Approach to the

Solitary Pulmonary Nodule

 The Solitary Pulmonary Nodule
• The term “solitary pulmonary nodule” (SPN) describes a
well-circumscribed, rounded, smooth edged, dense
pulmonary lesion, 3 cm or less in diameter, that is
completely surrounded by lung parenchyma
• Is NOT associated with atelectasis , pleural effusion or
adenopathy , does not touch the hilum or mediastinum
• “Coin lesion” .The older term “coin lesion” has been
replaced by SPN since these lesions are spherical, not flat.
• Lesions > 3 cm called “MASSES” and often malignant
 The Solitary Pulmonary Nodule
• Since the SPN by definition is a radiographic finding,
radiologic workup is intrinsic to the diagnostic workup
• The initial step in evaluation is to determine whether the
abnormality is in fact a solitary pulmonary nodule.
• This assessment is important because up to 20% of
suspected nodules prove to be entities mimicking a
solitary pulmonary nodule such as rib fractures, skin
lesions, or composite areas of increased opacity
 The Solitary Pulmonary Nodule
• Incidence of cancer from 10 – 70%
• Found on 0.09 to 0.20 % of all CXRs
• (approximately 1 in 500)
• 150,000 SPNs found annually
• 90% Solitary pulmonary nodules are most
often detected incidentally when a chest x-
ray is taken for other reasons.
• Increased further with incidental findings on CT
 Why is it concerning?
• SPN are concerning for what they could
represent
• The absolute #1 concern is if the SPN is the
harbinger of a malignancy
• What is more critical is the fact that the earlier
you diagnose the malignancy the better the
survival rate will be
 Why is it concerning
• Chest. 1997 Jun;111(6):1486-7
• Patients with stage IA (T1N0M0) disease have
the best prognosis.
• These patients have a 61 to 75% 5-year
survival following surgical resection
• Radiol Clin North Am 2000; 38:1–9
• Unfortunately almost 50% of patients have
extrathoracic spread by the time of diagnosis
• these patients only had a 15% 5 year survival
 Why is it concerning?
• With these numbers in mind, it is
absolutely critical to give the SPN the
attention it deserves
• If not worked up properly it will
effectively push patients who do carry a
malignancy with in the SPN from the 75%
survival into the 15% survival
• That is just unacceptable
 Solitary Pulmonary Nodule
• Basic strategy is to identify malignant versus
benign
• Nodules prove to be malignant in 40% of cases
• Most often Bronchogenic carcinoma (25% )
• Most common benign is hamartoma
Solitary pulmonary nodule
A solitary nodule is assumed to be
primary lung cancer until proved
otherwise . One must consider the
relationship of age to the incidence of
malignancy .
Age (Yr) Malignancy (%)
35-44 15
45-49 26
50-59 41
60-69 50
70-79 70
 Most solitary pulmonary
nodules should be resected after
through investigations, shows
that systemic dissemination has
not yet occured .
Review of previous chest films
may help determine the growth
pattern of the nodule .
A malignant nodule will usually
have a doubling time of 20-500
 Early Resection
• Studies have proven that early resection results in
5-year survival rate of 50%
• If nodule is 1cm or less rate is about 80%
• Survival rate after discovery of bronchogenic
carcinoma is 15% and hence the importance of
early discovery in terms of cure
 Differential Diagnosis
• Neoplasms
• Malignant –
• Metastasis,
• Primary Lung Carcinoma
• Benign Tumors
• Inflammatory
• Granulomas
• TB,
• Histo,
• Sarcoid, etc.),
• Abscess,
• Hydatid Cyst,
• Fungus Ball,
• Org. Pneumonia,
• Bronchiectatic cyst
 Differential Diagnosis
• Vascular
• Infarct,
• Pulm Vein anomaly,
• Rheum Nodule,
• Wegener’s,
• AVM,
• Pulm Art Aneurys (behcets disease)
• Developmental
• Bronchogenic cyst,
• Pulmonary sequestration
• Nipple shadow
It is important to note that the majority of
SPN are of a benign etiology
 Benign nodules
• Hamartoma 8% (popcorn lesion)
• Granuloma
• Rheumatoid granuloma,
• Healed infarct,
• Pulmonary anurysm,
• Wagener’s granulomatosis
• Hemangioma
• Schwannoma
• Fibroma
• Lipoma
• Leiomyoma
• Teratoma
SO now if we have a patient with an SPN
on CXR or CT what to be done?
Postgrad Med 2003;114(2):29-35
• Ask (history, profession, habits, sign, symptoms)
• Assess (X-ray, age, size, shape, margins, calcification, position,)
• Assign (benign or malignant)
• Advice (Follow up)
• Arrange (CT, PET)
• Attain (Biopsy)
• Attempt (Surgical Resection)
 Assessing Growth
• There are three categories to place the patient in
assessing growth
• No change in two years / or Growth Rate of
benign nature
• Indeterminate because of no old studies
• Growth Rate of possible malignancy
 No change in two years
• Radiologic stability is the best predictor of a benign
etiology.
• Since the 1950’s it has been well established that if the
SPN has not grown in 2 years it is benign. (JAMA 1958;
166:210–215 )
• If old radiographs show no change in two years, no
further work up is needed
Benign vs. Malignant Doubling Time
• The time it takes for the apparent volume to
double is referred to as the doubling time
• one doubling in volume is equivalent to the
nodule diameter increasing by only 26% to
28%
• Benign nodules representing acute inflammatory
changes have a doubling time of less than 20
days
• In contrast, stable granulomas and hamartomas
may enlarge slowly and have a doubling time of
more than 500 days

