2. DEFINITION
Coin lesion
A solitary pulmonary nodule is defined as a single
discrete pulmonary opacity that is surrounded by
normal lung tissue that is not associated with
adenopathy or atelectasis.
<3 cms-SPN
> 3 cms-MASS
3. Features of a spn
A solitary radiographic shadow does not exceed 3
cm in its largest diameter.
It may have any contour.
It may be calcified or cavitated.
Satellite lesions may be present.
The lesion is surrounded by air containing lung or,
if it is adjacent to visceral pleura or over the
convexity of the thorax at least 2/3 rds of its
circumference is contiguous to air – containing
lung.
4. INCIDENCE AND PREVALENCE
CXR-order of 1 to 2 per thousand chest
radiographs
90 percent are noted as an incidental finding on
radiographic examination
12. CLINICAL CRITERIA TO
DIFFERENTIATE BENIGN &
MALIGNANT
Clinical benign malignant
age < 35 yrs > 35 yrs
symptoms absent present
Past history&
functional capacity
High incidence of
granuloma,TB
exposure
Smoker , diagnosis
of primary
elsewhere
13. radiographic
benign malignant
size Small ( <3 cm in diameter
)
Large ( > 3 cms )
location No predilection except TB Predominantly upper lobes
(except metastasis )
contour Smooth margins Margins spiculated
calcification Central, laminated ,diffuse
,popcorn
Rare (or) eccentric
calcification
Satellite lesions More common Less common
Serial studies over 2 yrs Stable ( no change) Not stable
Doubling time < 20 or >400 days 30 – 180 days
14. Ct features
benign malignant
calcification Diffuse or central Absent or
eccentric
fat Diagnostic of
hamartoma
Absent
Bubble like
lucencies
uncommon Common in
adenocarcinoma
Enhancement
with IV contrast
< 15HU > 25 HU
16. Age is one of the most consistent risk factors.
the incidence of malignancy in
patients aged 45 to 54 - 63 %
aged 54 to 64 - 74%
those above the age of 75 - 96%
19. Growth Rate:
Doubling Time
Volume = 4/3 r 3
25% increase in diameter results in doubling of
volume
Non-malignant disease: less than 20 days or
greater than 400 days
Malignant lesions: 30 to 180 days
20. Primary bronchogenic carcinoma is most
common primary malignancy
A h/o current or prior extra pulmonary malignancy
increase risk
Mostly of colon,breast,kidney,head and
neck,melanoma,sarcoma etc..
21. BENIGN SPN
These are more common in young and non
smokers.
Hamartomas ; most common
are developmental malformations
Contains cartilage,fibromyxoid stroma,adipose
tissue
Incidence- >70 years, equal in both sexes
Average size -1.5 cm, mostly asymptomatic
22. Infectious granulomas; >90% of benign spn
most common ; histoplasmosis
, coccidiomycosis,
tuberculosis
clues like h/o travel, residence, occupation are
useful
29. Work-up of SPN:
Imaging and Procedures
CXR
CT Scan
PET Scan
Bronchoscopy
Biopsy
TTNA, FNA
VATS, Open
30. Imaging techniques
PLAIN X-RAY CHEST
Mostly discovered routinely while asymptamatic
PA,lateral views are must
a nodule of same size for 2 years is benign
Digital x ray can improve detection
31. COMPUTED TOMOGRAPHY
Indications;1) assessing indeterminate nodules
<3cm 2)staging of
larger lesions 3)evaluating accessibility for
biopsy or resection
HRCT more useful in determining calcification
patterns, .
nodules of density >185 hf -benign
<185 hf - indeterminate
Nodules may be characterized as
SOLID,
PARTLY SOLID ,
GROUND GLASS opacities
32. Edge charcteristics of nodules can offer insight
into whether lesion is benign or malignant
33. Benign lesions are often well circumscribed with
round appearance
Malignant nodules tend to have irregular or lobulated
borders
Ct characters s/o malignancy :
Spiculated margins
Pleural retraction
Feeding vessel sign
Vascular convergence
Dilated bronchus leading into nodule
Cavitations
34. Nodule –lung interface ;
1) spiculated appearance s/o malignancy
2)plural tags seen in 60-80% of peripheral
malignancies
Air bronchogram; -in lung malignancies
- focal air collections,
- common in bronchoalveolar carcinomas.
Nodule enhancement-CT; <15 hf enhancement is
benign
38. The superior resolution of multidetector scanners
has also facilitate the development of
VOLUMETRIC CT
Allow growing lesions to be identified earlier than
conventional transverse ct
Three dimensional volume analysis enabled
tumor growth to be detected in 5mm nodules as
early as 30days after initial ct
Ct volume doubling time <400days or a new solid
component in a previously nonsolid nodule was
defined POSTIVE (nelson trial)
Sensitivity and specificity is high.
