Solitary Pulmonary Nodule Differential Diagnoses

  • Author: Asif Alavi, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Feb 23, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Asif Alavi, MD  Resident Physician, Department of Internal Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View Medical Center

Asif Alavi, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Nader Kamangar, MD, FACP, FCCP, FCCM  Associate Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View-UCLA Medical Center; Associate Program Director, Pulmonary and Critical Care Multi-Campus Fellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/Olive View-UCLA Medical Center; Site Director, Pulmonary/Critical Care Fellowship Program, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP  Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Sat Sharma, MD, FRCPC, and Sri R Navaratnam, MBBS, PhD, FRCPC, to the development and writing of this article.

References

  1. Lillington GA. Management of solitary pulmonary nodules. Dis Mon. May 1991;37(5):271-318. [Medline].

  2. Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. Sep 2007;132(3 Suppl):94S-107S. [Medline].

  3. [Guideline] Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. Sep 2007;132(3 Suppl):108S-130S. [Medline]. [Full Text].

  4. Cardinale L, Ardissone F, Novello S, et al. The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. Radiol Med. May 29 2009;[Medline].

  5. Swensen SJ, Viggiano RW, Midthun DE, et al. Lung nodule enhancement at CT: multicenter study. Radiology. Jan 2000;214(1):73-80. [Medline]. [Full Text].

  6. Midthun DE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with low dose spiral computed tomography. Lung Cancer. Aug 2003;41 (suppl 2):S40.

  7. Ost D, Fein AM, Feinsilver SH. Clinical practice. The solitary pulmonary nodule. N Engl J Med. Jun 19 2003;348(25):2535-42. [Medline]. [Full Text].

  8. Xu DM, van der Zaag-Loonen HJ, Oudkerk M, Wang Y, Vliegenthart R, Scholten ET, et al. Smooth or Attached Solid Indeterminate Nodules Detected at Baseline CT Screening in the NELSON study: Cancer Risk during 1 Year of Follow-up. Radiology. Jan 2009;250:265-72. [Medline]. [Full Text].

  9. Godoy MC, Naidich DP. Subsolid pulmonary nodules and the spectrum of peripheral adenocarcinomas of the lung: recommended interim guidelines for assessment and management. Radiology. Dec 2009;253(3):606-22. [Medline]. [Full Text].

  10. Ahn MI, Gleeson TG, Chan IH, McWilliams AM, Macdonald SL, Lam S. Perifissural nodules seen at CT screening for lung cancer. Radiology. Mar 2010;254(3):949-56. [Medline]. [Full Text].

  11. Turan O, Ozdogan O, Gurel D, Onen A, Kargi A, Sevinc C. GROWTH OF A SOLITARY PULMONARY NODULE AFTER 6 YEARS DIAGNOSED AS ONCOCYTIC CARCINOID TUMOUR WITH A HIGH 18-FLUORODEOXYGLUCOSE (FDG) UPTAKE IN POSITRON EMISSION TOMOGRAPHY-COMPUTED TOMOGRAPHY (PET-CT). Clin Respir J. Nov 30 2011;[Medline].

  12. Behzadi A, Ung Y, Lowe V, Deschamps C. The role of positron emission tomography in the management of non-small cell lung cancer. Can J Surg. Jun 2009;52(3):235-42. [Medline].

  13. Gould MK, Maclean CC, Kuschner WG, Rydzak CE, Owens DK. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions: a meta-analysis. JAMA. Feb 21 2001;285(7):914-24. [Medline].

  14. Goldsmith SJ, Kostakoglu L. Role of nuclear medicine in the evaluation of the solitary pulmonary nodule. Semin Ultrasound CT MR. Apr 2000;21(2):129-38. [Medline].

  15. Yi CA, Lee KS, Kim BT, Choi JY, Kwon OJ, Kim H. Tissue characterization of solitary pulmonary nodule: comparative study between helical dynamic CT and integrated PET/CT. J Nucl Med. Mar 2006;47(3):443-50. [Medline].

  16. Tsunezuka Y, Shimizu Y, Tanaka N, Takayanagi T, Kawano M. Positron emission tomography in relation to Noguchi's classification for diagnosis of peripheral non-small-cell lung cancer 2 cm or less in size. World J Surg. Feb 2007;31(2):314-7. [Medline]. [Full Text].

