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{{Solitary pulmonary nodule}}
{{Solitary pulmonary nodule}}
{{CMG}}
{{CMG}}{{AE}}{{MV}} {{JE}}


==Recommendations for management based on appearance==
==Overview==
===Nodules found during screening===
The [http://www.acr.org/Quality-Safety/Resources/LungRADS Lung-RADS] reporting system helps determine management.<ref name="pmid25664444">{{cite journal| author=Pinsky PF, Gierada DS, Black W, Munden R, Nath H, Aberle D et al.| title=Performance of Lung-RADS in the National Lung Screening Trial: A Retrospective Assessment. | journal=Ann Intern Med | year= 2015 | volume= 162 | issue= 7 | pages= 485-91 | pmid=25664444 | doi=10.7326/M14-2086 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25664444  }} </ref> Categories 1 (negative) and 2 (benign appearance) are negative screening results while categories 3 (probably benign) and 4 (suspicious) are positive screening results.


===Nodules found incidentally===
Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule. On CT, characteristic findings of solitary pulmonary nodules, include: ground-glass opacity, rounded mass, and less than 30mm.<ref name="pmid8190965">{{cite journal |vauthors=Rosado-de-Christenson ML, Templeton PA, Moran CA |title=Bronchogenic carcinoma: radiologic-pathologic correlation |journal=Radiographics |volume=14 |issue=2 |pages=429–46; quiz 447–8 |year=1994 |pmid=8190965 |doi=10.1148/radiographics.14.2.8190965 |url=}}</ref><ref name="pmid19234288">{{cite journal |vauthors=Parker MS, Chasen MH, Paul N |title=Radiologic signs in thoracic imaging: case-based review and self-assessment module |journal=AJR Am J Roentgenol |volume=192 |issue=3 Suppl |pages=S34–48 |year=2009 |pmid=19234288 |doi=10.2214/AJR.07.7081 |url=}}</ref> The evaluation of solitary pulmonary nodule will depend on 7 characteristics: calcification patterns, size, location, size, growth, shape, margins, attenuation, and contrast enhancement.<ref name="pmid19234288">{{cite journal |vauthors=Parker MS, Chasen MH, Paul N |title=Radiologic signs in thoracic imaging: case-based review and self-assessment module |journal=AJR Am J Roentgenol |volume=192 |issue=3 Suppl |pages=S34–48 |year=2009 |pmid=19234288 |doi=10.2214/AJR.07.7081 |url=}}</ref>
====Solid nodules====
 
For response by physicians to lung nodules found on CT scans, the [[clinical practice guideline]]s by the [[American College of Chest Physicians]] (ACCP) recommends<ref name="pmid23649456">{{cite journal| author=Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP et al.| title=Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e93S-120S | pmid=23649456 | doi=10.1378/chest.12-2351 | pmc=PMC3749714 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649456  }} </ref>:
==CT==
* If less than 8 mm, use guidelines in table below by the Fleischner society (see table below).
*Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule
* For nodules greater than 8 mm in diameter, assess the patients risk of complications from thoracic surgery:
*On CT, characteristic findings of solitary pulmonary nodules, include:
** If high risk for complications of surgery, obtain non-surgical biopsy
:*Single to multiple intraparenchymal lesion
** If low to moderate risk for complications of surgery, assess probability of cancer by a validated calculation. The model developed at the Mayo Clinic has been the most extensively validated<ref name="pmid9129544">{{cite journal| author=Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES| title=The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. | journal=Arch Intern Med | year= 1997 | volume= 157 | issue= 8 | pages= 849-55 | pmid=9129544 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9129544  }} </ref>. An open-source version is [https://openrules.ocpu.io/home/www/pulmnodule.html available online].
:*Less than 3 cm in size
:*Rounded or spiculated lesion
[[File: Solitary pul nodule.png|400px|left|thumb| CT scan showing solitary pulmonary nodules (Picture courtesy: [https://openi.nlm.nih.gov/detailedresult?img=PMC4770395_rb-49-01-0035-g05&query=solitary%20pulmonary%20nodules&it=xg&req=4&npos=15 National Library of Medicine])]]
<br style="clear:left">
 
The evaluation of solitary pulmonary nodule will depend on the following characteristics:
 
