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A solitary pulmonary nodule, sometimes referred to as a coin lesion, is a < 3 cm isolated, rounded opacity on the chest radiograph outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy Most are asymptomatic and represent an unexpected finding on chest radiography The finding is important because it carries a significant risk of malignancy The frequency of malignancy in surgical series ranges from 10% to 68% depending on patient population Most benign nodules are infectious granulomas Benign neoplasms such as hamartomas account for less than 5% of solitary nodules The goals of evaluation are to identify and resect malignant tumors in patients who stand to benefit from resection while avoiding invasive procedures in benign disease The task is to identify nodules with a sufficiently high probability of malignancy to warrant biopsy or resection or a sufficiently low probability of malignancy to justify observation Symptoms alone rarely establish the cause, but clinical and radiographic data can be used to assess the probability of malignancy The patient s age is important Malignant nodules are rare in persons under age 30 Above age 30, the likelihood of malignancy increases with age Smokers are at increased risk, and the likelihood of malignancy increases with the number of cigarettes smoked daily Patients with a prior malignancy have a higher likelihood of having a malignant solitary nodule The first and most important step in the radiographic evaluation is to review old radiographs Comparison with prior studies allows estimation of doubling time, which is an important marker for malignancy Rapid progression (doubling time less than 30 days) suggests infection; longterm stability (doubling time over 465 days) suggests benignity Certain radiographic features help in estimating the probability of malignancy Increasing size is correlated with malignancy A recent study of solitary nodules identified by CT scan showed a 1% malignancy rate in those measuring 2 5 mm, 24% in 6 10 mm, 33% in 11 20 mm, and 80% in 21 45 mm The appearance of a smooth, well-defined edge is characteristic of a benign process Ill-defined margins or a lobular appearance suggest malignancy A high-resolution CT finding of spiculated margins and a peripheral halo are both highly associated with malignancy Calcification and
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Periodic evaluation of asymptomatic people at high risk for lung cancer is an attractive strategy without demonstrated benefit Available evidence from the Mayo Lung Project suggests that serial chest radiographs can identify a significant number of early stage malignancies but that neither disease-specific mortality from lung cancer nor all-cause mortality is affected by screening The illusory benefits of screening have been attributed to lead time, length time, and overdiagnosis biases Since three large randomized clinical trials published between 1984 and 1986 came to similar conclusions, screening for lung cancer has not been recommended by any major advisory group The availability of rapid-acquisition, low-dose helical computed tomography (LDCT) has rekindled enthusiasm for lung cancer screening LDCT is a very sensitive test Compared with chest radiography, LDCT identifies between four and ten times the number of asymptomatic lung malignancies LDCT may also increase the number of false-
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its pattern are also helpful clues Benign lesions tend to have dense calcification in a central or laminated pattern Malignant lesions are associated with sparser calcification that is typically stippled or eccentric Cavitary lesions with thick (> 16 mm) walls are much more likely to be malignant High-resolution CT offers better resolution of these characteristics than chest radiography and is more likely to detect lymphadenopathy or the presence of multiple lesions High-resolution CT is indicated in any suspicious solitary pulmonary nodule
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Based on clinical and radiologic data, the clinician should assign a specific probability of malignancy to the lesion The decision whether and how to obtain a diagnostic biopsy depends on the interpretation of this probability in light of the patient s unique clinical situation The probabilities in parentheses below represent guidelines only and should not be interpreted as prescriptive In the case of solitary pulmonary nodules, a continuous probability function may be grouped into three categories In patients with a low probability (< 8%) of malignancy (eg, age under 30, lesions stable for more than 2 years, characteristic pattern of benign calcification), watchful waiting is appropriate Management consists of serial imaging studies (CT scans or chest radiographs) at intervals that would identify growth that would suggest malignancy Three-dimensional reconstruction of high-resolution CT images provides a more sensitive test for growth Patients with a high probability (> 70%) of malignancy should proceed directly to resection following staging, provided there are no contraindications to surgery Biopsies rarely yield a specific benign diagnosis and are not indicated Optimal management of patients with an intermediate probability of malignancy (8 70%) remains controversial The traditional approach is to obtain a diagnostic biopsy either through transthoracic needle aspiration (TTNA) or bronchoscopy Bronchoscopy yields a diagnosis in 10 80% of procedures depending on the size of the nodule and its location In general, the bronchoscopic yield for nodules that are < 2 cm and peripheral is low Complications are generally rare TTNA has a higher diagnostic yield, reported to be between 50% and 97% The yield is strongly operator-dependent, however, and is affected by the location and size of the lesion Complications are higher than bronchoscopy, with pneumothorax occurring in up to 30% of patients, with up to one-third of these patients requiring placement of a chest tube Disappointing diagnostic yields and a high false-negative rate (up to 25 30% in TTNA) have prompted alternative approaches Positron emission tomography (PET) detects increased glucose metabolism within malignant lesions with high sensitivity (85 97%) and specificity (70 85%) Many diagnostic algorithms have incorporated PET into the assessment of patients with inconclusive highresolution CT findings A positive PET increases the likelihood of malignancy, and a negative PET correctly excludes cancer in most cases False-negative PET scans can occur
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with tumors with low metabolic activity (well-differentiated adenocarcinomas, carcinoids, and bronchioloalveolar tumors), and follow-up imaging is typically performed at discrete intervals to ensure absence of growth PET has several drawbacks, however: resolution below 1 cm is poor, the test is expensive, and availability remains limited Sputum cytology is highly specific but lacks sensitivity It is used in central lesions and in patients who are poor candidates for invasive diagnostic procedures Researchers have attempted to improve the sensitivity of sputum cytology through the use of monoclonal antibodies to proteins that are up-regulated in pulmonary malignancies Such tests offer promise but remain research tools at this time Video-assisted thoracoscopic surgery (VATS) offers a more aggressive approach to diagnosis VATS is more invasive than bronchoscopy or TTNA but is associated with less postoperative pain, shorter hospital stays, and more rapid return to function than traditional thoracotomy These advantages have led some centers to recommend VATS resection of all solitary pulmonary nodules with intermediate probability of malignancy In some cases, surgeons will remove the nodule and evaluate it in the operating room with frozen section If the nodule is malignant, they will proceed to lobectomy and lymph node sampling, either thoracoscopically or through conversion to standard thoracotomy
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Gurney JW Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis Part I Theory Radiology 1993 Feb;186(2):405 13 [PMID: 8421743] MacMahon H et al Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society Radiology 2005 Nov;237(2):395 400 [PMID: 16244247] Winer-Muram HT The solitary pulmonary nodule Radiology 2006 Apr;239(1):34 49 [PMID: 16567482]
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