Semin Ultrasound CT MR 2000;21(2):97-115

 Benign vs. Malignant Doubling Time
• If the SPN has a doubling time of <20 days or
>500 days the patient is in the clear and can be
followed
• If however the SPN doubling time falls in
between 20 and 500 days the SPN must be
assumed malignant until proven otherwise and
surgical intervention is now recommended.

Postgrad Med 1997;101(3):145-50

 Growth of a Nodule
• Malignant nodules grow at a constant rate
expressed as doubling time
• This usually falls between 20 and 500 days with a
median of 120 days
• An increase of 28% in nodule diameter indicates
doubling
 Growth of a Nodule
• Benign lesions grow slowly with doubling time
exceeding 500 days
• It is almost conclusively a benign lesion if size is
stable for 2 years ( doubling time exceeding 720
days )
• A doubling time of less than 20 days signifies
inflammatory process
 Growth Rate:
Doubling Time
• Volume = 4/3 Π r 3
• 28% increase in diameter results in doubling of
volume
• Non-malignant disease: less than 20 days or
greater than 500 days
• Malignant lesions: 20 to 500 days Av.120
 Malignant Doubling Time
• With the numbers crunch, biopsy in this
case is not worth the risks because a
malignant diagnosis would not change
resection therapy
• So in this case, surgical resection is
highly recommended
• If the patient is reluctant or the risk of
surgery is really high and if diagnosis is
likely to be sure of before going to the OR,
then biopsy can be undertaken.
 Benign vs Malignant
• Age <40 • >40
• nodule diameter<1.5 • >1.5
• never smoked • ever smoked
• nodule edge type1 • type3
• doubling time >500 d • 20 to 500 days
• calcification in benign • indeterminate pattern
• Needle Bx: benign dis • malignant disease
• suspicious cells

• Needle Bx: Nonspecific

 High Resolution CT
• HRCT is the most sensitive and specific for
assessing the size, shape, calcification and edge of
a nodule
• Type 1 Type 2 Type 3 Type 4
 Likelihood of cancer with the appearance
of a nodule's edge
• Type 1 nodules :smooth, regular edge….20%.
• Type 2 nodules: smooth, irregular edge…. 33%.
• Type 3 nodules: spiculated edge…. 83%.
• Type 4 nodules: fuzzy, multispiculated edge or
corona radiata…. 93%
 Factors Influencing
Probability of Malignancy
• Size • Patient age
• Growth rate • Gender
• Number • Smoking history
• Density • Occupational history
 LUNG NODULE
MALIGNANT FEATURES
• New or growing lesion
• Spiculated margin
• Large size (>3cm)
Spiculated nodule

MALIGNANT
 MALIGNANT

Irregular
contour
Spiculated margin

Bronchus leads to it

MALIGNANT
 LUNG NODULE
DEFINITE BENIGN
CHARACTERISTICS

• Absence of growth for 2 years

• Definite benign calcifications
• Extensive calcification
• Smooth margins
• Small size (< 3 cm)
Very white (like bone)
BENIGN
BENIGN

