The solitary lung nodule. A diagnostic dilemma. hazem youssef
Incidentally discovered pulmonary nodule are a diagnostic challenge. This presentation is focused on the different features of lung nodules and their management.
Imaging plays an important role in diagnosis and formulating differential diagnosis in case of Solitary pulmonary nodule. It helps in differentiating and predicting benign and malignant nodules.
The solitary lung nodule. A diagnostic dilemma. hazem youssef
Incidentally discovered pulmonary nodule are a diagnostic challenge. This presentation is focused on the different features of lung nodules and their management.
Imaging plays an important role in diagnosis and formulating differential diagnosis in case of Solitary pulmonary nodule. It helps in differentiating and predicting benign and malignant nodules.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Solitary pulmonary nodules radiology ppt is very good power point presentation from various source radiology assistant and latest guidelines. this power-point also includes many sign with multiple xray, ct and mri images. this will help alot. Thanks.
Describes the basic radiology of diffuse interstitial disease ,with differential diagnosis of reticular interstitial pattern and how to approach HRCT findings .
Discrete,well marginated opacity that is less than or equal to 3cm in diameter is described as Solitary Pulmonary Nodule.Definitions,incidence,prevalence,etiology,evaluation and management has been described in this powerpoint presentation.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Solitary pulmonary nodules radiology ppt is very good power point presentation from various source radiology assistant and latest guidelines. this power-point also includes many sign with multiple xray, ct and mri images. this will help alot. Thanks.
Describes the basic radiology of diffuse interstitial disease ,with differential diagnosis of reticular interstitial pattern and how to approach HRCT findings .
Discrete,well marginated opacity that is less than or equal to 3cm in diameter is described as Solitary Pulmonary Nodule.Definitions,incidence,prevalence,etiology,evaluation and management has been described in this powerpoint presentation.
Update in evaluation of solitary pulmonary noduleDr Varun Bansal
definition of solitary pulmonary nodule and subsolid nodule, various differences to distinguish between benign and malignant nodule, characteristics of subsolid nodule, treatment and followup of solid and subsolid pulmonary nodule.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
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ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Solitary pulmonary nodule
1. An Approach to Solitary
Pulmonary Nodule
Dr Subash Pathak
1st Year Resident
Radiodiagnosis
NAMS
2. solitary pulmonary nodule
• Spherical intraparenchymal opacity 3 cm or less in diameter,
completely surrounded by lung parenchyma, without
associated mediastinal adenopathy or atelectasis
• (Haaga)
• Lesions > 3 cm are defined as masses; are considered
malignant unless proven otherwise.
3. • Radiological evaluation of SPN is one of the
-most common and
-most difficult diagnostic dilemmas in thoracic radiology.
• Detection and work-up of SPNs are critical because SPNs may
be malignant and lung cancer has an overall mortality rate of
up to 85%
• Prevalence has increased as a result of growing use of Chest
CT- especially its use to screen for occult lung cancer.
• Before detailed diagnostic evaluation ,determine whether
- Nodular opacity seen on C-Xray is real or artifact
• If real, whether it is SPN
4. • First to determine
• Is the lesion truly solitary?
• Is the lesion intrapulmonary?
• Is the lesion nodule?
5. Is the lesion truly solitary ?
• Dominant pulmonary nodule in X-ray may be associated with smaller
nodules.
• Careful search by CXR PA , lat view & in some cases CT may be
necessary.
• Multiple pulmonary nodules of similar sizes and appearance
- usu mets or granuloma
- require different evaluation than solitary
lesions.
6. Is the lesion intrapulmonary ?
• Intrapulmonary lesions
-discrete opacities at least moderately well marginated by aerated
lung on both frontal and lateral radiographs
• Pleural and mediastinal lesion
- base forms obtuse angles with lung and is not outlined by lung .
9. Is the lesion nodule?
• Discrete round or oval opacity 4-30mm in diameter
• Linear and angular opacities are not nodules and represent scar or areas of linear
atelectasis.
• 3D analysis or volumetric CT can help to differentiate flat scar from true SPNs
• MILIARY – 2-4 MM [sutton]
• <2 mm - miliary
• 2-7 mm – micronodule
• 7-30 mm – pulmonary nodule
• >30 mm - mass
10. • Once SPN identified –radiologist should initiate
series of investigations
-to determine whether nodule is definitely benign
or suspicious form ( i.e. indeterminate)
A step wise approach is needed.
