Lung mass resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]


Lung mass (also known as "Pulmonary mass") is defined as any area of pulmonary opacification that measures more than 30 mm (3 cms) in the lung. Lung mass are abnormal growths found in the lung which can be either be benign or malignant. The most common cause of a pulmonary mass is lung cancer. Other less common causes of lung mass include granuloma, lipoma, tuberculosis, and aspergillosis.


Lung mass may be classified on the basis of histopathology into benign lung mass and malignant lung mass. In addition, lung mass can be sub-classified according to the location, imaging features, size, and distribution.

Lung mass
Imaging Features
Malignant mass
Benign mass
•Hyperdense pulmonary mass
•Cavitating pulmonary mass


The common causes of lung mass include:[1][2][3][4][5]

Life Threatening Causes

Common Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients of lung mass.

Identify cardinal findings that increase the pretest probability of lung mass
❑ Chronic cough
Chest pain
Loss of appetite
Advise chest x ray (CXR)
Lung opacity on chest X ray (CXR)
Size >3 cms; classified as lung mass
Size <3 cms; classified as pulmonary nodule
High resolution chest CT scan
Check previous CXR
Imaging features
Previous CXR normal; suggesting new growth
Previous CXR shows opacity but stable in size since then
Hyperdense pulmonary mass
❑Internal/eccentric calcification
Cavitating pulmonary mass
❑ Gas-filled area
❑ Thick/spiculated wall (must be greater than 2-5 mm)
Follow up every 2-3 yrs
Other diagnostic studies
❑ Sputum cytology

❑ Endobronchial ultrasound
❑ Endoscopic ultrasound
❑ Bronchoscopy
❑ Mediastinoscopy
High resolution chest CT scan
Highly suspicious for malignancy
•Age >60yrs
•Current smoker
•Size >2cms
Moderately suspicious for malignancy
•Age 40-60yrs
•Current smoker
•Size 0.8-2cms
Low suspicion of malignancy or benign features
•Age <40yrs
•Non smoker
•Size <0.8cm
PET or biopsy
Serial CT scans
PET with biopsy
No evidence of malignancy
Surgical excision/Chemotherapy or Radiotherapy depending upon histopathology
No growth over time
Lesion grows over time
Surgical excision/Chemotherapy or Radiotherapy depending upon histopathology
Serial CT scans
No further workup
PET with or biopsy
Surgical excision/Chemotherapy or Radiotherapy depending upon histopathology

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[6][7][8]

Characterize the symptoms:

Low grade fever
Chest pain

❑ At rest
❑ Exertional


Obtain a detailed history:
Past medical history
❑ Personal history of cancer
❑ Family history of cancer
❑ Positive history of active/passive smoking

❑ Number of cigarettes/year
❑ Number of years/months of active smoking
❑ Number of years/months of second-hand smoking
❑ Number of years/months of smoking cessation

❑ Previous primary infection of tuberculosis
❑ Onset of pulmonary symptoms

❑ Acute (< 6 weeks)
❑ Chronic (> 6 weeks)

❑ Previous or current lung disease, such as:

Chronic obstructive pulmonary disease
Interstitial lung disease

Medication history

❑ Intake of the following drugs:
Chemotherapy drugs
Examine the patient:
General appearance:

❑ Patients look older than actual age
❑ Confused

Low grade fever
❑ Decreased SPO2

❑ Measure weight daily at the same time after the first void

Cool and clammy (suggestive of hypoperfusion)
Cyanosis (suggestive of severe hypoxemia)

HEENT examination:
Jugular vein distention (suggestive of Pulmonary HTN)
❑ Positive hepatojugular reflux

Respiratory examination
❑ Rapid rate of breathing

Pleural friction rub
❑ Crackling or bubbling noises
Whispered pectoriloquy
❑ Decreased/absent breath sounds
❑ Dullness at lung bases (suggestive of pleural effusion
Crackles/crepitations/rales (suggestive of pleural effusion)
Cheyne-stokes respiration


❑ Hyporesonance
❑ Dull percussion
Tactile fremitus
❑ Reduced chest expansion

Abdominal examination

❑ Palpable soft-tissue mass

Extremity examination
Pedal edema
Clubbing of fingers
❑ Swelling of hands and feet
❑ Weakness