Smooth margin
BENIGN
BENIGN
 BENIGN

Note the smooth contour

 BENIGN GRANULOMA

Homogeneous white= benign calcification

Very subtle nodule
There it is
SMOOTH BENIGN
Postgrad Med 2003;114(2):29-35
 Indeterminate Growth Rate
• This is where the real dilemma is created and
every radiological and clinical clue must be taken
into consideration to make a decision.
• First step is to look at all patterns of the SPN and
determine if a “typically benign or malignant
pattern can be found”
 Calcification
• Radiographic pattern of calcium deposition is
helpful
• Benign lesions tend to have central, laminated
(bull’s eye), diffuse or popcorn pattern
• Malignant lesions have speckled or eccentric
pattern
 TYPES OF CALCIFICATION
• BENIGN
• Central = granuloma
• Nodule completely calcified = granuloma
• Popcorn = hamartoma
• Target = granuloma
• MALIGNANT
• Spicculated or punctate = malignant
• Eccentric = malignant
Benign Calcifications
Popcorn calcification=
hamartoma

BENIGN
 Hamartoma
• Regarded as benign developemental deformity
• 1-3cms lesion containing cartilage, epithelium,
fibro-fatty tissue
• Single, may be multiple
• Slow growing
• Ussually periphral
• Central calcification
• males
 Popcorn Calcification
• Classic “popcorn” pattern
often seen in hamartomas
• HRCT can show fat and
cartilage in half of cases
HAMARTOM
A
Hamartoma
Fat
• Fat on CT
• benign
hamartoma can
be diagnosed
with confidence
Benign Calcification:
Popcorn Calcification
Popcorn Calcification
• Popcorn
calcification or
Chondroid
Calcification
• Pattern typical of
hamartomas
 Granulomas

• About 40% of all SPNs are granulomas—small,

granular inflammatory lesions.
• The word "granuloma" comes from the Latin word
"granum," meaning "grain" or "seed."
• Granulomas are characterized by a nodular
appearance and a unique cellular pattern that can
be seen through a microscope.
Benign Calcification:
Central Calcification
 Calcification
• Laminated or central
pattern
• Typical of granuloma
 Histoplasmoma
• Tend to B\L multiple with LN
• Rarely slowly progressive apical or post.
pulm.nodule
• Usually in presence of pre exist. lung ds. B’ectatic
or emphysema
• Calcified centre smtime with calcified laminae
• Prevalent in USA,also in many other tropical parts
• Self limiting in 2-3 wks
• Remnant calcified granuloma in lung .
a

Histoplasmoma
Solid or Central Calcification
• A solid
calcified SPN
is found in
association
with prior
granulomatous
infection, most
commonly
histoplasmosis
or tuberculosis
Histoplasmoma
 Hydatid cyst
• Echinococcus infection
• Human accidental intermediate host
• Slow steadily growing
• Spherical lession with well defined edges or uniform
density
• Ussually multiple and bilateral
• May rupture to give salty expectoration
• Thus cyst with level,… later calcified walls
• Casoni test ,latex agglutination ,complement
fixation test diagnostic
Hydatid cyst in lung.
This patient had a
single large cyst in the
left lung.
 Rheumatoid nodules
• A \ w arthritis , fibrosis
• > Men, middle age,
• RA factor may be positive
• May have chylous pleural effussion,
• Single or multiple nodules With or without
cavitation
• Ussually 1-3 cms may be upto 10 cms ,
• Subpleural commonly
• Nodule in coalminers “Caplan Syndrome”
Arteriovenous malformation
 Other benign tumors

• fibromas (fibrous connective tissue),

• lipomas (fat),
• leiomyomas (smooth muscle),
• hemangiomas (dilated blood vessels),
• papillomas (epithelial cells).
Speckled or Punctate Calcification
• Speckled or
Punctate
calcifications
• Represent
malignant
calcification and
• Should not be
taken as benign
Eccentric Calcification
• Eccentric
Calcification
• a sign of
malignant
potential
 Calcification
• Suggests benign diagnosis
• With CT the reference standard,
• CXR has sensitivity 50%,
• specificity 87%, and
• PPV 93% for identifying calcification
Postgrad Med 2003;114(2):29-35
 Radiological Findings
• If you have definitive findings suggestive of
benign pattern than no further work up is needed.
• If still no answer after SCTIE or other radiologic
finding further work up is needed
 Size
• Size of the SPN can also help out at this point to
help make a decision
• In general, smaller nodules are more likely to be
benign and larger lesions malignant
• 80% of benign SPNs are less than 2 cm in
diameter
• However, small size is not necessarily reliable
evidence of benignity because 15% of malignant
nodules are less than 1 cm in diameter
approximately 42% are less than 2 cm in
diameter

