The problem of solitary pulmonary nodule

The problem of The problem of Solitary pulmonary Solitary pulmonary

nodulenoduleDr/Ahmed A. BahnassyDr/Ahmed A. Bahnassy

Consultant radiologistConsultant radiologist

MBCHB-MD-FRCR (London –MBCHB-MD-FRCR (London –UK)UK)

DD of Solitary pulmonary DD of Solitary pulmonary nodule nodule

SPNSPN

Ii is defined as a focal opacity ,visible Ii is defined as a focal opacity ,visible on chest radiograph or CT ,with the on chest radiograph or CT ,with the following criteria :following criteria :

1.Relatively well defined .1.Relatively well defined .

2.Surrounded-at least partially - by 2.Surrounded-at least partially - by lung .lung .

3.Roughly spherical in shape.3.Roughly spherical in shape.

4.3 cm or less in diameter (more than 3 4.3 cm or less in diameter (more than 3 cm is termed mass )cm is termed mass )

Clinical evaluationClinical evaluation Hx of smoking.Hx of smoking. Age over 40.Age over 40. Occupational exposure.Occupational exposure. Lung fibrosis.Lung fibrosis. COPD.COPD. Family Hx of Lung cancer.Family Hx of Lung cancer. Travel History Travel History TB skin test.TB skin test. Other diseases (Rheumatoid arthritis )Other diseases (Rheumatoid arthritis ) Malignancy .(solitary metastasis or increased Malignancy .(solitary metastasis or increased

likelihood of 1ry bronchogenic Ca for H & N breast likelihood of 1ry bronchogenic Ca for H & N breast ,bile ducts ,oes. ,cervix ,bladder ,prostate ,etc up to ,bile ducts ,oes. ,cervix ,bladder ,prostate ,etc up to 3 folds )3 folds )

Radiographic evaluationRadiographic evaluation

Morphological Characteristics.Morphological Characteristics. Density.Density. Growth rate .Growth rate .

I-Morphological I-Morphological CharacteristicsCharacteristics

Size :Size :

The likelihood of The likelihood of malignancy is malignancy is directly related to directly related to size reaching more size reaching more than 85 % for SPN than 85 % for SPN more than 2 cm .more than 2 cm .

DiameterDiameterMalignanMalignancy ratecy rate

<<1cm1cm35%35%

1-21-2 cmcm50%50%

2-32-3 cmcm80%80%

Location :Location :

2/3 of lung cancers occur in upper 2/3 of lung cancers occur in upper lobes.lobes.

60% seen in lung periphery .60% seen in lung periphery .

Only 10 % seen in medial third .Only 10 % seen in medial third .

Mets tend to be subpleural or Mets tend to be subpleural or outer 1/3 of lung.outer 1/3 of lung.

2/3 of mets are in lower lobes.2/3 of mets are in lower lobes.

Edge Appearance :Edge Appearance :

90% of lesions with irregular or 90% of lesions with irregular or spiculated edges are malignant.spiculated edges are malignant.

20% only of well defined lesions are 20% only of well defined lesions are malignant (e.g.: Mets or carcinoid malignant (e.g.: Mets or carcinoid tumor )tumor )

Corona Maligna or radiata represent Corona Maligna or radiata represent either desmoplastic reaction around the either desmoplastic reaction around the tumor or actual invasion of surrounding tumor or actual invasion of surrounding lung …common with BAC and lung …common with BAC and adenocarcinomaadenocarcinoma

CarcinomaCarcinomaFocal scarringFocal scarringBrncioalveolar cell carcinomaBrncioalveolar cell carcinoma

Pleural tail in Pleural tail in adenocarcinomaadenocarcinoma

Pleural tag refers to linear density Pleural tag refers to linear density (fibrosis) extending to pleural (fibrosis) extending to pleural surface .surface .

Pleural tag in Pleural tag in adenocarcinomaadenocarcinoma

GranulomaGranuloma

HamartomaHamartoma

MetastasisMetastasis..

Benign lesion-smooth Benign lesion-smooth edgesedges

MetsMets

HamartomaHamartoma

Halo signHalo sign

Halo of ground glass opacity Halo of ground glass opacity surrounding a nodule .surrounding a nodule .

