Solitary Pulmonary Nodules: Part II. Evaluation of the Indeterminate Nodule1
Jeremy J. Erasmus, MD ,
H. Page McAdams, MD and
John E. Connolly, MD
1 From the Department of Radiology, Duke University Medical Center, Erwin Road, Durham, NC 27710 (J.J.E., H.P.M.), and the Department of Radiology, Rush Presbyterian Medical Center, Chicago, Ill (J.E.C.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 19, 1999; revision requested March 29 and received June 9; accepted June 10. Address reprint requests to J.J.E.
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Figure 1. Effect of initial nodule size on perception of growth. Schematic illustrates two volume doublings of a 4-mm nodule and a 3-cm nodule. Because the eye perceives the arithmetic increase in diameter rather than the change in volume, the smaller nodule appears to be growing more slowly than the larger one, even though both are doubling in volume at the same rate.
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Figure 2a. Pulmonary infarct in 65-year-old woman who presented with pleuritic chest pain. (a) Close-up posteroanterior radiograph of the right lung shows a poorly marginated nodule peripherally in the lower lobe. Because of symptoms suggestive of pulmonary embolism, technetium-99m microaggregated albumin perfusion scintigraphy was performed. (b) Tc-99m microaggregated albumin perfusion scintigram shows multiple segmental perfusion defects, findings consistent with pulmonary embolism. Results of a ventilation scan (not shown) were normal.
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Figure 2b. Pulmonary infarct in 65-year-old woman who presented with pleuritic chest pain. (a) Close-up posteroanterior radiograph of the right lung shows a poorly marginated nodule peripherally in the lower lobe. Because of symptoms suggestive of pulmonary embolism, technetium-99m microaggregated albumin perfusion scintigraphy was performed. (b) Tc-99m microaggregated albumin perfusion scintigram shows multiple segmental perfusion defects, findings consistent with pulmonary embolism. Results of a ventilation scan (not shown) were normal.
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Figure 2c. Pulmonary infarct in 65-year-old woman who presented with pleuritic chest pain. (a) Close-up posteroanterior radiograph of the right lung shows a poorly marginated nodule peripherally in the lower lobe. Because of symptoms suggestive of pulmonary embolism, technetium-99m microaggregated albumin perfusion scintigraphy was performed. (b) Tc-99m microaggregated albumin perfusion scintigram shows multiple segmental perfusion defects, findings consistent with pulmonary embolism. Results of a ventilation scan (not shown) were normal.
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Figure 3. Round pneumonia in a 23-year-old woman who presented with cough and fever. Close-up posteroanterior radiograph of the left lung shows a poorly marginated nodule in the midlung. Because of clinical symptoms, the patient was treated for community-acquired pneumonia. Follow-up radiography performed 2 weeks later demonstrated complete resolution of the nodular area of increased opacity.
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Figure 4a. Pulmonary hematoma in a 65-year-old woman. (a) Posteroanterior radiograph obtained 1 week after the patient underwent aortic valve replacement shows a well-marginated nodule in the middle of the left lung. (b) Initial postoperative anteroposterior radiograph shows bilateral pleural tubes and an area of increased opacity adjacent to the tip of the left pleural tube, a finding that is consistent with intrapulmonary hematoma. Follow-up radiography demonstrated resolution of the nodule.
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Figure 4b. Pulmonary hematoma in a 65-year-old woman. (a) Posteroanterior radiograph obtained 1 week after the patient underwent aortic valve replacement shows a well-marginated nodule in the middle of the left lung. (b) Initial postoperative anteroposterior radiograph shows bilateral pleural tubes and an area of increased opacity adjacent to the tip of the left pleural tube, a finding that is consistent with intrapulmonary hematoma. Follow-up radiography demonstrated resolution of the nodule.
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Figure 5. Effect of age and smoking history on pCa in an indeterminate pulmonary nodule. Close-up chest CT scan of the right lung shows a 7-mm, smoothly marginated, noncalcified nodule in the middle lobe. On the basis of decision analysis, observation would be the most cost-effective management strategy in a 35-year-old nonsmoker (pCa = 0.01) or current smoker (pCa = 0.05), and biopsy would be the most cost-effective management strategy in a 70-year-old nonsmoker (pCa = 0.07) or current smoker (pCa = 0.50) (cf Table 2).
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Figure 6. Metastatic melanoma in a 40-year-old man. Contrast-enhanced CT scan shows enhancement of 35 HU in a right lung nodule, a finding that is suggestive of malignancy. Metastatic melanoma was confirmed at resection.
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Figure 7a. Non-small cell lung cancer in a 65-year-old man. (a) Chest CT scan shows a small nodule in the left lower lobe. (b) Axial FDG PET scan shows marked FDG accumulation in the nodule, a finding that is suspicious for malignancy. Lung cancer was confirmed at resection.
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Figure 7b. Non-small cell lung cancer in a 65-year-old man. (a) Chest CT scan shows a small nodule in the left lower lobe. (b) Axial FDG PET scan shows marked FDG accumulation in the nodule, a finding that is suspicious for malignancy. Lung cancer was confirmed at resection.
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Figure 8a. Pulmonary cyst in a 42-year-old man with emphysema who was undergoing pre-lung transplantation evaluation. (a) Posteroanterior radiograph shows emphysema and a well-marginated nodule in the left lower lobe. (b) Chest CT scan helps confirm the homogeneous left lower lobe nodule. (c) Axial FDG PET scan obtained at the same level as b shows no increased metabolic activity in the region of the nodule. These findings are consistent with benignity, and hemorrhagic cyst was diagnosed at lung transplantation 18 months later. C = normal cardiac uptake, V = vertebra. (Fig 8 reprinted, with permission, from reference 19.)
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Figure 8b. Pulmonary cyst in a 42-year-old man with emphysema who was undergoing pre-lung transplantation evaluation. (a) Posteroanterior radiograph shows emphysema and a well-marginated nodule in the left lower lobe. (b) Chest CT scan helps confirm the homogeneous left lower lobe nodule. (c) Axial FDG PET scan obtained at the same level as b shows no increased metabolic activity in the region of the nodule. These findings are consistent with benignity, and hemorrhagic cyst was diagnosed at lung transplantation 18 months later. C = normal cardiac uptake, V = vertebra. (Fig 8 reprinted, with permission, from reference 19.)
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Figure 8c. Pulmonary cyst in a 42-year-old man with emphysema who was undergoing pre-lung transplantation evaluation. (a) Posteroanterior radiograph shows emphysema and a well-marginated nodule in the left lower lobe. (b) Chest CT scan helps confirm the homogeneous left lower lobe nodule. (c) Axial FDG PET scan obtained at the same level as b shows no increased metabolic activity in the region of the nodule. These findings are consistent with benignity, and hemorrhagic cyst was diagnosed at lung transplantation 18 months later. C = normal cardiac uptake, V = vertebra. (Fig 8 reprinted, with permission, from reference 19.)
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Copyright © 2000 by the Radiological Society of North America.