• The differential diagnosis of a solitary pulmonary
nodule is broad
• Management depends on whether the lesion is
benign or malignant and whether it is solid or
subsolid in attenuation.
12. Differential diagnosis: Persistent Subsolid SPNs
Malignant:
• Lung adenocarcinoma (including preinvasive lesions, atypical adenomatous hyperplasia,
and adenocarcinoma in situ).
• Metastasis from melanoma
• RCC
• Adenocarcinoma of the pancreas, breast, and GIT
• Lymphoproliferative disorders.
Benign:
• Organising Pneumonia
• Focal interstitial fibrosis
• Endometriosis
13. Clinical evaluation
• Clinical estimation of risk of malignancy is important.
• Factors with increased risk of lung cancer:
• Patient’s age
• Presence of symptoms: Hemoptysis
• History of smoking
• History of exposure to asbestos, uranium, radon
• Family history: increased with h/o first degree relative with lung cancer.
• Past history: patient’s with history of malignancy and pulmonary fibrosis,
history of cancer who underwent resection of small nodules, increased risk of
malignancy even for smaller nodules.
14. Radiographic evaluation
• Chest X-ray
• CT /MDCT
• FDG PET
• MRI- in difficult to assess cases such as Pancoast tumors
• USG- guided biopsy for peripherally based SPNs
• TNB
15. CXR
• Initial examination.
• Most SPNs - incidental finding.
• Nearly 90% of newly discovered SPNs on chest
radiographs may be visible in retrospect on prior
radiographs
• Visualization of some nodules difficult due to
superimposed structures
• Poorer resolution than CT for calcification or size.
• Prior CXR imp study growth pattern
16. CT chest
The advantages of CT over CXR
• Better size estimation (diameter from largest cross-
sectional area or volume measurement)
• Better border resolution
• Hidden areas assessment - lung apices, perihilar regions,
and costophrenic angles
• Detection of multiple nodules
• Enhancement & nodule attenuation characterisation
• Staging of Malignancy possible
• CT can help guide needle biopsy
Cause of many SPNs will remain undetermined after initial
& thin-section CT exam. If nodule is at least 10 mm in
diameter CECT.
18. Size
• 3 cm cutoff between mass and
nodule is defined as lesions >3
cm are usually malignant while
smaller lesions can be either
benign or malignant.
• Cohort study by Swensen et al
showed the relationship
between the size of a SPN and
the chance of malignancy in a
cohort at high risk for lung
cancer.
Size Total Malignancy
< 4 mm 2038 0%
4-7 mm 1034 1%
8-20 mm 268 15%
> 20 mm 16 75%
19. Location
• Malignancy:
• RT>Lt (1.5X)
• Upper lobes (70%)
• Squamous - central
• Adenocarcinoma- peripheral
• Metastatic - subpleural or outer 1/3rd of lung / 2/3rd in lower lobes
• IPF - lung cancer involve periphery of lower lobe, site in which fibrosis
is most likely to occur
• Benign nodules - equally distributed in upper and lower lobes.
20. Shape
• Benign lesions:
Polygonal (multifaceted)
Three dimensional ratio > 1.78
• Large three dimensional ratio
indicates relatively flat lesion:
sign of benignity.
• Lung carcinomas- irregular,
lobulated or notched.
• Hamartomas and metastasis-
round, oval and smooth with a
non-lobulated edge. Transverse image (left) and coronal reconstruction
(right)Three-dimensional ratio = transverse dimension :
vertical dimension
21. Margin
• Thin section CT more accurate than CXR
• Corona radiata sign: High association with
malignancy(PPV: 90%).
False positives include lipoid
pneumonia, focal atelectasis,
tuberculoma, PMF, pleural tail of
peripheral granuloma, organizing
pneumonia
• Lobulated or scalloped margins:
Intermediate probability
• Smooth margins: More likely benign;
exception,
Metastasis
20% of primary lung malignancies (adenoCa)
Carcinoid
23. Calcifications
• Most important imaging feature to distinguish benign SPNs from
malignant SPNs
• CXR with low KVp and CT esp dual energy (more sensitive)
• In general, calcification implies benignity.
• SPNs < 9 mm rarely visible in CXR; if that sized nodule clearly seen
likely to be diffusely calcified and hence benign.
