Solitary Pulmonary Nodule

Principles

• Definition: single. • 3 cm. surrounded by normal lung, no LAN or pleural effusion

• Often "incidentalomas." but may represent early potentially curable localized malignancy

Etiologies

Benign (70%)

Malignant (30%)

Granuloma (80%):TB. histo. cocci Hamartoma (10%) Bronchogenic cyst.AVM. pulm infarct Echinococcosis, ascariasis. aspergilloma Wegener's. Rheumatoid nodule Lipoma, fibroma, amyloidoma. pneumonitis

Bronchogenic carcinoma (75%): adeno & large cell (peripheral) squamous & small cell (central) Metastatic (20%): breast, head & neck, colon, testicular, renal, sarcoma, melanoma Carcinoid, primary sarcoma

Risk of Cancer

Feature

Low

Intermediate

High

Diameter (cm)

1.5

1.5-2.2

s2.3

Nodule shape

smooth

scalloped

spiculated

Age(y)

_<45

45-60

>60

Smoking

never

current (si ppd)

current (>1 ppd)

Smoking cessation

none, quit ¿7 y

quit <7 y ago

never quit

(NEJM 2003;348:253S)

(NEJM 2003;348:253S)

Initial evaluation

• History: h/o cancer, smoking, age (<30 y - 2% malignant -15% ea. decade 30)

• CT: size/shape. Ca. LAN. effusions, bony destruction, c/w old studies

0 Ca —» T likelihood malignant; laminated — granuloma; "popcorn" -» hamartoma Diagnostic studies

• PET: detects metab. activity of tumors, 97% Se & 78% Sp for malig. (espec if 8 mm)

also useful for surgical staging b/c may detect unsuspected mets (Lancet 2001:2:659) useful in deciding which lesions to bx vs. follow w/ serial CT (jThor Oncol 2006.1:71)

• Transthoracic needle biopsy: if tech. feasible. 97% will obtain definitive tissue dx

(ajr 2005:185:1294); if non-informative or malignant -» resect

• Video-assisted thorascopic surgery (VATS): for percutaneously inaccessible lesions;

highly sensitive and allows resection; has replaced thoracotomy

• Transbronchial bx: most lesions too small to reliably sample w/o endobronchial

U/S (Cheu 2003:123:604); bronch w/ brushings low-yield unless invading bronchus

Management

• Low-risk: serial CT (q3mos ■ 4. then q6mos x 2); shared decision w/ Pt regarding bx

• Intermediate-risk: PET. transthoracic needle bx or transbronchial bx depending on location, co-morbidities and Pt preference; if non-informative — VATS

• High-risk (and surgical candidate):VATS lobectomy if malignant

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