PANCE Blueprint Pulmonary (10%)

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 more likely to be benign
  • Ill-definedlobular, 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 → compare to older CXR if available →
  2. Send for CT →
  3. If suspicious (depending on radiographic findings below) will need a 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
Fleischner Society pulmonary nodule recommendations

The Fleischner Society pulmonary nodule recommendations pertain to the follow-up and management of indeterminate pulmonary nodules detected incidentally on CT and are published by the Fleischner Society.

Solid nodules

Single

Single solid nodule <6 mm (<100 mm3)

  • low-risk patients: no routine follow-up required
  • high-risk patients: optional CT at 12 months (particularly with suspicious nodule morphology and/or upper lobe location; see “risk assessment” below)

Solitary solid nodule 6-8 mm (100-250 mm3)

  • low-risk patients: CT at 6-12 months, then consider CT at 18-24 months
  • high-risk patients: CT at 6-12 months, then CT at 18-24 months

Solitary solid nodule >8 mm (>250 mm3)

  • low-risk and high-risk patients: consider CT at 3 months, PET/CT, or tissue sampling

Multiple

Multiple solid nodules <6 mm (<100 mm3)

  • low-risk patients: no routine follow-up required
  • high-risk patients: optional CT at 12 months

Multiple solid nodules >6 mm (>100 mm3)

  • low-risk patients: CT at 3-6 months, then consider CT at 18-24 months
  • high-risk patients: CT at 3-6 months, then CT at 18-24 months

When multiple nodules are present, the most suspicious nodule should guide further individualized management.

Subsolid nodules

Single

Single ground glass nodule <6 mm (<100 mm3)

  • no routine follow-up required

Single ground glass nodule ≥6 mm (>100 mm3)

  • CT at 6-12 months, then if persistent, CT every 2 years until 5 years

Single part-solid nodule ≥6 mm (>100 mm3)

  • CT at 3-6 months, then if persistent and solid component remains <6 mm, annual CT until 5 years

Multiple

Multiple subsolid nodules <6 mm (<100 mm3)

  • CT at 3-6 months, then if stable consider CT at 2 and 4 years in high-risk patients

Multiple subsolid nodules ≥6 mm (>100 mm3)

  • CT at 3-6 months, then subsequent management based on the most suspicious nodule(s)

The guideline does not apply to lung cancer screening, patients younger than 35 years, or patients with a history of primary cancer or immunosuppression.

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?
A
CT scan of the chest
B
Needle biopsy of the lesion
Hint:
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.
C
Positron emission tomography of the chest
Hint:
Positron emission tomography (PET scan) would be indicated if the CT scan was nonconclusive.
D
Fiberoptic bronchoscopy
Hint:
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?
A
Bone scan
Hint:
Bone scanning is indicated for evaluation of bone metastases, most commonly secondary to cancer of the breast or prostate.
B
Thoracotomy
Hint:
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.
C
Mediastinoscopy
Hint:
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.
D
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?
A
Review old radiographs
B
Order chest CT
C
Schedule lung biopsy
Hint:
See A for explanation.
D
Prepare for surgical lung resection
Hint:
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.
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