pulmonary
Nodule
Dr. Subhajit Sen MD
Consultant Pulmonologist.

2. Dilemma of Coin lesions
 Long challenged the
Clinicians.
Benign or Malignant.
Observe or Intervene.
Scope of surgery.
 Requires systemic approach

3. Definition
• A single discrete pulmonary opacity, ≤3cm in
diameter, that is surrounded by normal lung
tissue that is associated with adenopathy or
atelectasis.
• Larger opacities: Pulmonary masses.

4. Conventional Radiography
 CXR is the conventional
method.
 CT scan may show
multiple nodules.
 Subcentimeter nodules
≤8mm in size.

5. Incidence
• 1-2 per 1000 CXR.
• 90% incidental.
• Broad differential Diagnosis.

6. Differential Diagnosis
 Malignant :
1. Bronchogenic ca.
2. Carcinoid.
3. Pulmonary
Lymphoma.
4. Pulmonary
Sarcoma.
5. Plasmacytoma.
6. Solitary metastasis.
 Benign:
1. Hamartoma (
most common).
2. Adenoma.
3. Lipoma
 Infectious Granuloma:
1. Tuberculosis.
2. Histoplasmosis.
3. Coccidiodomycoisis.
4. Mycetoma
5. Ascariasis.
6. Echinococcal cyst.
7. Dirofilariais

7.  Non infectious
Granulomas:
1. Rheumatoid
Arthritis.
2. Sarcoidosis.
3. GPA.
4. Others.
Miscellaneous:
1. BOOP.
2. Silicosis.
3. Hematoma.
4. Fibrosis/scar.
5. Spherical pneumonia.
6. AV malformation.
7. Bronchogenic Cyst

8. Imaging techniques
 CXR:
1. Most commonly used
tool.
2. 0.8-1cm in size, 30
Doublings.
3. PA and Lateral views.
4. Rule out artefacts or
overlying structure.
5. Obtain past CXRs.
6. >2 years or <2months
usually non Malignant.

9. CT Thorax
 Better Delineation.
 Slices through the
nodule.
 Exact location of the
lesion.
 Borders.
 Relation to adjoining
structures.

10. CT Thorax
 Density of nodules:
Solid, Non Solid.
 Pure ground glass,
partly ground glass.
 Edge: Well
circumscribed,
irregular or lobulated,
spiculated.

12. CT Thorax
 Malignant nodule:
1. Spiculated nodule.
2. Pleural retraction.
3. Feeding vessels sign.
4. Vascular convergence.
5. Dilated bronchus
leading to nodule.
6. Pseudo cavitation.

13. CT Thorax

14. PET CT
 Non invasive method for
diffarentiating.
 Sensitivity 87%-95%
 Helps in staging.
 SUVmax 2.5.
 Not usefull for <8mm
lesions.
 False negative : AIC,
Minimally invasive,
mucinous adeno ca.
 False positive :TB, NTM,
Endemic Mycosis, RA,
Sarcoidosis.

15.  Systematic approach to SPN: Malignant or
Benign

16. Risk Assessment

17. Doubling time concept
 Doubling of volume not diameter.
 Doubling diameter : means eight fold increase in
volume.
 Doubling of volume : 30% increase in diameter.
 <20 days or >400 days benign.

18. Histological types Doubling time
Adenocarcinoma 187 days
Squamous cell ca 100 days
Large cells 92 days
Small cell 33 days

19. SPN ON CXR
Stable> 2years
Benign calcification
Solid SPN Subsolid SPN
Old Films
NO
CT with 1 mm
section through
nodule

20. Solid Lung nodule
Solid SPN
<8 mm
FU as per
Fleischner
society
guidelines
upto 24
months
>8 mm
Low risk
Serial CT
3m,6m,12m,
24m
Intermediate
risk
PET CT
High Risk
Tissue
diagnosis

21. Solid Lung Nodules <8mm

22. Non Solid lung nodules
Pure Ground glass nodules Partly Ground Glass
Nodule ≤ 5mm : no follow up ≤8 mm, screening 3,12,24m,
then annual CT for 1-3 years
>5 mm, re evaluate at 3m.
No change then follow up
annually for 3-5years
>8 mm CT imaging at 3
months followed by PET
and/or biopsy if lesion persist

23. Diagnostic Modalities
 Transthoracic needle Aspiration:
1. For peripheral lesions.
2. Sensitivity 90% for malignant lesions
3. Major complication: Pneumothorax.
4. Incidence: 10-30%.

24.  FOB: Brush, Washings, Biopsy, TBNA.
 EBUS-TBNA especially if PET positive.
 Thoracoscopy, Mediastinoscopy.
 Surgical resection

25. Surgical risk assessment
 Spirometry & DLCO
 FEV1 and DLCO ≥40%
 If not then CPET, VO2max ≥ 15ml/kg/min
 Resection of nodule, segmentectomy,
lobectomy

26. Summary
 Providing cost effective, patient centred care
may be difficult and challenging.
 Pre test probability of Cancer.
 Surgical risk and benefits.
 Individualised approach.