Pulmonary nodule in Radiology

dr. Arlavinda A Lubis, SpRad(k)Onk

Evaluating Pulmonary Nodules

• Pulmonary nodules ≤ 4 mm have a low risk of being cancerous

• Pulmonary nodules between 4-8 mm are of intermediate risk for
cancer
Follow up CT scans for both categories are recommended on
different schedules

• Pulmonary nodules >8 mm and mixed solid/ground glass nodules

are suspicious for cancer;
Percutaneous needle aspiration biopsy (PNAB), positron emission
tomography (PET), or video assisted thoracic surgery (VATS)
should be considered
Data analysis
• Available data indicate < 1% of very small (<5 mm)
nodules in patients without a history of cancer will
demonstrate malignant behavior

• Percentage of malignancy (Midthun et al) :

– nodules smaller than 3 mm: 0.2 %
– nodules 4–7 mm: 0.9%
– nodules 8–20 mm : 18%
– Nodules larger than 20 mm : 50%
Data analysis

• Classified nodules:
– ground-glass opacity; ground-glass opacity with a
solid component; solid nodule.
– Mean volume doubling times were 813 days, 457
days, and 149 days, respectively (Hasegawa et al)
Common Etiologies of Solitary Pulmonary Nodules

• Benign

– Nonspecific granuloma (15 to 25 percent)

– Hamartoma (15 percent)
– Infectious granuloma (15 percent)
– Aspergillosis
– Coccidioidomycosis
– Cryptococcosis
– Histoplasmosis
– Tuberculosis
etiologies of pulmonary solitary nodule
• Malignant

– Adenocarcinoma (47 percent)

– Squamous cell carcinoma (22 percent)

– Metastasis (8 percent)

– Non–small cell carcinoma (7 percent)

– Small cell carcinoma (4 percent)

Multiple nodule
• Multiple pulmonary nodules may be caused by malignant or benign
diseases.

• In patients without a known primary malignant tumor:

●Multiple pulmonary nodules that are ≥1 cm in diameter or detected

by conventional chest radiography are most likely due to metastatic
disease from a malignant solid organ primary tumor

●Multiple pulmonary nodules that are <5 mm in diameter,

juxtaposed to either the visceral pleura or an interlobar fissure, and
detected incidentally, are more likely to be benign lesions, such as
granulomata, scars, or intraparenchymal lymph nodes
Etiology of multiple lung nodules

• Unfortunately, the most common cause of

multiple lung nodules is cancer that has
spread (metastasized) to the lungs from
other regions of the body
• The most common of these include breast
cancer, colon cancer, prostate cancer, and
bladder cancer
Etiology of multiple lung nodules

• Cancers other than lung cancer in the

lungs, such as lymphomas, and Kaposi’s
sarcoma
Etiology of multiple lung nodules

• Benign Tumors – hamartomas

• Autoimmune - Wegeners
granulomatosis, sarcoidos, eosinophilic
granules, rheumatoid nodules                   
                            
Etiology of multiple lung nodules

• Infections                                                
 Bacterial infections – septic nodules
(spread of infection via the bloodstream from
another area of the body), tuberculosis,
nocardiosis
• Fungal infections – aspergillosis,
histoplasmosis, coccidiomycosis,
cryptococcosis      
•  Parasites – echinococcus (hydatid cysts)
Etiology of multiple lung nodules

• Inflammatory (pneumoconiosis) – better

known as black lung disease (coal miner’s
lung), silicosis
anatomy of the right lung
anatomy of the left lung
Lung segmentation
Chest radiography
-the chest radiograph is often the first
imaging modality to suggest the diagnosis
of bronchogenic carcinoma.
-Lung cancer may present as a
straightforward spiculated mass, ground
glass density mass
-In some situations, no further imaging will
be necessary when bulky contralateral
mediastinal adenopathy is present or when
an obvious bony lesion is identified
Chest x ray

• CT scanning of the chest is often needed

because of the lack of sensitivity of the
chest radiographs in detecting mediastinal
lymph node metastases and chest wall
and mediastinal invasion
Computed tomography

• The ability to evaluate the entire thorax at

the time of nodule assessment is of further
benefit - staging TNM
• detection rate of nodules <5 mm in
diameter
• detection of pleural invasion by tumour
Magnetic resonance imaging

• MRI can be more accurate than CT in

staging
• better soft tissue contrast, multiplanar
imaging capability, and therefore useful for
superior sulcus tumours and evaluation of
the aortopulmonary window
Magnetic resonance imaging

• useful in the assessment of mediastinal

and chest wall invasion by virtue of its
ability to determine fat-stripe invasion and
involvement of the diaphragm and spinal
canal
• disadvantages compared to CT, being
slower and more expensive with poorer
spatial resolution and providing limited lung
parenchyma information
Magnetic resonance imaging

• MRI can overestimate lymph node size

because of respiratory movement, causing
the blurring together of discrete nodes into
a larger, conglomerate mass
• poorly tolerated by claustrophobic patients
and is contra-indicated in patients with
indwelling electromagnetic devices and
some prosthetic heart valves
Positron emission tomography

• is a new imaging modality whose role in

the assessment of lung cancer is still
being determined
• Its advantage over other modalities lies in
its sensitivity in detecting malignancy and
its ability to image the entire body in one
examination.
Positron emission tomography

• detects malignancy in focal pulmonary

opacities with a sensitivity of 96%,
specificity of 88% and an accuracy of 94%
in lesions of ≥10 mm
• The main disadvantage for PET is the lack
of availability and relatively high cost of
each examination
Thank you….