'''Calcification'''
*Calcification patterns are commonly seen in granulomatous disease and hamartomas
*Calcification patterns are normally a sign of benignancy
*Characteristic benign calcification patterns of pulmonary nodule, include:
:*Diffuse
:*Central
:*Laminated
:*Popcorn
[[File: Calcified lung nodule white arrow.png|400px|left|thumb| CT scan showing a calcified solitary pulmonary nodules (white arrow) (Picture courtesy: [https://openi.nlm.nih.gov/detailedresult?img=PMC3259307_13244_2010_39_Fig6_HTML&query=Calcified%20solitary%20pulmonary%20nodules&it=xg&req=4&npos=2 National Library of Medicine])]]
<br style="clear:left">


{| class="wikitable"
'''Size'''
|+ Fleischner society guidelines for follow-up and management of nodules <8 mm Detected Incidentally at non-screening CT<ref name="pmid16244247">{{cite journal| author=MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP et al.| title=Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. | journal=Radiology | year= 2005 | volume= 237 | issue= 2 | pages= 395-400 | pmid=16244247 | doi=10.1148/radiol.2372041887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16244247  }} </ref>
*Different types of size ranges for pulmonary nodule, include:
! Nodule Size (mm)
:* Nodules less than 4mm
! Low† risk patients
:* Nodules between 4mm and 7mm
! High‡ risk patients
:* Nodules between 8mm and 20mm
|-
:* Nodules more than 20mm
| <= 4
| No follow-up needed.
| Follow-up at 12 months. If no change, no further imaging needed.
|-
| >4 - 6
| Follow-up at 12 months. If no change, no further imaging needed.
| Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change.
|-
| >6 - 8
| Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change.
| Initial follow-up CT at 3 - 6 months and then at 9 -12 and 24 months if no change.
|-
| >8
| Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy.
| Same at for low risk patients.
|-
| colspan="3" |† Low risk patients: Minimal or absent history of smoking and of other known risk factors.<br/>‡ High risk patients: History of smoking or of other known risk factors.
|}


====Subsolid nodules====
'''Location'''
The ACCP suggests subsolid nodules may require an extended duration of surveillance for growth or signs of a solid component as these are often premalignant or malignant<ref name="pmid23649456">{{cite journal| author=Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP et al.| title=Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e93S-120S | pmid=23649456 | doi=10.1378/chest.12-2351 | pmc=PMC3749714 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649456  }} </ref>. The Fleischner society has published guidelines for the management of subsolid nodules<ref name="pmid23070270">{{cite journal| author=Naidich DP, Bankier AA, MacMahon H, Schaefer-Prokop CM, Pistolesi M, Goo JM et al.| title=Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. | journal=Radiology | year= 2013 | volume= 266 | issue= 1 | pages= 304-17 | pmid=23070270 | doi=10.1148/radiol.12120628 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23070270  }} </ref>.
*Locations of pulmonary nodule, include:
:*Perilymphatic
[[File: Perilymphatic solitary pulmonary nodules.jpg |400px|left|thumb| CT scan showing a Perilymphatic solitary pulmonary nodules of [[sarcoidosis]] (Picture courtesy: [https://radiopaedia.org/cases/pulmonary-sarcoidosis?lang=gb Radiopaedia])]]
<br style="clear:left">
:*Perifissural
[[File: Perifissural solitary pulmonary nodules.png|400px|left|thumb| CT scan showing a Perifissural solitary pulmonary nodule (white circle) (Picture courtesy: [https://en.wikipedia.org/wiki/Lung_nodule#/media/File:CT_of_perifissural_nodule.png Wikipedia])]]
<br style="clear:left">
:*Centrilobular
[[File: Centrilobular_solitary_pulmonary_nodule.png |400px|left|thumb| CT scan showing a Centrilobular solitary pulmonary nodule (black arrowheads) (Picture courtesy: [https://openi.nlm.nih.gov/detailedresult?img=PMC2893311_kjr-11-407-g003&query=Centrilobular%20solitary%20pulmonary%20nodule&it=xg&req=4&npos=4 National Library of Medicine])]]
<br style="clear:left">