Radiographics 20:43, 2000

 Size of SPN
• Most SPN are less than 2 cm in diameter
• Malignant nodules
• 40% less than 2 cm
• 15% less than 1 cm
• 1% less than 7 mm
• 0% less than 5 mm
 Margins
• Smooth, well-defined margins most often indicate a
benign nodule
• However 21% of malignant nodules have a smooth well-
defined margin
• a lobulated margin may reflect uneven growth of a SPN
and can indicate malignancy
• although 25% of benign nodules, particularly
hamartomas, are lobulated

Radiology 179:469, 1991

 Patterns of Margins
• Corona radiata sign
• Fine linear strands
extending 4-5 mm
outward
• Spiculated on CXRs
• 84 – 90% are malignant
Patterns of Margins
Patterns of Margins

Spiculated
lipoid
pneumonia
 Patterns of Margins
• Scalloped border
• Intermediate probability
of cancer
• Smooth border suggestive
of benign diagnosis
 Other Characteristics
• Air bronchograms and
pseudocavitation more
commonly malignant
• Cavitation with thick (>15
mm vs < 5 mm) more
often maligant
Air Bronchograms
 Cavitation
• Although cavitation can occur in necrotic
malignant SPNs, inflammatory lesions can also
cavitate.
• The thickness of the cavity wall can be helpful in
distinguishing benign from malignant lesions.
• Cavities with a greatest wall thickness less than 5
mm are almost always benign
• whereas most of those with a maximal wall
thickness greater than 15 mm are malignant
 Cavitation
Thick walled
cavity which
came back as
squamous cell
carcinoma.
 RADIOGRAPHIC
PRESENTATIONS OF LUNG
CANCER

• Mass or nodule
• Atelectasis (lung collapse)
• Non-resolving pneumonia
• Mediastinal lymph node enlargement
 ADENOCARCINOMA

• Peripheral
• Spiculated
• < 4 cm
• Uncommon Hilar and mediastinal lymph
node enlargement Early metastases to brain,
adrenals, liver, bone
• Can arise from an existing scar - scar
carcinoma
 Peripheral

ADENOCARCINOMA
Small

ADENOCARCINOMA
ADENOCARCINOMA
 SQUAMOUS CELL CARCINOMA
• Central endobronchial
• post obstructive pneumonia
• atelectasis
 Central
Calcified hilar
granuloma

SQUAMOUS CELL CARCINOMA

 Ascending aorta

Main pulmonary
SVC artery

Central hilar
mass

Descending aorta

SQUAMOUS CELL CARCINOMA

 SQUAMOUS CELL CARCINOMA
• Apical - Pancoast or superior sulcus tumour
PANCOAST TUMOUR
Destroyed 3rd rib
Destroyed 3rd rib

Mass

PANCOAST TUMOUR
 SQUAMOUS CELL CARCINOMA
• Slow growing (1 - 10 cm)
• Cavitation (10 - 20%)
• DDx - lung abscess
• Late metastases
 Central cavity

DDX - Lung abscess

SQUAMOUS CELL
CARCINOMA
 SMALL CELL LUNG CANCER
• Central > peripheral
• Massive hilar and mediastinal adenopathy
• Early distant spread
Large mass
Large mediastinal SMALL CELL
nodes
CARCINOMA
SMALL CELL CARCINOMA
 LARGE CELL CARCINOMA
• Large peripheral mass ~ 7 cm
• Rapid growth
• Early distant spread
LARGE CELL CARCINOMA
 Large peripheral mass

LARGE CELL CARCINOMA

Large
peripheral mass

LARGE CELL CARCINOMA

 LARGE CELL
CARCINOMA

Large peripheral
mass
LARGE CELL
CARCINOMA
 BRONCHIOLOALVEOLAR
CARCINOMA
• Peripheral nodule
• Non-resolving focal “pneumonia”
• Diffuse bilateral “pneumonia”
• hilar and mediastinal nodal enlargement uncommon
• distant spread uncommon
Looks like pneumonia
but …….
 Air bronchogram

