Approach for Patient with Solitary Pulmonary Nodule

 

A solitary pulmonary nodule (or "coin lesion") is:

(1) generally round

(2) < 3 cm in diameter (a nodule > 3 cm in diameter is called a "mass" and has a high risk of being malignant)

(3) completely surrounded by pulmonary parenchyma

 

Parameters for determining the risk that the solitary nodule is cancerous:

(1) diameter of the nodule in cm

(2) age of the patient in years

(3) smoking status

(4) smoking cessation status

(5) characteristic of the nodule margin

(6) calcification pattern

Parameters	Low Risk (< 10%)	Intermediate Risk (10 - 60%)	High Risk ( > 60%)
diameter in cm	< 1.5 cm	1.5 - 2.2 cm	>= 2.3 cm
age in years	< 45 years	45 - 60 years	> 60 years
smoking status	never smoked	current smoker with <= 20 cigarettes per day	current smoker > 20 cigarettes per day
smoking cessation	never smoked or quit > 7 years ago	quit < 7 years ago	never quit
nodule margins	smooth	scalloped	corona radiata or spiculated
calcification pattern	laminated, central or "popcorn"		stippled or eccentric

 

where:

• The corona radiata sign consists of very fine linear strands extending 4-5 mm outward from a nodule on CT scan.

 

Evaluation of a nodule identified on standard CT scan:

(1) If the nodule shows a benign calcification pattern or has been stable for 2 years on high resolution CT, then the lesion is probably benign and no further testing is required.

(2) If the nodule does not show a benign calcification pattern or has increased in size based on comparison with archival films, then the type of evaluation depends on an assessment of the pertinent factors.

 

Factors determining the next step:

(1) probability of cancer

(2) the patient's surgical risk (based on predicted postoperative FEV1, maximum oxygen uptake)

(3) the presence or absence of comorbid conditions

(4) the patient's preference

(5) available surgical expertise

(6) available radiologic expertise

 

If the probability of malignancy is low, then serial high-resolution CT scans can be performed at 3, 6, 9, 12, 18 and 24 months.

 

If the probability of cancer is high and the patient is a surgical candidate, then video-assisted thoracoscopic surgery can be performed, with frozen section of the nodule and resection if malignant.

 

Else perform additional imaging studies, with surgery done if results high risk or serial high resolution CT scans done at 3, 6, 9, 12, 18 and 24 months if not:

(1) If the lesion is >= 1 cm in diameter perform PET scan.

(2) If the lesion is peripheral consider transthoracic fine needle aspiration.

(3) If an air-bronchus sign is present or the nodule is near to a large bronchus, consider bronchoscopy.

(4) Else consider contrast enhanced CT.