  17. Naalsund A, Maublant J. The solitary pulmonary nodule--is it malignant or benign? Diagnostic performance of Tc-depreotide SPECT. Respiration. 2006;73(5):634-41. [Medline].

  18. van 't Westeinde SC, Horeweg N, Vernhout RM, Groen HJ, Lammers JW, Weenink C, et al. The role of conventional bronchoscopy in the work-up of suspicious CT screen detected pulmonary nodules. Chest. Feb 2 2012;[Medline].

  19. Herth FJ, Eberhardt R, Becker HD, Ernst A. Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: a prospective trial. Chest. Jan 2006;129(1):147-50. [Medline]. [Full Text].

  20. Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J. Oct 2002;20(4):972-4. [Medline]. [Full Text].

  21. Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-Analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule. Chest. Oct 6 2011;[Medline].

  22. Lacasse Y, Wong E, Guyatt GH, Cook DJ. Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis. Thorax. Oct 1999;54(10):884-93. [Medline].

  23. Chung T. Fine needle aspiration of the solitary pulmonary nodule. Semin Thorac Cardiovasc Surg. Jul 2002;14(3):275-80. [Medline].

  24. Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest. Jan 2003;123(1 Suppl):89S-96S. [Medline]. [Full Text].

  25. [Guideline] MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. Nov 2005;237(2):395-400. [Medline]. [Full Text].

  26. Gurney JW. Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis. Part I. Theory. Radiology. Feb 1993;186(2):405-13. [Medline]. [Full Text].

  27. Watanabe A, Koyanagi T, Obama T, et al. Assessment of node dissection for clinical stage I primary lung cancer by VATS. Eur J Cardiothorac Surg. May 2005;27(5):745-52. [Medline]. [Full Text].

  28. Shennib H. Intraoperative localization techniques for pulmonary nodules. Ann Thorac Surg. Sep 1993;56(3):745-8. [Medline].

  29. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. Sep 1995;60(3):615-22; discussion 622-3. [Medline].

  30. Cummings SR, Lillington GA, Richard RJ. Estimating the probability of malignancy in solitary pulmonary nodules. A Bayesian approach. Am Rev Respir Dis. Sep 1986;134(3):449-52. [Medline].

  31. Chhajed PN, Bernasconi M, Gambazzi F. Combining bronchoscopy and positron emission tomography for the diagnosis of the small pulmonary nodule < or = 3 cm. Chest. Nov 2005;128(5):3558-64.

  32. Decamp MM Jr. The solitary pulmonary nodule: aggressive excisional strategy. Semin Thorac Cardiovasc Surg. Jul 2002;14(3):292-6. [Medline].

  33. Erasmus JJ, Connolly JE, McAdams HP, Roggli VL. Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions. Radiographics. Jan-Feb 2000;20(1):43-58. [Medline].

  34. Erasmus JJ, McAdams HP, Connolly JE. Solitary pulmonary nodules: Part II. Evaluation of the indeterminate nodule. Radiographics. Jan-Feb 2000;20(1):59-66. [Medline].

  35. Ginsberg RJ. The solitary pulmonary nodule: can we afford to watch and wait?. J Thorac Cardiovasc Surg. Jan 2003;125(1):25-6. [Medline].

  36. Gould MK, Lillington GA. Strategy and cost in investigating solitary pulmonary nodules. Thorax. Aug 1998;53 Suppl 2:S32-7. [Medline].

  37. Hartman TE. Radiologic evaluation of the solitary pulmonary nodule. Radiol Clin North Am. May 2005;43(3):459-65, vii. [Medline].

  38. Herder GJ, van Tinteren H, Golding RP. Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography. Chest. Oct 2005;128(4):2490-6.

  39. Jain P, Kathawalla SA, Arroliga AC. Managing solitary pulmonary nodules. Cleve Clin J Med. Jun 1998;65(6):315-26. [Medline].

  40. Laurent F, Remy J. [Management strategy of pulmonary nodules]. J Radiol. Dec 2002;83(12 Pt 1):1815-21. [Medline].

  41. Lillington GA. Management of solitary pulmonary nodules. How to decide when resection is required. Postgrad Med. Mar 1997;101(3):145-50. [Medline].

  42. Lillington GA. Solitary pulmonary nodules: new wine in old bottles. Curr Opin Pulm Med. Jul 2001;7(4):242-6. [Medline].