25. • Exception: when the patient is known to have primary tumor
• Example:
• Diffuse calcification: Osteosarcoma/Chondrosarcoma
• Central/Popcorn calcification: Primary GI malignancy/ patients who
previously had chemotherapy.
29. Malignancy and calcifications
• Nearly 10% of malignant nodules- calcification in CT.
• Amorphous, stippled or eccentric pattern is seen most commonly in malignant
lesions
• Eccentric: benign/malig with dystrophic ca/engulfed benign calcified lesion
• Stippled: or psammomatous Ca mets from mucin secreting tumours as colon
or ovary
• Assess margin and size even if the lesion is calcified; central calcification in a
spiculated SPN should prompt concern for malignancy
• Malignant SPN with benign Ca in carcinoid, osteosarcoma, chondrosarcoma
With the exception of SPNs in patients with a history of bone malignancy, SPNs
with a benign pattern of calcification are indeed benign.
30. Calcification patterns
CT scan in an 80-year-old man shows a
2.2-cm-diameter nodule in the left upper
lobe with eccentric calcification.
31. Fat attenuation (-40 to -120 HU)
Hamartoma with left lower lobe nodule
showing low attenuation -46 HU
• Causes:
• Lipoid pneumonia
• Hamartoma: 50% cases
• Pulmonary mets in RCC or
liposarcoma
• Demonstration of fat is difficult if the
nodule is small as partial volume
inclusion of lung may interfere with
attenuation measurements.
32. Air Bronchogram Sign
• Air bronchogram is more commonly seen
in malignant pulmonary nodules 29%
than in benign nodules 6%.
• Most common:
BAC (Bronchoalveolar cell
carcinoma)
Adenocarcinoma.
Lymphoma
Air bronchograms (bubble like lucncies/
pseudocavitation) may simulate cavities,
upto 55% BAC.
Represent desmoplastic reaction to tumor
that distorts airway.
34. Cavitation
• Occurs in-
• Infections (abscess, infectious granulomas)
• Inflammations
• Vasculitides/pulmonary infarctions
• Malignancies, both primary and metastatic; more in Squamous cell type.
• Up to 15% of lung cancers cavitate but most are >3 cm.
• Cavitatory nodules
• Smooth and thin walls- Benign lesions ( < 5 mm – 92% benign)
• Thick and irregular walls- Malignant lesions ( > 15 mm – 95 % malignant)
• Wall thickness from 5-15 mm indefinite
35. Lung cancer manifesting as increased wall
thickness of cystic air space
77/m, right upper lobectomy for
adenocarcinoma, shows cystic air space in
the rt lower lobe
f/u CT after 6 mo shows new soft tissue
component along the wall/ increased wall
thickness
36. Solid and Ground glass component
• Studies show nodules containing a ground-glass component are more
likely to be malignant.
• Solid lesions: malignancy rate 7%.
• Partly solid lesions: malignancy rate 63%.
• Non-solid lesions: malignancy rate 18%.
37. Halo Sign
• CT feature showing poorly defined rim of ground glass attenuation
around the nodule.
• May represent: Hemorrhage, tumor infiltration or perinodular
inflammation.
• Originally described for invasive aspergillosis; also seen in:
• Adenocarcinoma in situ
• Kaposi sarcoma
• Lung mets from angiosarcoma, choriocarcinoma and osteosarcoma
38. Reverse halo sign
• Central area of ground glass attenuation surrounded by a halo or
crescent of consolidation.
• First described in cryptogenic organizing pneumonia.
• Can be seen in pts with lung cancer after radiofrequency ablation.
• Paracoccidioidomycosis, tuberculosis, lymphomatoid granulomatosis,
Wegener granulomatosis, sarcoidosis,
39.
40. Reverse halo sign
63 y male with left lower lobe mets
from pancreatic ca 1 month after radiofrequency ablation
41. Percutaneous needle biopsy
• For peripheral nodules > 5 mm
• Under fluoroscopy or CT guidance/ USG if lesion abuts pleura
• Interpretation of FNAB specimens:
• Malignant
• Specific benign
• Nonspecific benign- further evaluation; may be malignant but
sample obtained outside nodule or from necrotic area.
• If further growth after nonspecific benign diagnosis, consider repeat
biopsy or resection.