BRONCHIOLOALVEOLAR CARCINOMA
 Air
bronchogram

Multifocal

BRONCHIOLOALCEOLAR CELL CARCINOMA

Air space
disease
 No Specific Pattern Found
• With no specific finding, all risk factors must be
taken into account.
• Trying to milk the SPN for as much information it
can be
• It may help stratify the risk in the patient
 Indeterminate SPN
• After milking the SPN for all its characteristics it
is now important to milk the patient for all
relevant information
• Key points include:
• smoking history;
• symptoms;
• comorbid conditions (particularly severe emphysema);
• history and type of prior malignancy;
• prior infections and environmental exposures.
 Work-up of SPN: CXR

• No change in two years - no further evaluation

• Characteristic calcifications of benign disease
• Lateral films for “hidden” lesions
• Initial CXR then serial CT Scans
Decision Making
Postgrad Med 2003;114(2):29-35
N Engl J Med 348:2535-2542
 Clinical Decision
• Now after evaluating the entire clinical picture
and clinically identifiable risks its time to
determine where they fall into Low, Moderate or
High risk
• Pretest probability of cancer determines most cost-
effective strategy
• Low : radiographic follow-up
• Intermediate : CT and PET
• High : CT followed by biopsy or surgery
• Very high : surgery*
 Low risk indeterminate SPN
• 30 year old male, never smoked,
• nodule is <1cm with no previous studies,
• no environmental exposure,
• Review all prior CXR
• No specific pattern found
• Get CT scans
• found on CT not seen on CXR
• If probability of cancer is <10% wait and watch
• Can follow for two years
 Moderate Risk
• Now we have a patient who isnt clearly low risk.
• Maybe older age,
• questionable smoke or environmental history but
not quite screaming high risk, what to do?
• If it is high thoracotomy should intervene
• Bronch & NAB reserved for pt who are reluctant
to go for surgery before Dx
• PET SCAN is now recommended
• PET is slightly more effective,noninvasive
• If PET is +ve but other criteria are low for
malignancy, then ANB is needed to R/O infectious
granulomas
 CT Scan
• CT can help distinguish a solitary pulmonary
lesion from multiple pulmonary nodules
• CT Scan with contrast to evaluate mediastinum
• Serial scans at 3, 6, 12, and 24 months
• Can consider trial of antibiotics prior to repeat scan in 6
weeks
• Newer CT techniques
• Volumetric analysis
• Multi-slice scanner
 Contrast-Enhanced CT
• Degree on enhancement on spiral CT after
injection of contrast
• One study used an increase in attenuation of 20
Hounsfield units as threshold for malignant
lesions
• Sensitivity 95-100%,
• specificity 70-93%*
• Local expertise varies
*Zhang, Radiology
 Spiral CT with IV contrast
Enhancement (SCTIE)
• Computed tomography (CT) (particularly thin-
section CT) is 10–20 times more sensitive than
standard radiography and allows objective,
quantitative assessment of calcification
• SCTIE the imaging modality of choice for the SPN
and should be obtained on all newly diagnosed
SPNs
• A number of benign etiologies for SPNs have a
characteristic appearance on CT
 CT Densitometry
• Involves measurement of attenuation values
• Expressed in Hounsfield units, as compared to
reference “phantom”
• Usually higher for benign nodules
• Allows for identification of 35 – 55% of
subsequently identified benign lesions
 CT Densitometry
• One large, multicenter trial, only 1 of 66 nodules
identified as benign later found to be malignant*
• Cutoff used was 264 Hounsfield units
• More conventional cutoff is 185, which yielded a
higher false negative rate

*Zerhouni, Radiology
 Lung cancer screening
New CT techniques detect suspicious nodules 3x
more than CXR, malignant tumors 4x and stage 1
tumors 6x

