Solitary Pulmonary Nodule

1
Solitary Pulmonary Nodule
Victor Ghobrial, MD Balkison Maharajh,
MD Botrous Zeidan, MD
2
HPI

• 61 F presented with black stools hematemesis, a
  week before was treated for gastric ulcer by
  cauterization
• Also gave Hx of abnormal mammography and recent
  exicional Bx which was ve for malignancy

3
PMH

• PUD
• Pneumonia a year ago multiple F/U CXR
• TIAs
• Lumpectomy Lt breast benign tissue
• Hysterectomy
• Appendectomy
• Urinary bladder suspension

4
Meds

• Servent
• Vanceril
• Mevacor
• Prilosec
• Alprazolam
• Premarin
• NKDA

5
Social Hx

• Smoked 1 pack/day over 40 years
• Lives with family
• Takes care of 3 handicapped persons

6
Family Hx

• Positive colon cancer, CAD, stroke
• Negative DM, HTN

7
ROS

• Lost 40 lbs over one year
• Positive for lightheadedness, abd pain
• Negative for CP, SOB, fever

8
Physical Exam

• Looks older than stated age
• Vitals WNL
• Recent well healing scar Rt breast
• Otherwise unremarkable

9
Labs

• Hgb Hct WBCs Plt MCV
  
  8.8 26 13.3 495 91
• PT INR PTT
  11.0
  1.1 30
• Lytes, BUN/ Cr WNL

10
X-Ray

• CXR
• CT

11
Pathology

• Low grde in-situ Rt breast cancer without
  involvement of axillary lymph nodes

12
Hospital Course

• Transfused with PRBCs Hgb 11.3
• EGD Erosive gastric ulcer was cauterized, AVM of
  duodenum was cauterized Bx for CLO was done
  

13
CT Guided Bx

• Negative for cancer cells
• Dense neutrophil infiltrate suggestive of abscess
  formation

14
Solitary Pulmonary Nodule

• Basic strategy is to identify malignant versus
  benign
• Definition Opacity with diameter lt 3cm
• Larger lesions are called masses
• It occurs in 1 every 500 CXR

15
Solitary Pulmonary Nodule

• Nodules prove to be malignant in 40 of cases
• Most often Bronchogenic carcinoma
• Most common benign is hamartoma
• Benign lesions rheumatoid granuloma, healed
  infarct, pulmonary anurysm, Wagners
  granulomatosis

16
Early Resection

• Studies have proven that early resection results
  in 5-year survival rate of 50
• If nodule is 1cm or less rate is about 80
• Survival rate after discovery of bronchogenic
  carcinoma is 15 and hence the importance of
  early discovery in terms of cure

17
Growth of a Nodule

• Malignant nodules grow at a constant rate
  expressed as doubling time
• This usually falls between 25 and 450 days with a
  median of 120 days
• An increase of 28 in nodule diameter indicates
  doubling

18
Growth of a Nodule

• Benign lesions grow slowly with doubling time
  exceeding 500 days
• It is almost conclusively a benign lesion if size
  is stable for 2 years ( doubling time exceeding
  720 days )
• A doubling time of less than 20 days signifies
  inflammatory process

19
Calcification

• Radiographic pattern of calcium deposition is
  helpful
• Benign lesions tend to have central, laminated
  (bulls eye), diffuse or popcorn pattern
• Malignant lesions have speckled or eccentric
  pattern

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High Resolution CT

• HRCT is the most sensitive and specific for
  assessing the size, shape, calcification and edge
  of a nodule
• Type 1 Type 2 Type 3 Type 4

21
PET Scan

• Highly valuable noninvasive tool
• It is 95 sensitive for identifying malignancy
  and 85 specific
• False positive results may occur in lesions that
  contain active inflammatory tissue
  (histoplasmomas)

22
Biopsy

• Bx has a high yeild in establishing Dx
• Bronchoscopy can not access a nodule if it is
  peripheral and small
• If CT shows a bronchus entering a nodule its
  yeild is much higher
• Transthorathic needle aspiration (NAB) has a
  sensitivity of 80 to 90

23
Surgery

• Thoracotomy to resect a malignant nodule carries
  significant death of 3 to 4 but for a benign
  lesion it is 0.3
• Thoracoscopy carries less significant morbidity
  and lessens hospital stay
• It is not known if the 5-years survival is
  different between the two approaches

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Benign vs Malignant

• Age lt48
• nodule diameterlt1.5
• never smoked
• nodule edge type1
• doubling time gt500 d
• calcification in benign
• Needle Bx benign dis
  
  
• Needle Bx Nonspecific

• gt48
• gt1.5
• ever smoked
• type3
• 30 to 400 days
• indeterminate pattern
• malignant disease
• suspicious cells

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Decision Making

• Review all prior CXR
• Get CT scans
• If probability of cancer is lt10 wait and watch
• If it is high thoracotomy should intervene
• Bronch NAB reserved for pt who are reluctant to
  go for surgery before Dx

26
Decision Making

• If results are intermediate Thoracotomy, NAB and
  PET are equal in terms of 5-years survival
• PET is slightly more effective,noninvasive
• If PET is ve but other criteria are low for
  malignancy, then ANB is needed to R/O infectious
  granulomas