42. Bronchoscopy
• For nodules located in the inner one third of the lung fields or in close
approximation to a bronchus on CT scans.
• Limited use in lesions < 2 cm.
• Lesions > 2 cm, the yield of malignancy varies from 40-69%
{malignancy risk ~75%}.
43. Thoracoscopy or thoracotomy
1. In patients with an indeterminate nodule and
a high probability of malignancy,
2. In needle Bx proven malignant nodule- -A
thoracotomy and lobectomy.
44. Subsolid SPNs
• Contain a portion of ground glass attenuation that is higher than that of
normal lung parenchyma and lower than that of soft tissue, such as blood
vessels.
• Can be:
• Pure ground glass attenuation Partly solid i.e. areas of soft
GGANs tissue attenuation interspersed
with ground glass attenuation
45. • Subsolid nodules may result from infection, inflammation,
hemorrhage or neoplasm.
• Inflammatory causes resolve at short-interval reassessment.
• Persistent subsolid nodules are more likely to be malignant; more
specifically lung adenocarcinoma.
46. Imaging
• CT techniques
• Challenging to detect SSNs due to their poorly defined margins and low
contrast relative to surrounding lung parenchyma.
• MDCT and post processing techniques improve the detection rates.
• Thin sections volumetric CT data helps assessing the 3D of the lesion and
helps differentiate from linear scarring or atelectasis.
• Thin sections avoid misinterpreting volume averaging from parenchymal,
mediastinal and chest wall structures as true SSNs.
47. CT findings and Morphology
• SSN detected reassess with CT at 3 months most
infectious or inflammatory origin may resolve or regress.
• If persistent, assess for other morphological features.
• Association with adenocarcinoma
• Are more likely to present as SSNs than other histological subtypes.
• The IASLC, ATS, ERS classification system uses multidisciplinary approach using
pathologic and imaging findings and molecular biology techniques.
• Non-mucinous and mucinous varieties.
• Non-mucinous varieties present as SSNs while mucinous varieties present as
solid nodule or consolidative changes.
48. Classification of nonmucinous forms of lung adenocarcinoma and CT
features of subsolid nodules
2011 IASLC, ATS, and ERS Classification CT Features
Atypical adenomatous hyperplasia GGAN
Adenocarcinoma in situ GGAN with a possible solid component
Minimally invasive adenocarcinoma GGAN, partly solid nodule
Lepidic predominant adenocarcinoma Partly solid nodule, solid nodule
Invasive adenocarcinoma classified by predominant
subtype
Partly solid nodule with a solid component, solid
nodule
49. Nodule attenuation
Nonsolid (GGAN):
• Inflammation
• Premalignant: AAH, AIS
• Malign: MIA, invasive
adenoca
Solid: most metastatic
nodules are solid
Partly solid:
solid component often contains
invasive adenocarcinoma
50. • Soft-tissue component of a subsolid nodule may represent an invasive
component and/or fibrosis with alveolar collapse.
• Currently, the degree of invasion is reported to directly correlate with
the size of the soft tissue component at CT.
• Various methods are investigated to quantify the degree of invasion
based on the soft tissue attenuation values.
• Comparing attenuation values of the solid component of the SSNs
with the pathological features shows significant higher attenuation
values in invasive than noninvasive/microinvasive.
• Proportion of solid to ground glass component of SSNs.
51. Figure 9b Fleischner Society recommendations for measuring subsolid lesions at CT. CT image obtained with wide and/or
lung window settings shows the ground-glass-attenuation component (arrowheads) of the lesion. Measurements are based
on the average of the long and short axis dimensions. Determination of the percentage of solid to ground-glass-attenuation
components is important, because the greater the solid component, the more likely that the lesion is an invasive
adenocarcinoma. * = solid component.
RadioGraphics,
52. Other morphological features
• Variable utility to differentiate benign from malignant.
• Size
• Unlike solid nodules, limited use.
• A study of resected persistent GGANs showed AAH had mean diameter of 8
mm, adenocarcinoma of 13 mm, and fibrosis (or organizing pneumonia) of 12
mm.
• Shape
• Round shape is more common in malignant subsolid nodules (65%) than
benign nodules (17%); in contrast another study showed round shape to
indicate AAH rather than adenocarcinoma.
53. • Notches in the nodule margin and pleural tags more frequent in
invasive adenocarcinoma than in MIA and AIS.