Neurological examination
Altered mental status
❑ Slurred speech

Order tests:

CBC (rule out anemia)
❑ Calcium
Alkaline phosphatase
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
❑ Total bilirubin
Albumin and lactate dehydrogenase

Chest X-ray
❑ Rounded or spiculated mass
❑ Bulky hilum (representing the tumor and local nodal involvement)
❑ Lobar collapse
❑ Cavitation may be seen as an air-fluid level
Pleural effusion

High resolution chest CT scan
❑ Single pulmonary nodule or mass
❑ Localized area of parenchymal consolidation
❑ Bubble-like areas of low attenuation within the mass (characteristic finding)
❑ Hilar and mediastinal lymphadenopathy is uncommon
❑ Persistent peripheral consolidation

Other diagnostic studies
Sputum cytology
Endobronchial ultrasound
Endoscopic ultrasound

Staging of disease; TNM Classification:

❑ Stage IA
❑ Stage IB
❑ Stage IIA
❑ Stage IIB
❑ Stage IIIA
❑ Stage IIIB
❑ Stage IV



The following table depicts the TNM classification for lung cancer:

TNM classification of lung cancer [9]
T: Primary tumor
TX Any of: Primary tumor cannot be assessed
Tumor cells present in sputum or bronchial washing, but tumor not seen with imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor size less than or equal to 3 cm across, surrounded by lung or visceral pleura, without invasion proximal to the lobar bronchus
T1a Tumor size less than or equal to 2 cm across
T1b Tumor size more than 2 cm but less than or equal to 3 cm across
T2 Any of: Tumor size more than 3 cm but less than or equal to 7 cm across
Involvement of the main bronchus at least 2 cm distal to the carina
Invasion of visceral pleura
Atelectasis/obstructive pneumonitis extending to the hilum but not involving the whole lung
T2a Tumor size more than 3 cm but less than or equal to 5 cm across
T2b Tumor size more than 5 cm but less than or equal to 7 cm across
T3 Any of: Tumor size more than 7 cm across
Invasion into the chest wall, diaphragm, phrenic nerve, mediastinal pleura or parietal pericardium
Tumor less than 2 cm distal to the carina, but not involving the carina
Atelectasis/obstructive pneumonitis of the whole lung
Separate tumor nodule in the same lobe
T4 Any of: Invasion of the mediastinum, heart, great vessels, trachea, carina, recurrent laryngeal nerve, esophagus, or vertebra
Separate tumor nodule in a different lobe of the same lung
N: Lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis to ipsilateral peribronchial and/or hilar lymph nodes
N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes
N3 Any of: Metastasis to scalene or supraclavicular lymph nodes
Metastasis to contralateral hilar or mediastinal lymph nodes
M: Metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1a Any of: Separate tumor nodule in the other lung
Tumor with pleural nodules
Malignant pleural or pericardial effusion
M1b Distant metastasis

Prevention of Lung mass

Effective measures for the primary prevention of lung mass include smoking cessation and avoidance of second hand smoking. In general, lifestyle changes with diet rich in vitamins and antioxidants such as healthy diet rich with fruits and vegetables and regular exercise, may decrease the risk of tumorigenesis and malignancy.



  • According to the clinical practice guideline issued by the American College of Chest Physicians (CHEST) in 2013, screening for suspected lung cancer by low-dose CT (LDCT) is recommended every year among smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years.[15]

Treatment of Lung mass

  • The treatment of patients with lung mass varies and depends upon the underlying histology and staging of the disease (Note: Around 95% lung mass cases are lung cancer).[16][17]
  • Widespread and malignant disease is treated with chemotherapy or with/without radiotherapy, as surgery is not an option in patients with advanced disease.
  • Patients with benign and resectable tumors are generally treated with surgical excision.
  • Surgical excision is considered the mainstay therapy for malignant lung mass.
  • In lung mass, surgical procedure selection will depend on the size, margins, and invasion of the tumor.
  • Common surgical procedures for the treatment of lung mass include wedge resection, segmentectomy, lobectomy, and lung volume reduction surgery.
  • The medical therapy for lung cancer on the basis of staging is given below:[18][19][20][21][22][23]
Stage Treatment
Stage I Radiation therapy AND consider chemotherapy for high risk stage IB
Stage II (T2a, N0 OR T3, N0) Consider chemotherapy for high risk stage II AND radiation therapy
Stage II (T1a, N1 OR T1b, N1 OR T2a, N1 OR T2b, N1) Chemoradiation
Stage III Chemoradiation
  • For details on medical therapy of lung cancer, click here.