Henschke et al: Early Lung Cancer Action Project: overall design and findings from
baseline screening. Lancet, 1999;354:99-105
 PET Scan
• Highly valuable noninvasive tool
 PET SCAN
• Positron emission tomography (PET) with
18-fluorodeoxyglucose (FDG) has proven
to be an excellent mode of tumor imaging
• 18-FDG (fluorodeoxyglucose)
• increased uptake by metabolically active cells
• does not enter glycolysis
 PET SCAN
• Increased activity is demonstrated in cells
with high metabolic rates, as is seen in
tumors and areas of inflammation
• Taken up by cells in glycolysis but is
bound within cells and cannot enter normal
glycolytic pathway
• It can also tell us about if any metastatic
disease is present thus altering treatment
 Limitations
Positron Emission Tomography
• However the spatial resolution of PET is currently
7 to 8 mm, and so the imaging of SPNs < 1 cm is
unreliable
• False negatives in tumors with low uptake such as
bronchoalveolar cell carcinoma It is 95% sensitive
for identifying malignancy and 85% specific
 Limitations
Positron Emission Tomography
• False positive results may occur in lesions that
contain active infection or inflammatory tissue
(histoplasmomas)
• High post test likelihood of malignancy (14%) in
high risk patients with negative PET
 Thoracic PET Scan: Potential Sources of Error

• False Positive Results: • False Negative Results:

 Metabolically active infectious

 Tumors with low metabolic
activities:
or inflammatory lesions:
 Bronchoalveolar CA.
 Carcinoid tumors.
 Sarcoidosis.  Mets: renal cell and testis.
 Rheumatoid nodules.
 TB.  Small tumors-<1cm.
 Fungal granuloma.
 Others.
 Hyperglycemia-keep sugars
below 150mg%.
 PET Scan
• Allows more accurate identification of tumors, lymph
nodes, and metastatic disease
• May provide staging information
• Up to 14% of patients otherwise eligible for
surgery have occult extra thoracic disease on
whole-body PET
• Benign disease Malignant disease
• 96% sensitivity 96% sensitivity
• 88% specificity 77% specificity
 Pet Scan
• Gould et al performed a meta-analysis of
the literature on pulmonary nodules and
masses and PET scanning and found an
overall sensitivity of 96.8% and specificity
of 77.8% for detecting malignancy.
• PET scans also have a 96% sensitivity and
88% specificity with 94% accuracy in the
diagnosis of benign nodules

JAMA 2001; 285:914–924

 Utilization of PET Scans
• Negative PET in high risk patients still need tissue
diagnosis…so why get it?
• PET not usually indicated unless it will change
management
• So depending on the PET Scan result we can base
our treatment
• If PET is positive than we can refer the patient to
CT Surgery for resection options
• If PET is negative than can follow
 Positron Emission Tomography
• CT combined with PET for staging was often
superior to conventional approaches
• Reduced number of surgeries by 15%
• Cost savings per patient