• Other features more frequent in malignant subsolid lesions are:
• Lobulations
• Spiculation
• Well defined but coarse interface
• Pseudocavitation or bubbly appearance (due to sparing of alveoli or bronchi
by tumor infiltration)
55. Nodule growth
• Assessed on the basis of volume doubling time.
• Nodules being spherical, volume calculated by 4πr3
• Double the volume manifests as 26% increase in diameter in CXR
• Infectious/inflammatory nodules- doubling time < 20 days.
• Malignant solid SPNs have doubling time in the range of 20-400 days, usu <
100 days.
• Nodules with doubling time > 400 days are benign.
• Exception is subsolid adenocarcinoma which may take upto 1346 days
doubling time; so imaging reassessment is recommended for extended
time.
• For adenocarcinomas, range of volume doubling time is longest for GGANs,
then PSNs followed by solid lesions.
56. Exceptions
• Malignant SPN with short doubling time:
• Mets from choriocarcinoma, seminoma and osteogenic sarcoma
• Giant cell carcinoma, pulmonary carcinosarcoma and blastomas
• Associated with hemorrhage
• Malignant SPN with long doubling time: Carcinoid/ well-differentiated
adenocarcinoma
• Falsely large nodules;
• Adjacent inflammatory change, atelectasis, or scars
• Partial volume effect when thin sections CT not used
57. Limitations
• Limitations of use of DT to determine benignity of nodule
• Growth rate can’t be estimated in previously nonvisualised nodule (since
noncalcified nodules <1cm usually not visible in CXR)
• >35 yrs -pt should not be evaluated prospectively to determine benignity by
following growth rate ( do Bx)
58. Alternative to volume assessment in SSNs
• Mass measurement:
• CT data used to calculate X-ray attenuation values of SSN which is
proportional to tissue density i.e. mass per unit volume.
• Multiply nodule volume and density= mass.
• Allows detection of growth of SSN earlier and subject to less
variability than volume or diameter measurements.
59. Subsolid lesion in 56 yr old man which increased in size
CECT 1.3 cm nodule with pure GGA in
Left lower lobe
CT after 3 yrs size= 1.8 cm > double
volume
60. • Solid nodules with stable size over 2 years are considered benign.
• In case of SSNs, since the lesions are smaller and poorly defined
growth may be difficult to perceive.
• Unlike in solid nodules where growth is based only on size, in SSNs
growth may manifest as;
• Increase in size
• Increase in attenuation
• Development of solid component
• Increase in size of solid component
• These features indicate increased risk of malignancy
61. Increased attenuation in a SSN- indicator of possible malignancy
CT chest with coronal reformation
showing 1.2 cm SSN in left upper lobe
F/u image after 1 year shows increased
attenuation and increased size
62. Development of soft tissue component in a subsolid lesion:
increased risk of malignancy
CECT showing 1.8 cm nodule with pure
GGA in left upper lobe; pulmonary vessels
and air bronchogram sign are visible
F/u CT 3 months later showing new solid
component posteriorly/ turned out to be
adenocarcinoma
63. Temporary regression of SPNs
• Most lung cancers grow at steady exponential rate, however transient decrease
in size may occur attributed to development of fibrosis and subsequent
collapse of fibrosis.
• Continued reassessment warranted to confirm long term stability or regression.
64. Temporary regression of SPNs
• Initial presentation shows
nodule in left lower lobe
• 1 year f/u image shows
decreased size
CT at 2 years nodule show
increased size and lobularity
65. Nodule enhancement
• Applied for solid SPNs.
• Can be assessed for lesions as small as 5 mm.
• Degree of nodule enhancement correlates with the degree of vascularity,
which increases in malignant lesions.
• Malignant nodules enhance > 20 HU (less specific, exception active
inflammation), whereas benign lesions enhance < 15 HU.
• Nodules enhancing < 15 HU are definitely benign (NPV, 96%; sensitivity,
98%; specificity, 58%; accuracy, 77%).
• Limitations:
• Better for lesions < 2 cm (high chance of benignity/less likely to have substantial
necrosis).
• CT enhancement can be calculated only in lesions with a relatively spherical shape
and homogenous attenuation (i.e. no e/o fat, calcification, cavitation, or necrosis).
