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Lung nodule is a tomographic finding that every physician has faced at least once in their life. Therefore, I am posting a tweetorial with tips/tricks in lung nodule - from the Game of Nodules #CHEST2020 @accpchest @AAB_IP @virenkaul @ChrisCarrollMD @sfaiz212 @dfellerk
1/15
- Nodules < 6 mm have < 1% risk of being malignant
- 8-20 mm nodules carry 15% risk of malignancy
- High risk features: spiculation, upper-lobe
- The diagnostic yield of pulmonary nodules is higher if located in the upper-lobe (NAVIGATE trial),
- Nodules < 6 mm have < 1% risk of being malignant
- 8-20 mm nodules carry 15% risk of malignancy
- High risk features: spiculation, upper-lobe
- The diagnostic yield of pulmonary nodules is higher if located in the upper-lobe (NAVIGATE trial),
2/15
airway leading to the lesion (bronchus sign), as well as using multiple instruments during biopsy. Additionally, the use of ultrathin scope (3 mm outer diameter) with EBUS is associated with diagnostic yield of 74% vs 59% when thin scope (4 mm) is used
airway leading to the lesion (bronchus sign), as well as using multiple instruments during biopsy. Additionally, the use of ultrathin scope (3 mm outer diameter) with EBUS is associated with diagnostic yield of 74% vs 59% when thin scope (4 mm) is used
3/15
- Growth rate is expressed in volume doubling time (VDT: time it takes for the nodule to double in volume)
- Doubling in tumor volume corresponds to an increase of 26% in nodule diameter (4πrˆ3/3)
- Growth rate is expressed in volume doubling time (VDT: time it takes for the nodule to double in volume)
- Doubling in tumor volume corresponds to an increase of 26% in nodule diameter (4πrˆ3/3)
4/15
- dt = (t x log 2) / [3 x (log (d2/d1)] - dt: doubling time in days, t: time in days between scans, d2: diameter at the second image, d1: diameter at the first image
- 2-year stability: presumptive of a benign etiology
- VDT malignant solid nodules typically within 400 days
- dt = (t x log 2) / [3 x (log (d2/d1)] - dt: doubling time in days, t: time in days between scans, d2: diameter at the second image, d1: diameter at the first image
- 2-year stability: presumptive of a benign etiology
- VDT malignant solid nodules typically within 400 days
5/15
Ground grass nodules have longer VDT, therefore longer follow-up is advisable. If > 5 mm in diameter, annual surveillance is recommended for at least 3 years (grade 2C). If > 10 mm, early follow-up at 3 months followed by surgical biopsy and/or resection if it persists
Ground grass nodules have longer VDT, therefore longer follow-up is advisable. If > 5 mm in diameter, annual surveillance is recommended for at least 3 years (grade 2C). If > 10 mm, early follow-up at 3 months followed by surgical biopsy and/or resection if it persists
6/15
- NLST (low dose CT for lung cancer screen) stopped early after 6.5 years of follow-up. Lung cancer mortality reduced by 20% (95% CI, 6.8-26.7%)
- Number Needed to Screen (NNS) to prevent one lung cancer death: 320 (1,339 in breast, 817 in colon cancer)
- NLST (low dose CT for lung cancer screen) stopped early after 6.5 years of follow-up. Lung cancer mortality reduced by 20% (95% CI, 6.8-26.7%)
- Number Needed to Screen (NNS) to prevent one lung cancer death: 320 (1,339 in breast, 817 in colon cancer)
7/15
- Several models to estimate the probability of malignancy are available, including Gurney (1993), Mayo Clinic (1997), VA (2007), PKUPH (2012), Brock (2013). Some models incorporate PET scan results, such as Herder (2005), TREAT (2014), BIMC (2015)
- Several models to estimate the probability of malignancy are available, including Gurney (1993), Mayo Clinic (1997), VA (2007), PKUPH (2012), Brock (2013). Some models incorporate PET scan results, such as Herder (2005), TREAT (2014), BIMC (2015)
8/15
- Presence and pattern of calcification in a SPN can help differentiate benign from malignant
- Four benign patterns of calcification: central, diffuse solid, laminated and “popcorn-like”
- Presence and pattern of calcification in a SPN can help differentiate benign from malignant
- Four benign patterns of calcification: central, diffuse solid, laminated and “popcorn-like”
9/15
The first three are seen with prior infection (eg histoplasmosis and tuberculosis). When present, they are reliable indicators of a benign etiology
- Popcorn-like is characteristic of chondroid calcification in a hamartoma, and its prevalence is 5-50%
The first three are seen with prior infection (eg histoplasmosis and tuberculosis). When present, they are reliable indicators of a benign etiology
- Popcorn-like is characteristic of chondroid calcification in a hamartoma, and its prevalence is 5-50%
10/15
- 38-63% of benign nodules are not calcified
- Histoplasma capsilatum gives rise to a variety of calcified intrathoracic calcific deposits, such as mediastinal lymph nodes, broncholithiasis, mediastinal granuloma, solitary or multiple intrapulmonary calcified histoplasmomas
- 38-63% of benign nodules are not calcified
- Histoplasma capsilatum gives rise to a variety of calcified intrathoracic calcific deposits, such as mediastinal lymph nodes, broncholithiasis, mediastinal granuloma, solitary or multiple intrapulmonary calcified histoplasmomas
11/15
- Hypercalcemia due to granulomatous infections or supplemental vitamin D is rare but may contribute to calcification of intrathoracic granulomas
- Hypercalcemia due to granulomatous infections or supplemental vitamin D is rare but may contribute to calcification of intrathoracic granulomas
12/15
- It is rare when secondary to Coccidioides immitis infection. On the other hand TB is a common cause of intrathoracic calcifications, mainly dystrophic and may present as parenchymal granulomas, mediastinal LN, fibronodular areas of lung involvement
- It is rare when secondary to Coccidioides immitis infection. On the other hand TB is a common cause of intrathoracic calcifications, mainly dystrophic and may present as parenchymal granulomas, mediastinal LN, fibronodular areas of lung involvement
13/15
- Hypercalcemia can be seen in TB caused by excessive production of 1,25 vitamin D
- Diffuse nodular calcification of the lung may be the result of hematogenous infection
- Hypercalcemia can be seen in TB caused by excessive production of 1,25 vitamin D
- Diffuse nodular calcification of the lung may be the result of hematogenous infection
14/15
- Rarely sarcoidosis may produce multiple micro nodular calcifications, radiographically similar to pulmonary alveolar microlithiasis (PAM). The former is within epithelioid granulomas, the latter are intra-alveolar microliths
- Rarely sarcoidosis may produce multiple micro nodular calcifications, radiographically similar to pulmonary alveolar microlithiasis (PAM). The former is within epithelioid granulomas, the latter are intra-alveolar microliths
15/15
- A typical Pulmonary Arterial Venous Malformation (PAVM) appears as a well-defined peripheral nodule, rounded or multilobulated related to aneurysmal connection, with feeding arteries and draining veins, and both must be present in order to make a diagnosis of PAVM
- A typical Pulmonary Arterial Venous Malformation (PAVM) appears as a well-defined peripheral nodule, rounded or multilobulated related to aneurysmal connection, with feeding arteries and draining veins, and both must be present in order to make a diagnosis of PAVM