Commonly present in Leukemic patient Commonly present in Leukemic patient with invasive aspergillosis (represent with invasive aspergillosis (represent hemorrhagic infarction )hemorrhagic infarction )

Can occur with any other infections .Can occur with any other infections .

Can be seen with BAC and Can be seen with BAC and adenocarcinoma (representing lepidic adenocarcinoma (representing lepidic growth )growth )

Causes of Halo signCauses of Halo sign

Invasive aspegillosisInvasive aspegillosisWegener GranulomatosisWegener Granulomatosis..BACBAC..Kaposi sarcomaKaposi sarcoma..MetsMets..TB, nocardiosisTB, nocardiosis..CMV infectionCMV infection..PCPPCPBOOPBOOP

Invasive aspergillosisInvasive aspergillosis

BACBAC

Shape :Shape :

Lung Ca tends to be irregular , Lung Ca tends to be irregular , lobulated or notched.lobulated or notched.

Granuloma are rounded.Granuloma are rounded.

Hamartoma and metastasis are Hamartoma and metastasis are round ,oval or lobulated.round ,oval or lobulated.

Scars , atelectasis may appear linearScars , atelectasis may appear linear ..

AVM and mucous plugs are particular AVM and mucous plugs are particular in shapein shape

Air bronchogram and Air bronchogram and pseudocavitation.pseudocavitation.

CavitationCavitation

Air crescent signAir crescent sign

Air-Fluid levelAir-Fluid level

Satellite nodules ..GALAXY signSatellite nodules ..GALAXY sign

Feeding vessel signFeeding vessel sign

Showing a vessel ending into and Showing a vessel ending into and feeding a lesion feeding a lesion

Associated with infarction ,AVM , Associated with infarction ,AVM , metastasis ,septic emboli .metastasis ,septic emboli .

II-DensityII-Density

Ground Glass opacityGround Glass opacity

CalcificationCalcification

Causes Causes

Benign Vs malignant patterns of Benign Vs malignant patterns of calcificationscalcifications

Bull eye calcificationBull eye calcification

Target calcification -Target calcification -HistoplasmomaHistoplasmoma

POP corn calcification -POP corn calcification -hamartomahamartoma

Eccentric calcification in Eccentric calcification in adenoCaadenoCa

Water densityWater density

Fat densityFat density

Contrast enhancementContrast enhancement

HRCT –Malignant HRCT –Malignant looking masslooking mass

Increase 40 HU Increase 40 HU (>15 ) post (>15 ) post contrast. .typical of contrast. .typical of malignancy (77% malignancy (77% accuracy)accuracy)

Contrast opacificationContrast opacification

AVMAVM

Pulmonary vein varix.Pulmonary vein varix.

Pulmonary artery aneurysmPulmonary artery aneurysm

III-GrowthIII-Growth Doubling time is the time required for a Doubling time is the time required for a

lesion to double its volume .lesion to double its volume . 26% increase in nodule diameter is one 26% increase in nodule diameter is one

doubling doubling Doubling of diameter is 3 volume Doubling of diameter is 3 volume

doublings.doublings. Range of doubling time of carcinomas is 1 Range of doubling time of carcinomas is 1

week to 16 months.week to 16 months. Doubling time <1 month or >200 days is Doubling time <1 month or >200 days is

likely to be benign .likely to be benign . No growth over 2 years most likely benign.No growth over 2 years most likely benign.

How to evaluateHow to evaluate??

See prior examinationsSee prior examinations..

If not availableIf not available

Small lesions follow up is at 3,6 Small lesions follow up is at 3,6 months ,1 and 2 yearmonths ,1 and 2 year..

Very small lesions (3mm)..yearly Very small lesions (3mm)..yearly follow upfollow up

SPECT & PET Scan SPECT & PET Scan additionsadditions

Using FDG high activity in PET is Using FDG high activity in PET is associated with malignancyassociated with malignancy

Biopsy takingBiopsy taking.. FOB =fiber optic bronchoscopy..for central lesions.FOB =fiber optic bronchoscopy..for central lesions. TNB =Trans thoracic needle biopsy ..For peripheral TNB =Trans thoracic needle biopsy ..For peripheral

lesions.lesions.

Strategy for nodule Strategy for nodule evaluationevaluation