66. Nodular enhancement
CT 54/F with endometrial hyperplasia
Post contrast nodule enhanced with
attenuation value 109 HU; biopsy showed
carcinoid
67. Nodule metabolism
• Metabolism of glucose is increased in malignancies.
• This property is utilized in functional imaging with 18F labelled
fluorodeoxyglucose (FDG) positron emission tomography (PET) as an
alternative to nodule enhancement measurement in the evaluation of
solid SPNs.
• FDG standardized uptake value (SUV) is commonly used.
• SUV cutoff of 2.5 is used.
• Sensitivity and specificity around 90% in >/= 10 mm malignant
nodules.
68. Considerations
• SUV uptake needs to be interpreted taking into consideration the risk
factor assessment and imaging features i.e. pretest likelihood.
• Negative PET with low pretest likelihood (20%)= likelihood of malignancy
1% while negative PET with high pretest likelihood (80%)= likelihood of
malignancy 14%.
• PET is poor in evaluating GGANs and PSNs (sensitivity, 10%; specificity,
20%).
• Limited spatial resolution of PET so false negative findings in < 10 mm
nodules.
• False negative PET findings: Carcinoid tumors and adenocarcinomas.
• False positive PET findings (low PPV): Infection and inflammation.
69. PET negative neuroendocrine tumors
Unenhanced CT well circumscribed
nodule in the middle lobe
PET/CT show no FDG uptake; biopsy
revealed carcinoid
70. PET in subsolid lesion
57/M with thyroid and prostate ca, CT
shows 1.5 cm subsolid lesion in left lower
lobe with >5 mm soft tissue component.
PET/CT done preop shows no FDG uptake/
biopsy showed adenocarcinoma
71. PET in infections/inflammatory lesions
• 30/M, asymptomatic, unenhanced
CT shows 3 cm solid lesion in the
right lower lobe.
• PET/CT SUV uptake 16.7 2 month f/u CT regression of
the lesion/ biopsy
granulomatous inflammation
72. Decision analysis and management
• Guidelines by the Fleischner Society and American College of Chest
Physicians (ACCP).
• Considerations include:
• Patient’s clinical risk factors/risk stratification (significant risk include
older age, current or past history of smoking, h/o extrathoracic malignancy
> 5 yrs before nodule detection).
• Nodule characteristics on imaging (high likelihood of malignancy include
size, spiculation, and an upper lobe location).
• Comparison with previous images for nodule growth (solid nodule stable
for >2 yrs or with benign pattern of calcification no further f/u needed).
• Decision as to either observe or aggressive management is made on the
basis of the size of nodule and risk of malignancy.
73. Management options
• Serial reassessment at CT
• CT enhancement study
• FDG PET
• Histologic analysis
• For reassessment, unenhanced, thin-section, limited coverage, low-
dose CT is recommended.
79. Indeterminate lesions
• Indeterminate lesions:
• Not fitting in benign and malignant lesion.
• Most patients fall into this category.
• As many as 75% of these patients have malignant nodules on further
evaluation.
• Management decision
• Indeterminate –
• Percutaneous needle Bx
• Bronchoscopy
• Thoracoscopy or thoracotomy.
80. Subsolid nodule
• Unlike solid nodules, management options less clearly defined and
limited to serial reassessment and histological analysis.
• CT enhancement studies are not applicable.
• FDG PET limited use as these lesions have low metabolic rate.
• No use in pure GGANs; in part solid nodules can be used if solid
component is > 8 mm (ACCP)/ > 10 mm (Fleischner).
• ACCP considers pretest probability of malignancy while Fleischner do
not.
• ACCP considers overall nodule size while Fleischner only consider the
solid component size.
81. 2017 updated
guideline of Fleischner
Society
Differences from previous
guideline:
1. Earlier 5 mm cutoff was used.
2. F/u at 3 month for defining
persistent nodule has been
increased to 12 months.
3. Total f/u period is increased to 5
years from previous 3 years.
84. Ca lung
• Adenoca and alveolar cell
ca
• Peripherally based SPN.
• Alveolar cell ca- air
bronchogram. Ground
glass appearance in CT.
85.
86. Solitary metastasis
• 75% mets- Multiple
• 25% mets- Solitary
• Documented primary favours solitary
mets.