==Example images==
==CT==


[[Image:Pulmonary AVM as nodule 2.jpg|thumb|center|Thorax CT]]
'''Growth'''
*The growth pattern of the pulmonary nodule plays an important role in the management strategy.<ref name="pmid22156993">{{cite journal |vauthors=Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H |title=Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry |journal=Radiology |volume=262 |issue=2 |pages=662–71 |year=2012 |pmid=22156993 |pmc=3267080 |doi=10.1148/radiol.11100878 |url=}}</ref>
*Nodule growth should be evaluated on a individual basis and based on the risk assessment score
* A 4x growth is associated with a 50% risk of malignancy<ref name="pmid22156993">{{cite journal |vauthors=Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H |title=Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry |journal=Radiology |volume=262 |issue=2 |pages=662–71 |year=2012 |pmid=22156993 |pmc=3267080 |doi=10.1148/radiol.11100878 |url=}}</ref>


<div align="left">
'''Shape'''
<gallery heights="200" widths="200">
*Different types of shape for pulmonary nodule, include:
Image:Pulmonary AVM as nodule 3.jpg|Thorax CT
:*Polygonal
Image:Pulmonary AVM as nodule 4.jpg|Thorax CT
:*Spherical
</gallery>
</div>


'''Margins'''
*Different types of margins for pulmonary nodule, include:
:*Lobulated or scalloped margins
::*Intermediate malignancy probability
:*Smooth margins
:*:Associated with nodule benignancy 
[[File: Pul nodule borders.png|400px|left|thumb| CT scan showing types of solitary pulmonary nodule margins (Picture courtesy: [https://radiologykey.com/pulmonary-neoplasms-4/ Radiologykey])]]
<br style="clear:left">


<div align="left">
'''Attenuation'''
<gallery heights="200" widths="200">
*Different types of attenuation for pulmonary nodule, include:
Image:Pulmonary AVM as nodule 5.jpg|Thorax CT
*Solid pulmonary nodules
Image:Pulmonary AVM as nodule 6.jpg|Thorax CT
:*Malignancy rate of only 7%
</gallery>
*Calcified pulmonary nodules
</div>
*Partly solid pulmonary nodules
:*Malignancy rate of 63%
*Ground glass pulmonary nodules
:*Malignancy rate of 18%


'''Contrast enhancement'''
* Contrast enhancement of pulmonary nodules may be useful to determine benign or malignant features
* Benign pulmonary nodules usually have a contrast enhancement less than 15 HU


<div align="left">
On CT, radiological signs of pulmonary nodule, include:
<gallery heights="200" widths="200">
*'''Corona radiata sign''': highly associated with malignancy
Image:Pulmonary AVM as nodule 7.jpg|Thorax CT
*'''Air bronchogram sign''': airway surrounded by collection in alveolar spaces, non-specific sign
Image:Pulmonary AVM as nodule 8.jpg|Thorax CT
*'''Halo sign''': zone of ground-glass attenuation surrounding a pulmonary nodule or mass on CT images
</gallery>
*'''Tree-in-bud sign''': CT appearance of multiple areas of centrilobular nodules with a linear branching pattern
</div>
*'''Cheerio sign''': pulmonary nodules with a central lucent cavity as seen on CT. It is due to proliferation of (malignant or non-malignant) cells around an airway


====Halo Sign====
==CT Surveillance==


*The halo sign refers to a zone of ground-glass attenuation surrounding a pulmonary nodule or mass on CT images.
According to the [[American College of Chest Physicians]] (ACCP) for the CT surveillance of pulmonary nodules, recommends the following:<ref name="pmid23649456">{{cite journal| author=Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP et al.| title=Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. | journal=Chest | year= 2013 | volume= 143 | issue= 5 Suppl | pages= e93S-120S | pmid=23649456 | doi=10.1378/chest.12-2351 | pmc=PMC3749714 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23649456  }} </ref>
*The presence of a halo of ground-glass opacity or ground-glass attenuation is usually associated with hemorrhagic nodules.  
* If less than 8 mm, use guidelines by the Fleischner society (see table below).
*In severely neutropenic patients, the halo sign is highly suggestive of infection by an angioinvasive fungus, most commonly [[Aspergillosis | Aspergillus]].  
* For nodules greater than 8 mm in diameter, assess the patients risk of complications from thoracic surgery:
*Vascular invasion by this fungus results in thrombosis of small- to medium-sized vessels, which causes ischemic necrosis.
** If low to moderate risk for complications of surgery, assess probability of cancer by a validated calculation. The model developed at the Mayo Clinic has been the most extensively validated. An open-source version is [https://openrules.ocpu.io/home/www/pulmnodule.html available online].
*At pathologic examination, the nodules represent foci of infarction, and the halo of ground-glass attenuation results from alveolar hemorrhage.  
** If high risk for complications of surgery, assess probability of cancer by a validated calculation. If low to moderate risk of cancer follow up with CT scan surveillance. If moderate to high risk of cancer obtain non-surgical biopsy.<ref name="pmid9129544">{{cite journal| author=Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES| title=The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. | journal=Arch Intern Med | year= 1997 | volume= 157 | issue= 8 | pages= 849-55 | pmid=9129544 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9129544  }} </ref>
*Although it is less common, the halo sign may also be observed in nonhemorrhagic nodules, in which case either tumor cells or inflammatory infiltrate account for the halo of ground-glass attenuation.


