Solitary pulmonary nodule evaluation of solitary pulmonary nodule

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Overview

A hallmark feature in the evaluation of solitary pulmonary nodule is the malignancy risk assessment. The evaluation approach of solitary pulmonary nodule will mainly depend in the initial morphological evaluation of the nodule (size, margins, contours, and growth). Other characteristics, such as: location, clinical features, and distribution may be helpful for the risk assessment, therapeutical management, surveillance, and follow-up of solitary pulmonary nodule. Solitary pulmonary nodule can be divided into 4 risk categories: low risk, intermediate, moderate and high risk. Based upon these risk categories, complementary diagnostic studies and management, include: PET/CT scan, CT scan, non-surgical biopsy, and surgical resection.

Evaluation of Solitary Pulmonary Nodule

Initial Evaluation Algorithm

 
 
 
 
 
Solitary Pulmonary Nodule Detected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Step 1: Assess likelihood of cancer
Mayo Clinic Malignancy Risk Calculator
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Step 2: Review prior films
Is there a growth?
 
No previous films
*Refer to step 2A
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes, growing
 
 
 
No, stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Step 2B
Surveillance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Location
❑ Upper lobe
❑ Lower lobe
❑ Middle lobe
Size
❑ < 8mm
❑ > 8mm
Lesion characteristics
❑ Margins (irregular/regular)
❑ Shape (spiculated/rounded)
❑ Attenuation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Diagnostic Studies
❑ PET/CT scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk
❑ < 5%
 
Intermediate risk
❑ 5-65%
 
High risk
❑ > 65%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serial CT scans
 
Non-surgical biopsy
*Refer to Step 3: Treatment and Follow-up
 
Surgical resection
*Refer to Step 3: Treatment and Follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Malignancy Risk Assessment

The malignancy risk assessment for pulmonary nodule considers the following factors:[1]

  • Age
  • Smoking
  • Current
  • Never smoker
  • Cancer
  • Extrathoracic cancer more than 5 years prior
  • Nodule diameter
  • Spiculation
  • Yes
  • No
  • Upper lobe
  • Yes
  • No
  • The risk calculator is not validated for patients with history of cancer in the past 5 years.[1]


The malignancy of pulmonary nodule, can be categorized into 3 groups:

Low probability

  • Usually less than <5 percent
  • The nodule size is less than or equal to 4 mm
  • The nodule size is between 4-6 mm
  • Observation is suggested
  • Observation usually involves radiologic surveillance with serial CT scans.


Read More: http://www.atsjournals.org/doi/full/10.1164/rccm.201104-0679CI#.VvAbTxjf5mo

Intermediate probability

  • Between 5 to 65 percent
  • The nodule size is between 6-8 mm and associated risk factors
  • Diagnostic testing is indicated: positron emission tomography (PET), CT-FNA, and bronchoscopy

High probability

  • More than >65 percent
  • Follow similar management algorithm for lung cancer.

The patient risk assessment of pulmonary nodule, can be categorized into 2 groups:

  • High risk patients
  • Patient age is > 35
  • Positive smoking history
  • Male patients
  • Positive for prior malignancy
  • Other associated risk factors.
  • Low risk patients
  • Patient age < 35
  • Smoking history:
  • No smoking history
  • Female patients
  • Negative for prior malignancy
  • No associated risk factors

References

  1. 1.0 1.1 Swensen SJ, Silverstein MD, Ilstrup DM, et. al. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. 1997 Apr 28;157(8):849-55.