• An SPN is unlikely to be a mets in
absence of a known prior malignancy,
and a routine search for an extrathoracic
primary tumor is not cost-effective
• Common primary sites for sol mets
– Ca colon (1/3 of sol mets)
– Breast, kidney, testicular tumours, bone
sarcoma and malignant melanoma
• CT and CXR- no reliable features to
distinguish a solitary mets from primary
nodule.
SPN- A 1.5-cm lesion in left
upper lobe in pt with prior
colonic ca. Biopsy confirmed
this to be a metastatic
deposit
87. Hamartoma
• Malformation of tissue
normally found in organ
concerned.
• Large cartilaginous &
appreciable fatty component.
• 90% intrapulmonary origin.
• Incidental SPN- popcorn
calcification (30% cases), fat
density, peripheral location,
smooth or lobulated margin,
slow growth on serial
imaging.
88. Tuberculoma
• Mostly upper lobe
• Well defined. 25% lobulated margin.
• Calcification common (central or complete)
• Cavitation unusual.
• Satellite lesion common (80%)
• Usu size unchanged for years.
89. RoundPneumonia
• Spherical pneumonia caused by
• Haemophilus influenzae
• Streptococcus
• Pneumococcus
• Children are affected much more than adults
• Location
• Usually lower lobe
• Most often posterior
• May change size rapidly
• May have slightly irregular border and contain
air bronchogram
90. Lipoid Pneumonia
• Aspiration of mineral oil ingested by elderly to treat constipation
may produce localised pulmonary lesion.
• Radiologically
- a focal area of airspace opacification or a solid mass may be seen in
lower lobes.
- spiculated appearance may be due to inflammatory rxn leading to
fibrosis
91. Adenoma
• 90% around hilum
• 10% peripheral
• 25% SPN; 75% presents with effect of bronchial stenosis.
92. CT scan shows eccentric
dense calcification in a right
lower lobe carcinoid tumor.
Carcinoid tumors
• May present as SPNs
• Majority (80%) are
central endobronchial
lesions that presents
with atelectasis or
obstructive
pneumonias.
93. Summary
• Solid and subsolid SPNs are detected with increasing frequency
because of the widespread use of MDCT. Although most such
nodules are benign, lung cancer is a clinically important entity
in the differential diagnosis of SPNs.
• To ensure that appropriate treatment is initiated in a timely
fashion, the aim in evaluating SPNs is to correctly differentiate
malignant and benign lesions.
• Clinical assessment of patients’ risk factors for malignancy,
including age, smoking history, and history of malignancy, is
important .
94. • In terms of imaging evaluation, obtaining prior
radiographs or chest CT images is useful to determine
nodule growth.
• Further imaging evaluation, including CT
enhancement studies and PET/CT, helps determine
the malignant potential of solid SPNs.
• For solid nodules, CT enhancement of less than 15 HU
and low or no FDG uptake at PET/CT suggest
benignity.
• Awareness of potential pitfalls in nodule
enhancement and PET/CT evaluation of SPNs that
result from infectious or inflammatory conditions is
important to avoid misinterpreting imaging findings.
95. • For subsolid nodules, CT enhancement studies are not
applicable, and PET imaging is of limited use because of their
low metabolic activity.
• Because of the likelihood that persistent subsolid nodules
represent adenocarcinomas with indolent growth, serial
imaging reassessment for a minimum of 3 years and/or
obtaining tissue samples for histologic analysis are
recommended.
• At imaging follow-up of subsolid nodules, growth manifesting
as an increase in size, an increase in attenuation, development
of a solid component, or an increase in the size of a solid
component is suspicious for malignancy.
96. • Stratified according to patient risk factors for malignancy and nodule
characteristics, evidence-based clinical guidelines and
recommendations for the evaluation of solid and subsolid SPNs are
useful in decision analysis
97. References
• Update in the Evaluation of the Solitary Pulmonary Nodule
https://doi.org/10.1148/rg.346130092 RSNA article, October 2014,
Volume 34, Issue 6.
• Fleichner 2017 guideline for pulmonary nodules by Onno Mets and Robin
Smithuis, published on July 1, 2017.
• Solitary pulmonary nodule: benign versus malignant
• Differentiation with CT and PET-CT
• Ann Leung and Robin Smithuis
• Department of Radiology, Stanford University Medical Center, Stanford,
California and the Department of Radiology, Rijnland Hospital, Leiderdorp,
the Netherlands