39. POSITRON EMISSION TOMOGRAPHY;
malignant cells have increased uptake and
metabolism of glucose
18 flouro deoxy glucose is used
Less useful in <8mm nodules
False -ve ; in broncho alveolar carcinoma,
carcinoids,
mucinous adenocarcinomas
False +ve ;tuberculosis, endemic
mycosis,rheumatoid arthritis, sarcoidosis,
uncontrolled hyperglycemia
40. Integrated PET-CT scanners allow more precise
anatomic localization of areas of FDG uptake
than PET imaging alone
PET imaging also provides information regarding
lung cancer staging since it will detect
unsuspected distant metastasis.
41. Risk factors associated with a low probability of
malignancy
include
diameter less than 1.5 cm,
age less than 45 years,
absence of tobacco use,
Having quit for 7 or more years,
and a smooth appearance on radiography
42. Risk factors associated with a moderately
increased risk of malignancy include
diameter 1.5 to 2.2 cm,
age 45to 59,
smoking up to 20 cigarettes per day,
being a former smoker within the last 7 years
a scalloped edge appearance on radiograph
43. Risk factors associated with a high risk of
malignancy include
a diameter of 2.3 cm or greater,
age greater than 60 years,
being a current smoker of more than20 cigarettes
per day,
a history of prior cancer
Corona radiata appearance on radiograph
44.
45.
46. Biopsy techniques
Bronchoscopy; has limited usefulness
Nodules in inner or middle 1/3 has high yield
Less sensitive for smaller lesions
47. The presence of type 1 and type 2 , a bronchus
leading to or contained within the body of mass or
nodule on CT, has been subsequently termed as
POSITIVE BRONCHUS SIGN
Newer bronchoscopic techniques include
Electromagnetic navigation and guidance EMN
Radial endobronchial ultrasound EBUS
Ultrathin bronchoscopy
Guide sheath techniques
Virtual bronchoscopic navigation
48. Tsuboi and colleagues
described four types of
tumor–bronchus
relationships:
(1) the bronchial lumen is
patent up to the tumor;
(2) the bronchus is
contained in the tumor
mass;
(3) the bronchus is
compressed and
narrowed by the tumor,
but the bronchial mucosa
is intact; and
(4) the proximal bronchial
tree is narrowed by
peribronchial or
submucosal spread of the
tumor or by enlarged
49. Percutaneous needle aspiration
useful in outer 1/3 ,has high yield
Complication is pneumothorax
Contraindications;
1)fev1 <1litre
2)bulla in needle path
3)bleeding diathesis
4)post pneumonectomy
50. Work-up of SPN:
CT guided TTNA
Increasing utilization of TTNA
Not indicated for patients committed to
surgery
Accuracy for detecting malignancy 64-100%
Yield increased when cytopathologist present
Three results:
Malignant
Specific benign, e.g. TB
Non-specific benign, e.g. bronchoalveolar
hyperplasia
51.
52. Work-up of SPN:
CT guided TTNA
Complications:
Pneumothorax 25%, chest tube <5%
Hemoptysis <10%
Relative contraindications:
Pulmonary HTN, severe COPD, AVM’s, coagulopathy
Absolute contraindication:
One lung or bilateral lung transplant
53. Thoracotomy , mortality of 3 to 7 percent
Lobectomy using either open thoracotomy or
video-assisted thoracoscopic surgery with
lymph node resection and staging,remain the
standard of care for stage I bronchogenic
carcinoma.
54.
55.
56.
57. Diagnostic approach
1)On discovery : determine whether it is true
SPN,is spherical,is located in lung fields. CT
should be part of initial investigation.
2)Thorough history should be taken.
3)All prior x-rays,CT, should be compared with
present.
*if nodule unchanged for 2years no further follow
up
*if doubling time <18 months –malignant >18
months-indeterminate.
58. 4)estimate probability of malignancy
Low probability <10% -
benign calcification pattern , age <35 , stable for
2years, can be observed
with serial CT scans
59. High probability : for surgery
staging followed by VATS /Thoracotomy
PET scan useful for staging
Even if PET negative : biopsy or resection done
60. Moderate probability : (10 -60% risk).
After evaluation of x-ray & CT - 70-75%
indeterminate are malignant
PET scanning for those with nodules measuring 1
cm or greater in size .
Transthoracic fine-needle aspiration,
bronchoscopy if there is an air-bronchus sign, or
a contrast-enhanced CT are reasonable options.
If the results are positive, then surgery is clearly
warranted