Answer

Solitary pulmonary nodule or mass

There is a solitary nodule seen in the mid-zone of the right lung. No other pulmonary nodules or rib lesions are seen.

Nipple shadows can often cause confusion on plain films as they may resemble lung nodules. If any doubt exists then metallic skin markers should be positioned and further X-rays taken. This case example was a nipple shadow (see Fig. 1.61).

A common cause of true pulmonary nodule in a patient of this age would be bronchogenic carcinoma; metastasis, granuloma or infection are further possibilities.

Solitary pulmonary nodule

With this type of film (especially in a viva situation) you give the most likely differential diagnosis first and list the others in reducing order of probability. It is no good giving Wegeners granulomatosis as the opening differential, although possible, it is not the most likely diagnosis in a 54 70-year-old smoker (Table 1.9).

Fig. 1.61 Nipple shadow CT. Although a plain film with metallic nipple markers is usually sufficient, this CT clearly demonstrates the cause of the 'nodule' seen on the plain film.

Table 1.9 The solitary lung mass

Acquired

Tumour

Malignant

Bronchogenic carcinoma (look for rib mets)

Solitary metastasis

Breast (mastectomy), renal (surgical clips),

sarcoma, seminoma

Lymphoma

Benign

Carcinoid (central position)

Hamartoma (popcorn calcification) (see Fig. 1.62)

Infection

Bacterial

Round pneumonias (children)

Parasitic

Hydatid (?name, waterlilly sign)

Fungal

Histoplasmosis

Infarction

Pulmonary

Infarct (peripheral, wedge shaped)

Vascular

Pulmonary avm

(Large feeding vessel) (see Fig. 1.63)

Granuloma

TB

(Name, satellite lesion)

Wegeners

(Old films, ?dialysis line) (Fig. 1.64)

Sarcoid

Rheumatoid nodule

(Shoulder erosions, clavicle)

Trauma

Haematoma

(Rib fractures)

Congenital

Sequestered segment

(Usually basal)

Bronchogenic cyst

(Normally mediastinal)

Fig. 1.62 Hamartoma. 'Popcorn' calcification is almost pathonomonic of hamartoma, usually the lesion is slow growing and about half contain fat on CT.
Fig. 1.63 Arterio-venous malformation. These can appear like a suspicious nodule on chest X-ray. Feeding vessels are sometimes visible on the conventional X-ray but CT with contrast enhancement will demonstrate these very elegantly.
Fig. 1.64 Wegeners granulomatosis. This can appear as patchy alveolar infiltrate - either single or multiple which can also be complicated by cavitation.

You may be pressed for further causes of a solitary nodule by the examiner. This is a classic example of where to use a surgical sieve. You must try and narrow the differential by looking for any secondary signs on the film (look for the signs given in brackets).

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