*Gambhir, J Clin Oncol

 Positron Emission Tomography
• More expensive than other imaging modalities

*http://cms.hhs.gov, Dec
PET Images

Pieterman,
NEJM
2000;343:254-
PET Images

Pieterman,
NEJM
2000;343:254-
Integrated PET and CT

Lardinos, NEJM
2003;348:2500
-7
Integrated PET and CT

Lardinos, NEJM
2003;348:2500
-7
Sample Pre-biopsy Algorithm
CHEST 2004; 125:1522-1529
 Biopsy
• Bronchoscopic biopsy
• CT guided
• Transthoracic needle aspiration (TTNA)
Transthorathic needle aspiration (TTNAB) has a
sensitivity of 80% to 90%
• Fine needle aspiration (FNA)
• Surgical
• Video Assisted Thoracic Surgery (VATS)
• Open
BRONCHOSCOPY
 Bronchoscopy
• Limited role
• Transbronchial needle aspiration of mediastinal lymph
nodes
• Useful for large central lesions and endobronchial lesions
• Can detect infection
• No use in peripheral nodules
 Bronchoscopy
• Useful for lesions at least 2 cm
 INDICATION FOR
BRONCHOSCOPIC BIOPSY
• Central lesion ie. Near hilum
 Bronchoscopy
• Diagnostic yield varies in literature from 20 –
80%, depending on size of nodule and patient
population
• Yield depends on nodule size and proximity to
bronchial tree
• Yield 10% for < 1.5 cm, and 40 – 60% for > 2 – 3
cm
• 70% yield when CT reveals a bronchus leading to
lesion
 Bronchoscopy
• Relatively low risk
• Overall complication rate 5%
• 3% risk of pneumothorax
• 1% risk of hemorrhage
• 0.24% risk of death
 INDICATIONS FOR FNAB
• Peripheral lesion
• Central lesion without significant distal collapse
 DIAGNOSTIC YIELD OF FNAB
• 90 - 97%
 FNAB TECHNIQUE
• Out-patient procedure
• 22G needle
• Image guidance
• fluoroscopy
• computed tomography
• ultrasound
 Transthoracic FNA (TTFNA)
• Diagnostic yield up to 95% in peripheral lesions
• Higher complication rate
• Pneumothorax (10 - 30%)
• Hemoptysis (30%)
• About 5% of these require chest tube
 What are the limitations of Needle
Biopsy of Lung Nodules?
• In a small number of cases, the tissue
obtained during a biopsy may not be adequate
for diagnosis.
• Needle biopsy is not cost-effective for small
lesions one to two millimeters in diameter.
• The needle is too difficult to position into the
nodule and the nodule is too small to provide
enough tissue for an accurate diagnosis.
 What are the limitations of Needle
Biopsy of Lung Nodules?
• For patients with certain conditions a needle biopsy may
not be recommended.
• emphysema,
• lung cysts,
• blood coagulation disorder of any type,
• insufficient blood oxygenation,
• pulmonary hypertension, and
• certain heart failure conditions,
• Alternatives to lung biopsy usually include continued
follow-up with imaging and surgical removal of the
abnormality.
 CT-guided fine-needle aspiration biopsy
• The use of CT-guided fine-needle aspiration
biopsy in solitary pulmonary nodules has been
condemned historically as often being an
unnecessary step in the workup of these patients.
Sample Post-biopsy Algorithm
CHEST 2004; 125:1522-1529
Thracoscpic Resctn of Lung Nodules
 Lung cancer: Surgical options

• VATS
• Segmentectomy
• Lobectomy
• Sleeve resection
• Pneumonectomy
 Surgery
• Thoracotomy to resect a malignant nodule carries
significant death of 3% to 4% but for a benign
lesion it is 0.3%
• Thoracoscopy carries less significant morbidity
and lessens hospital stay
• It is not known if the 5-years survival is different
between the two approaches
 High Risk Patient
• 68 year old male,
• 100 pack years of smoking,
• Used to work with asbestos, and
• Coughing up blood
• RIGHT TO THE OR for resection.
 Conclusion
• The main point is to make sure you give
the SPN the respect it deserves.
• With timely diagnosis we can
effectively prevent morbidity and
mortality for our patients
• There is just no excuse for a patient to
die because we did not work up the
patient in a timely fashion.
 Medicolegal Aspects

• Physicians should discuss the possibility of lung

cancer presenting as a SPN in those patients who
have lesions that cannot be confirmed to be
benign based on their presence on old films with
over 2 years of stability, or classic calcification
typical of a benign lesion.
• Patients should play an active role in the decision
to remove, evaluate with invasive procedures, or
observe their SPN.
 Medicolegal Aspects

• The pros and cons of pulmonary resection should

be discussed and a recommendation made.
• This should be carefully documented in the patient
record, and if observation is chosen, advice for
follow up given.
• Then, it is important for the physician to insure
that follow up actually occurs.
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
Postgrad Med 2003;114(2):29-35
 Primary
Description
Tumor (T)
A small tumor that is not locally advanced or invasive
T1 Criteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the
main bronchus

A larger tumor that is minimally advanced or invasive

T2 Criteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but remains >2 cm from the
main carina; may cause segmental or lobar atelectasis

Any size tumor that is locally advanced or invasive up to but not including the
major intrathoracic structures
T3
Criteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium; main bronchus within 2
cm of the main carina (not involving the main carina); may cause atelectasis of the entire lung

Any size tumor that is advanced or invasive into the major intrathoracic structures
T4 Criteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, main carina;
malignant pericardial or pleural effusion; presence of satellite tumor nodule(s) within the primary tumor lobe

Regional
Lymph Node Description
Involvement (N)

Metastatic disease to nodes within the ipsilateral lung

N1 Criteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar nodes (nodal
stations 10 through 14)

Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to the
primary tumor
N2
Criteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes
(nodal stations 1 through 9)

Metastatic disease to nodes distant to those included in N2

N3 Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral scalene and/or
supraclavicular nodes
Metastases (M) Description
MO Local or regional disease, no distant metastases
M1 Disseminated disease, distant metastases present