PANCE Blueprint Pulmonary (12%)

Pulmonary nodules

Patient will present as → a 35-year-old female who was found to have a small (2.5 cm) pulmonary lesion on chest radiograph found incidentally after a screening exam for a positive PPD at work. The patient has no significant past medical history and is asymptomatic.

< 3 cm is a nodule if > 3 cm the lesion is considered  a "mass", smooth well defined edges are benign, ill defined, lobular or spiculated suggests cancer

  • Pulmonary nodules are also known as coin lesions.

The goal of initial testing is to estimate the malignant potential of the solitary pulmonary nodule. The first step is a review of plain x-rays and then usually obtain a CT

Steps to dealing with a pulmonary nodule:

  1. Incidental finding on CXR →
  2. Send for CT →
  3. If suspicious (depending on radiographic findings below) will need biopsy
    • Ill-defined, lobular or spiculated suggests cancer
  4. If not suspicious < 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr
    • Calcification, smooth well-defined edges, suggests benign disease

Radiographic characteristics help define the malignant potential of a solitary pulmonary nodule

  • Growth rate is determined by comparison with previous chest x-ray or CT, if available
    • A lesion that has not enlarged in 2 yr suggests a benign etiology
    • Tumors that have volume doubling times from 21 to 40 days are likely to be malignant
    • Small nodules (< 1 cm) should be monitored at 3 mo, 6 mo, and then yearly for 2 yr
  • Calcification suggests benign disease, particularly if it is central (tuberculoma, histoplasmoma), concentric (healed histoplasmosis), or in a popcorn configuration (hamartoma).
  • Margins that are spiculated or irregular (scalloped) are more indicative of cancer
  • Diameter < 1.5 cm strongly suggests a benign etiology; diameter > 5.3 cm strongly suggests cancer. However, nonmalignant exceptions include lung abscess, Wegener's granulomatosis, and hydatid cyst

Management depends on radiological findings - if malignant potential should be biopsied or if benign appearing can be followed as outlined in the previous section

Chest X-ray showing a solitary pulmonary nodule (indicated by a black box) in the left upper lobe

Chest X-ray showing a solitary pulmonary nodule (indicated by a black box) in the left upper lobe

Question 1
A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34 year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation?
CT scan of the chest
Needle biopsy of the lesion
A needle biopsy would be indicated for a person greater than 35 years old and/or with a history of smoking to evaluate a solitary pulmonary nodule.
Positron emission tomography of the chest
Positron emission tomography (PET scan) would be indicated if the CT scan was nonconclusive.
Fiberoptic bronchoscopy
Fiberoptic bronchoscopy would be indicated only in the presence of a history of tobacco use or if the lesion was suggestive of malignancy.
Question 1 Explanation: 
In the absence of old x-rays in a nonsmoking individual less than 35 years old, CT scan of the chest is the next step in the evaluation of a solitary pulmonary nodule.
Question 2
A 42 year-old male smoker presents for further evaluation of a 4 cm solitary pulmonary nodule discovered on a recent chest x-ray. Which of the following diagnostic tests is indicated next?
Bone scan
Bone scanning is indicated for evaluation of bone metastases, most commonly secondary to cancer of the breast or prostate.
Diagnostic thoracotomy is indicated for biopsy of the lesion should the CT scan of the chest indicate a suspicious malignant lesion that is inaccessible to thoracoscopy.
Mediastinoscopy can be utilized to further evaluate any enlarged mediastinal lymph nodes that may be found on the CT scan of the chest, but is not indicated prior to the CT scan.
CT scan of chest
Question 2 Explanation: 
A CT scan of the chest is needed to further evaluate the characteristics of the solitary pulmonary nodule and to determine lymph node involvement or presence of multiple lesions.
Question 3
A 40 year-old male nonsmoker in good health undergoes a routine chest x-ray for an insurance physical. Results show an isolated, well-defined, coin lesion 1 cm in size. Which of the following is the next step in the evaluation of this problem?
Review old radiographs
Order chest CT
Schedule lung biopsy
See A for explanation.
Prepare for surgical lung resection
See A for explanation.
Question 3 Explanation: 
The first and most important step in the radiographic evaluation is to review old radiographs to estimate doubling time, an important marker for malignancy.
There are 3 questions to complete.
Shaded items are complete.
Lung cancer (ReelDx) (Prev Lesson)
(Next Lesson) Obstructive pulmonary disease (PEARLS)
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