{| class="wikitable"
|+ Fleischner Society guidelines for follow-up and management of nodules <8 mm <br>Detected incidentally at non-screening CT<ref name="pmid16244247">{{cite journal| author=MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP et al.| title=Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. | journal=Radiology | year= 2005 | volume= 237 | issue= 2 | pages= 395-400 | pmid=16244247 | doi=10.1148/radiol.2372041887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16244247  }} </ref>
! Nodule Size (mm)
! Low risk patients†
! High risk patients‡
|-
| <= 4
| No follow-up needed
| Follow-up at 12 months.<br> If no change, no further imaging needed
|-
| > 4 - 6
| Follow-up at 12 months.<br>If no change, no further imaging needed
| Initial follow-up CT at 6 -12 months <br>If no change follow-up CT at 18 - 24 months
|-
| > 6 - 8
| Initial follow-up CT at 6 -12 months<br>If no change follow-up CT at 18 - 24 months
| Initial follow-up CT at 3 - 6 months<br> >If no change follow-up CT at 9 -12 and 24 months
|-
| > 8
| Follow-up CT at around 3, 9, and 24 months<br>Dynamic contrast enhanced CT, PET, and/or biopsy
| Same at for low risk patients
|-
| colspan="3" |† Low risk patients: Minimal or absent history of smoking and of other known risk factors.<br />‡ High risk patients: History of smoking or of other known risk factors
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Oncology]]

Latest revision as of 17:56, 22 July 2020

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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] Joanna Ekabua, M.D. [3]

Overview

Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule. On CT, characteristic findings of solitary pulmonary nodules, include: ground-glass opacity, rounded mass, and less than 30mm.[1][2] The evaluation of solitary pulmonary nodule will depend on 7 characteristics: calcification patterns, size, location, size, growth, shape, margins, attenuation, and contrast enhancement.[2]

CT

  • Computed tomography is the method of choice for the diagnosis of solitary pulmonary nodule
  • On CT, characteristic findings of solitary pulmonary nodules, include:
  • Single to multiple intraparenchymal lesion
  • Less than 3 cm in size
  • Rounded or spiculated lesion
CT scan showing solitary pulmonary nodules (Picture courtesy: National Library of Medicine)


The evaluation of solitary pulmonary nodule will depend on the following characteristics:

Calcification

  • Calcification patterns are commonly seen in granulomatous disease and hamartomas
  • Calcification patterns are normally a sign of benignancy
  • Characteristic benign calcification patterns of pulmonary nodule, include:
  • Diffuse
  • Central
  • Laminated
  • Popcorn
CT scan showing a calcified solitary pulmonary nodules (white arrow) (Picture courtesy: National Library of Medicine)


Size

  • Different types of size ranges for pulmonary nodule, include:
  • Nodules less than 4mm
  • Nodules between 4mm and 7mm
  • Nodules between 8mm and 20mm
  • Nodules more than 20mm

Location

  • Locations of pulmonary nodule, include:
  • Perilymphatic
CT scan showing a Perilymphatic solitary pulmonary nodules of sarcoidosis (Picture courtesy: Radiopaedia)


  • Perifissural
CT scan showing a Perifissural solitary pulmonary nodule (white circle) (Picture courtesy: Wikipedia)


  • Centrilobular
CT scan showing a Centrilobular solitary pulmonary nodule (black arrowheads) (Picture courtesy: National Library of Medicine)



Growth

  • The growth pattern of the pulmonary nodule plays an important role in the management strategy.[3]
  • Nodule growth should be evaluated on a individual basis and based on the risk assessment score
  • A 4x growth is associated with a 50% risk of malignancy[3]

Shape

  • Different types of shape for pulmonary nodule, include:
  • Polygonal
  • Spherical