  43. Lillington GA, Caskey CI. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med. Mar 1993;14(1):111-9. [Medline].

  44. Moses DA, Ko JP. Multidetector CT of the solitary pulmonary nodule. Semin Roentgenol. Apr 2005;40(2):109-25. [Medline].

  45. Ost D, Fein A. Evaluation and management of the solitary pulmonary nodule. Am J Respir Crit Care Med. Sep 2000;162(3 Pt 1):782-7. [Medline].

  46. Pepe G, Rossetti C, Sironi S, Landoni C, Gianolli L, Pastorino U. Patients with known or suspected lung cancer: evaluation of clinical management changes due to 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) study. Nucl Med Commun. Sep 2005;26(9):831-7. [Medline].

  47. Plachcinska A, Mikolajczak R, Kozak J, Rzeszutek K, Kusmierek J. A visual and semi-quantitative assessment of (99m)Tc-EDDA/HYNIC-TOC scintigraphy in differentiation of solitary pulmonary nodules. Nucl Med Rev Cent East Eur. 2004;7(2):143-50. [Medline].

  48. Schiavon F, Berletti R, Soardi GA. Multidisciplinary management of the solitary pulmonary nodule (SPN): our opinion. Radiol Med (Torino). Sep 2005;110(3):149-55.

  49. Shaham D, Guralnik L. The solitary pulmonary nodule: radiologic considerations. Semin Ultrasound CT MR. Apr 2000;21(2):97-115. [Medline].

  50. Siegelman SS, Zerhouni EA, Leo FP, Khouri NF, Stitik FP. CT of the solitary pulmonary nodule. AJR Am J Roentgenol. Jul 1980;135(1):1-13. [Medline].

  51. Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. Apr 28 1997;157(8):849-55. [Medline].

  52. Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest. Jan 2003;123(1 Suppl):89S-96S. [Medline].

  53. Tang AW, Moss HA, Robertson RJ. The solitary pulmonary nodule. Eur J Radiol. Jan 2003;45(1):69-77. [Medline].

 
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Right upper lobe nodule shows peripheral calcification and high Hounsfield unit enhancement, suggesting that the lesion is a calcified benign pulmonary nodule.
A 1.5-cm coin lesion in the left upper lobe in a patient with prior colonic carcinoma. Transthoracic needle biopsy findings confirmed this to be a metastatic deposit.
Mediastinal windows of the patient in the image above.
Right lower lobe nodule demonstrating central calcification. The most likely diagnosis is histoplasmosis.
Close-up view of a right lower lobe nodule demonstrating central calcification. The most likely diagnosis is histoplasmosis.
Left upper lobe cavitating solitary nodule eventually identified as active pulmonary tuberculosis from percutaneous needle biopsy findings.
A left upper lobe nodule with central lucency and poorly circumscribed margins was diagnosed as actinomycosis based on needle biopsy findings.
CT scan of the patient presented in the image above. After needle biopsy, the presence of classic sulfur granules confirmed actinomycosis.
A right lower lobe solitary pulmonary nodule later identified to be a hamartoma.
Wedge-shaped peripheral (pleural based) density observed secondary to pulmonary infarction (pulmonary embolism). This is termed the Hampton hump.
Left upper lobe 1.5-cm nodule shows negative CT scan numbers, suggesting fat in the lesion consistent with hamartoma.
A left upper lobe solitary pulmonary nodule. The differential diagnosis is large, but CT scan findings help narrow the differentials and establish the diagnosis.
Cavitating right lower lobe nodule later confirmed to be primary pulmonary lymphoma. Calcium deposits may also be present in the lesion.
This left lower lobe carcinoid tumor was quite bloody after a percutaneous needle biopsy was performed.
A lateral radiograph of the case in the image above.
CT scan of the patient in the previous 2 images shows a well-circumscribed lesion.
A "popcorn" calcification in the left lung nodule indicates a benign lesion or hamartoma. No further tests or observations are needed for this patient.
A 1.5-cm right upper lobe nodule on CT scan was determined to be a benign fibrous lesion on needle biopsy. A follow-up at 2 years showed no change in the size of this lesion.
The parenchymal lesion in this CT scan demonstrates low attenuation within the lesion, indicating the presence of fat. Fat density is only observed in hamartoma and lipoid pneumonia. The likely diagnosis is hamartoma.
This patient has a low risk for the right upper lobe nodule to be malignant; therefore, continued observation with repeat chest radiographs to establish a growth pattern is the best treatment option.
 
 
 
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