  1. CDC (Dec 1986). "1986 Surgeon General's report: the health consequences of involuntary smoking". CDC. PMID 3097495. Retrieved 2007-08-10.
    * National Research Council (1986). Environmental tobacco smoke: measuring exposures and assessing health effects. National Academy Press. ISBN 0-309-07456-8.
    * Template:Cite paper
    * California Environmental Protection Agency (1997). "Health effects of exposure to environmental tobacco smoke". Tobacco Control. 6 (4): 346–353. PMID 9583639. Retrieved 2007-08-10.
    * CDC (Dec 2001). "State-specific prevalence of current cigarette smoking among adults, and policies and attitudes about secondhand smoke—United States, 2000". Morbidity and Mortality Weekly Report. CDC. 50 (49): 1101–1106. PMID 11794619. Retrieved 2007-08-10.
    * Alberg, AJ (Jan 2003). "Epidemiology of lung cancer". Chest. American College of Chest Physicians. 123 (S1): 21S–49S. PMID 12527563. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
  2. Parent, ME (Jan 2007). "Exposure to diesel and gasoline engine emissions and the risk of lung cancer". American Journal of Epidemiology. 165 (1): 53–62. PMID 17062632. Unknown parameter |coauthors= ignored (help)
  3. Boffetta, P (Oct 1998). "Multicenter case-control study of exposure to environmental tobacco smoke and lung cancer in Europe". Journal of the National Cancer Institute. Oxford University Press. 90 (19): 1440–1450. PMID 9776409. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
  4. "Report of the Scientific Committee on Tobacco and Health". Department of Health. Mar 1998. Retrieved 2007-07-09.
    * Hackshaw, AK (Jun 1998). "Lung cancer and passive smoking". Statistical Methods in Medical Research. 7 (2): 119–136. PMID 9654638.
  5. Template:Cite paper
  6. Hyde L, Hyde CI (1974). "Clinical manifestations of lung cancer". Chest. 65 (3): 299–306. PMID 4813837.
  7. Spira A, Ettinger DS (2004). "Multidisciplinary management of lung cancer". N. Engl. J. Med. 350 (4): 379–92. doi:10.1056/NEJMra035536. PMID 14736930.
  8. Kundel HL (1981). "Predictive value and threshold detectability of lung tumors". Radiology. 139 (1): 25–9. doi:10.1148/radiology.139.1.7208937. PMID 7208937.
  9. Chheang, S; Brown K (June 2013). "Lung cancer staging: clinical and radiologic perspectives". Seminars in Interventional Radiology. 30 (2): 99–113. doi:10.1055/s-0033-1342950. PMC 3709937. PMID 24436525.
  10. Davis AM, Cifu AS. Lung Cancer Screening. JAMA. 2014;312(12):1248-1249. doi:10.1001/jama.2014.12272.
  11. Recommendations. US preventive services task force(2016) Accessed on March, 15th 2016
  12. McWilliams A, Tammemagi MC, Mayo JR, et. al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013 Sep 5;369(10):910-9. doi:10.1056/NEJMoa1214726.
  13. Lung Cancer: Screening Accessed on February 3, 2016 <nowiki><nowiki>
  14. National Lung Screening Trial. Wikipedia. Accessed on February 4,2016
  15. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB (2013). "Screening for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 143 (5 Suppl): e78S–92S. doi:10.1378/chest.12-2350. PMID 23649455. Summary in JournalWatch
  16. El-Sherif, A (Aug 2006). "Outcomes of sublobar resection versus lobectomy for stage I non-small cell lung cancer: a 13-year analysis". Annals of Thoracic Surgery. 82 (2): 408–415. PMID 16863738. Unknown parameter |coauthors= ignored (help)
  17. Fernando, HC (Feb 2005). "Lobar and sublobar resection with and without brachytherapy for small stage IA non-small cell lung cancer". Journal of Thoracic and Cardiovascular Surgery. 129 (2): 261–267. PMID 15678034. Unknown parameter |coauthors= ignored (help)


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