PULMONARY NODULES

 

††††††††††† SOLITARY

-40-50% malignant

-90% of these bronchogenic ca

-DDx: mets, carcinoid,

granulomas

 

CALCIFICATION

 

††††††††††† BENIGN

A.central

B.††††† laminated(granuloma)

C.diffuse

D.††††† popcorn(hamartoma)

 

††††††††††† WATCH & WAIT

Repeat CXR at 1 Ĺ, 3, 6, 12, 18, 24 mos

-IF growing or changing, get tissue

Doubling Time:

-malignant: 30-400 days

-benign: <20, >500 days

-2 yrs ( DT>730 days

 

SUSPICIOUS or NON-CALCIFIED

E.†† stippled

F.†† eccentric

 

Check previous radiographs

 

No growth in 2 yrs

 

Growth or No prior films

 

HRCT

1.†† Smooth, regular borders ( 20% malignant

2.†† Smooth, irregular borders ( 33% malignant

3.†† Spiculated ( 83% malignant

4.†† Corona radiata ( 93% malignant

 

<2cm(10-42% malignant), calcified, AND Type 1 or 2

 

>3cm(<5% of benign nodules) OR Type 3 or 4

 

Cavitary mass wall thickness:

<1mm all benign

>15mm 90% malignant

 

†††††† PROBABILITY OF CANCER

Qualitative or quantitative(Bayesian analysis)

 

 

 

 

Likelihood Ratios for Malignancy

 

Finding

Likelihood ratio

Overall prevalence

 

†††† clinical settings

0.7

††† poulation screen

0.1

Diameter(cm)

 

†††† <1.5

0.1

†††† 1.5-2.2

0.5

†††† 2.3-3.2

1.7

†††† 3.3-4.2

4.3

†††† 4.3-5.2

6.6

††††† >5.3

29.4

Patientís age(yrs)

 

†††† <35

0.1

†††† 36-44

0.3

†††† 45-49

0.7

†††† 50-59

1.5

†††† 60-69

2.1

†††† >70

5.7

Smoking

 

†††† Never

0.15

†††† Pipe or cigar

0.3

†††† Ever cigarettes

1.5

†††† Current or quit <9yrs

1.5

††††††††† Average cigs/day

 

††††††††††† 1-9

0.3

††††††††††† 10-20

1.0

††††††††††† 21-40

2.0

††††††††††† >40

3.9

Quit smoking(yrs)

 

†††† <3

1.4

†††† 4-6

1.0

†††† 7-12

0.5

†††† >13

0.1

 

††† Estimating the Probability of Cancer

 

Step 1. Find appropriate likelihood ratios(LR)

Step 2. Multiply all ratios

Step 3. Convert to probability:

 

†††††††††††††††††††††††††††††††† product of LRs

†††† Probability = ---------------------------

††††††††††††††††††††††††††††† 1 + product of LRs

 

Low risk (<5%)

 

Medium risk

 

High risk (>60-70%)

 

TBBx

-IF <2cm (10-30% sensitivity for malignancy

-IF >2cm, involves bronchus ( up to 90% sensitivity for malignancy

 

CT-PCNA

-97% accurate for malignant dx

-29% false negative for benign dx

-Most useful to evaluate metastatic disease

-OR to push for surgery in reluctant pt or

-pt with comorbidities

 

VATS

-Only peripheral lesions

-May be definitive

 

THORACOTOMY

 

MULTIPLE

 

2-3 nodules with

different characteristics

-consider multiple

processes

 

>3 nodules with

similar characteristics

-Metastases (more than all others combined)

-DDx: lymphoma, primary BACCa, IF AIDS

Kaposiís, benign tumors, granulomas.

 

 

REFERENCES

 

Mitruka et al. Diagnosing the indeterminate pulmonary nodule: Percutaneous biopsy versus thoracosopy. Surgery.118:676-84, 1995.

 

Lillington et al. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med.14(1): 111-9, 1993.

 

Wang et al. Transbronchial needle aspiration and percutaneous needle aspiration for staging and diagnosis of lung cancer. Clin Chest Med. 16(3): 535-52, 1995.

 

Lillington. Management of solitary pulmonary nodules: How to decide when resection is required. Postgraduate Med. 101(3): 145-150, 1997.

 

Howard et al. Clinical and Imaging Evaluation of the Solitary Pulmonary Nodule. American Fam Phys. 46(6): 1753-9, 1992.

 

Viggiano et al. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med. 13(1): 83-95.

 

Cummings et al. Estimating the Probability of Malignancy in Solitary Pulmonary Nodules: A Bayesian Approach. Am Rev Respir Dis. 134: 449-52.

 

 

†††††† DONE