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Solitary Pulmonary Nodule

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

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A not uncommon clinical and radiological dilemma. The first step is always to obtain previous chest radiology and then to assess the risk for malignancy. Bronchoscopy is generally not indicated as the lesion is outside the field of vision and not accessible
If no prior radiology then a CT chest is indicated. The finding of Calcification and/or fat on the CT chest are prognostically against malignancy
A lesion > 3 cm in a smoker is very suggestive of malignancy even more so if spiculated as does associated hilar lymphadenopathy
A positive 18-FDG-PET scan suggests a malignant lesion.
If there is diagnostic doubt a percutaneous needle biopsy is suggested. Where there is a high degree of suspicion then the decision may be to go directly to surgical resection.

Markers suggesting malignancy more likely in a pulmonary nodule are

Age > 40
History of smoking or exposure to asbestos
Lung cancer in 1st-degree relative
Increasing in size
Absence of calcification
size > 3 cm
Irregular borders
Upper zone is more likely cancer

Investigations

FBC, U&E, LFT,Glucose, Calcium
Chest X ray
CT chest which can be repeated at 3 months : interval scanning
Bronchoscopy
Needle biopsy: risk of PTX or bleeding
18-Flourodeoxyglucose scan shows the metabolic activity of the lesion. Activity is measured with a PET scanner. It is actively taken up and phosphorylated but cannot progress further and becomes trapped in the cell.

The differential diagnosis of Cavitary lung lesions can be represented by the mnemonic CAVITY
Carcinoma: squamous cell, melanoma, cervical, sarcoma metastasis Autoimmune: Granulomatosis with polyangiitis, Rheumatoid lung (Caplan's syndrome) Vascular: septic emboli Infection: TB (important finding as suggests active disease and infectivity), fungal (coccidio, aspergillosis, cryptosporidia, Nocardia), bacterial (esp. GNR, staph, strep) Hydatid cyst, Lung abscess Trauma: Young patients: these are often congenital lesions, such as a bronchogenic cyst or communicating sequestration

The differential diagnosis of Cavitary lung lesions can be represented by the mnemonic CAVITY

Carcinoma: squamous cell, melanoma, cervical, sarcoma metastasis

Autoimmune: Granulomatosis with polyangiitis, Rheumatoid lung (Caplan's syndrome)

Vascular: septic emboli

Infection: TB (important finding as suggests active disease and infectivity), fungal (coccidio, aspergillosis, cryptosporidia, Nocardia), bacterial (esp. GNR, staph, strep) Hydatid cyst, Lung abscess

Trauma:

Young patients: these are often congenital lesions, such as a bronchogenic cyst or communicating sequestration

Differential

Local pneumonia
Tuberculosis
Lung Tumour (benign or malignant)
Single metastasis to lung
Pneumonia
Pulmonary infarct
Mycetoma
Lymphoma
Hydatid cyst
Bronchogenic cyst
Rheumatoid nodule
Granulomatosis with polyangiitis (Wegener's granulomatosis)
Pulmonary haematoma
'Pseudotumour' - fluid collection in a fissure
Aspergilloma (usually surrounded by air crescent)
Cryptococcus
Aspergillus nodule

Revisions

Last updated 02/08/2018

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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