Pulmonary nodules

Lacey Washington, MD
 Topics

„Solitary pulmonary nodule or

mass
„ Multiple pulmonary nodules/masses
„ Pleural opacities
 Discussion
„ Stablefinding?
„ Two years generally regarded as benign
 Pulmonary Nodule
„ Differential diagnosis
– Mimics (not pulmonary)
– Infection
– Neoplasm
ƒ Malignant
ƒ Benign
– Vascular: AVM
– Infarct
– Cyst
– Mucoid impaction
 Action
„ Short-term followup
„ Inspiratory/expiratory or shallow oblique
films
„ Dual-energy subtraction
 If nodule persists
„ CT usually next step
Rib Fracture
Osteophyte
Chest x-ray
 True pulmonary nodule
„ CT
– Truly solitary
– Characterization
ƒ Attenuation
– Calcification
– Fat
– Ground-glass
– Cavitation (air)
ƒ Margins
 CT
„ Benign
„ Likelybenign
„ Possibly malignant
Case 1
 Calcification
„ Specific pattern
– Reliably benign
„ Other patterns
– May be malignant
– 14% of NSCLC calcify
– 37% of carcinoid tumors
Radiologic Features
„Density
–Ca++

– solid
– benign
Radiologic Features
„Density
–Ca++

– laminated
– benign
Radiologic Features
„Density
–Ca++

– central
– benign
Radiologic Features
„Density
–Ca++

– central
– benign
Radiologic Features
„Density
–Ca++

– “popcorn”
– probably benign
Radiologic Features
„Density
–Ca++

– “popcorn”
– hamartoma
Radiologic Features
„Density
–Ca++

– “popcorn”
– probably benign
Radiologic Features
„Density
–Ca++

– “popcorn”
– carcinoid tumor !
Case 2
 True pulmonary nodule
„ CT
– Truly solitary
– Characterization
ƒ Attenuation
– Calcification
– Fat
– Ground-glass
– Cavitation (air)
ƒ Margins
 Ground-glass attenuation
„ Pure: 80% benign
– > 1 cm higher risk of BAC
„ Part-solid: up to 67% malignant
– Often invasive adenocarcinoma
 Cavitation—not reliable
„ Smooth, thin-walled (<4 mm)
– More commonly benign
„ Thick,
irregular: may be benign or
malignant
 Margins
„ Smooth
– 30% malignant
„ Lobulated/Spiculated
– Most malignant
 Margins

Smooth
 Margins

Smooth Lobulated
 Margins

Smooth Lobulated Spiculated

 Followup

* MacMahon H, Austin JHM, Gamsu G, et al. Guidelines for management of

small pulmonary nodules detected on CT scans: a statement from the
Fleischner Society. Radiology 2005;237:395–400
 Additional evaluation
„ PET-CT
„ Biopsy
– Be careful of false negative results
 Additional evaluation
„ Nodule enhancement study
– 2 mL/sec; 300 mg/ml
– 420 mg iodine/kg
– Scans at 1, 2, 3, and 4 minutes after the
onset of injection
 Adenocarcinoma:
Enhancement > 15 HU

HU = 35 HU = 67
 Benign Nodule:
Enhancement < 15 HU

HU = 24 HU = 28
 Size
Diameter Risk of Malignancy

2- 3-mm 0.2%

4 - 7-mm 0.9%

8 - 20-mm 18%

> 20-mm 50%

Midthun DE, et al. Lung Cancer 2003; 41:S40 (suppl 2)

 Size
„ Nodule < 3 cm
„ Mass > 3 cm
„ Rules for SPN do not apply to masses
„ Mass: some cases of benign morphology
Case 3
 Case

Round Atelectasis
 Topics
„ Solitary pulmonary nodule or mass
„ Multiple pulmonary nodules/masses
„ Pleural opacities
 Topics
„ Solitary pulmonary nodule or mass
„Multiple pulmonary
nodules/masses
„ Pleural opacities
 Multiple pulmonary nodules
„ “Full-size”,> 1 cm diameter
„ Mid size, 5-10 mm diameter
„ Small, < 5 mm
 Full-size (>1 cm) pulmonary
nodules
„ Neoplasm „ Inflammatory
– Metastases – Wegener’s
– BAC – Rheumatoid
– Lymphoma – Sarcoid
– KS
„ Infection
– Fungal
– Septic emboli
– MAC
Smooth, solid nodules
Metastases
Irregular, ill-defined
Metastases
 Multiple Pulmonary Nodules
Mid size (5-10 mm)
„ Infection:
– Varicella
– Fungal
„ Neoplasm
– Metastases
– BAC
„ Pneumoconiosis
„ Sarcoidosis
Case 4
 Multiple Pulmonary Nodules:
Micronodular (<5 mm)
„ Infection
„ Granulomatous noninfectious
„ Neoplastic
„ Pneumoconiosis
„ Other
 Multiple Pulmonary Nodules:
Micronodular (<5 mm)
„ Infection
– Miliary: TB, histo, cocci
– Cellular bronchiolitis: mycoplasma, viral,
fungal, bacterial
„ Granulomatous noninfectious
– Sarcoid
– Hypersensitivity pneumonitis
 Multiple Pulmonary Nodules:
Micronodular (<5 mm)
„ Neoplastic:
– Metastases
– BAC
– LIP in AIDS (usually pediatric)
„ Pneumoconiosis
– Coal-worker’s, Silicosis
„ Other: Langerhans cell histiocytosis (EG)
 Multiple Cavitary Nodules
„ Infectious
„ Metastases
„ Wegener’s and rheumatoid
„ Septic Emboli
„ Hematoma/laceration
„ Papillomatosis
„ (EG)
 Multiple Cavitary Nodules
„ Infectious
– Gram negative
– Anaerobic
– Angioinvasive fungi
„ Metastases
– Classically squamous cell: head and neck,
cervix
Case 5
 Topics
„ Solitary pulmonary nodule or mass
„ Multiple pulmonary nodules/masses
„ Pleural opacities
 Topics
„ Solitary pulmonary nodule or mass
„ Multiple pulmonary nodules/masses

„Pleural opacities
 Focal extrapulmonary opacity
„ Obtuse margins with chest wall
„ Incomplete border sign
„ Pleura
„ Chest wall: assess bony structures
 Focal pleural opacity
„ Fluid loculation
„ Lipoma
„ Solitary fibrous tumor
„ (Solitary metastasis)
Case 5
Case
 Diffuse pleural opacity
„ Plaque
„ Fibrosis
„ Fluid
„ Tumor
– Mesothelioma
– Metastatic disease
Characteristics of
pleural air-fluid level
 Characteristics of
parenchymal air-fluid level
 Air-fluid level
„ Distinguish pleural (from parenchymal)
– Disparate measurements frontal and lateral
– Abuts chest wall
– Displaces parenchymal structures
– Lenticular shape
„ Pleural:
– Instrumentation
– Bronchopleural fistula