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 ½, 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 |
|
Patient’s 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
Kaposi’s,
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