Margins

  • Different types of margins for pulmonary nodule, include:
  • Lobulated or scalloped margins
  • Intermediate malignancy probability
  • Smooth margins
    Associated with nodule benignancy
CT scan showing types of solitary pulmonary nodule margins (Picture courtesy: Radiologykey)


Attenuation

  • Different types of attenuation for pulmonary nodule, include:
  • Solid pulmonary nodules
  • Malignancy rate of only 7%
  • Calcified pulmonary nodules
  • Partly solid pulmonary nodules
  • Malignancy rate of 63%
  • Ground glass pulmonary nodules
  • Malignancy rate of 18%

Contrast enhancement

  • Contrast enhancement of pulmonary nodules may be useful to determine benign or malignant features
  • Benign pulmonary nodules usually have a contrast enhancement less than 15 HU

On CT, radiological signs of pulmonary nodule, include:

  • Corona radiata sign: highly associated with malignancy
  • Air bronchogram sign: airway surrounded by collection in alveolar spaces, non-specific sign
  • Halo sign: zone of ground-glass attenuation surrounding a pulmonary nodule or mass on CT images
  • Tree-in-bud sign: CT appearance of multiple areas of centrilobular nodules with a linear branching pattern
  • Cheerio sign: pulmonary nodules with a central lucent cavity as seen on CT. It is due to proliferation of (malignant or non-malignant) cells around an airway

CT Surveillance

According to the American College of Chest Physicians (ACCP) for the CT surveillance of pulmonary nodules, recommends the following:[4]

  • If less than 8 mm, use guidelines by the Fleischner society (see table below).
  • For nodules greater than 8 mm in diameter, assess the patients risk of complications from thoracic surgery:
    • If low to moderate risk for complications of surgery, assess probability of cancer by a validated calculation. The model developed at the Mayo Clinic has been the most extensively validated. An open-source version is available online.
    • If high risk for complications of surgery, assess probability of cancer by a validated calculation. If low to moderate risk of cancer follow up with CT scan surveillance. If moderate to high risk of cancer obtain non-surgical biopsy.[5]
Fleischner Society guidelines for follow-up and management of nodules <8 mm
Detected incidentally at non-screening CT[6]
Nodule Size (mm) Low risk patients† High risk patients‡
<= 4 No follow-up needed Follow-up at 12 months.
If no change, no further imaging needed
> 4 - 6 Follow-up at 12 months.
If no change, no further imaging needed
Initial follow-up CT at 6 -12 months
If no change follow-up CT at 18 - 24 months
> 6 - 8 Initial follow-up CT at 6 -12 months
If no change follow-up CT at 18 - 24 months
Initial follow-up CT at 3 - 6 months
>If no change follow-up CT at 9 -12 and 24 months
> 8 Follow-up CT at around 3, 9, and 24 months
Dynamic contrast enhanced CT, PET, and/or biopsy
Same at for low risk patients
† Low risk patients: Minimal or absent history of smoking and of other known risk factors.
‡ High risk patients: History of smoking or of other known risk factors

References

  1. Rosado-de-Christenson ML, Templeton PA, Moran CA (1994). "Bronchogenic carcinoma: radiologic-pathologic correlation". Radiographics. 14 (2): 429–46, quiz 447–8. doi:10.1148/radiographics.14.2.8190965. PMID 8190965.
  2. 2.0 2.1 Parker MS, Chasen MH, Paul N (2009). "Radiologic signs in thoracic imaging: case-based review and self-assessment module". AJR Am J Roentgenol. 192 (3 Suppl): S34–48. doi:10.2214/AJR.07.7081. PMID 19234288.
  3. 3.0 3.1 Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, Naidich DP, Rusinek H (2012). "Pulmonary Nodules: growth rate assessment in patients by using serial CT and three-dimensional volumetry". Radiology. 262 (2): 662–71. doi:10.1148/radiol.11100878. PMC 3267080. PMID 22156993.
  4. Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP; et al. (2013). "Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines". Chest. 143 (5 Suppl): e93S–120S. doi:10.1378/chest.12-2351. PMC 3749714. PMID 23649456.
  5. Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES (1997). "The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules". Arch Intern Med. 157 (8): 849–55. PMID 9129544.
  6. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP; et al. (2005). "Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society". Radiology. 237 (2): 395–400. doi:10.1148/radiol.2372041887. PMID 16244247.

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