eMedicine Specialties > Pulmonology > Lung Tumors

Solitary Pulmonary Nodule

Author: Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Coauthor(s): Asif Alavi, MD, Resident Physician, Department of Internal Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View Medical Center; Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital; Sri R Navaratnam, MBBS, PhD, FRCPC, Assistant Professor, Department of Internal Medicine, Section of Hematology/Oncology, University of Manitoba; Consulting Medical Oncologist, Department of Hematology/Oncology, Cancer Care Manitoba
Contributor Information and Disclosures

Updated: Sep 11, 2009

Introduction

Background

A solitary pulmonary nodule is defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is without associated atelectasis or pleural effusion.

Patients with solitary pulmonary nodules are usually asymptomatic; however, solitary pulmonary nodules pose a challenge to both physicians and patients. Whether detected serendipitously or during a routine investigation, a nodule on a chest radiograph raises several questions: Is the nodule benign or malignant? Should it be investigated or observed? Should it be surgically resected?

Most solitary pulmonary nodules are benign, but they may represent an early stage of lung cancer. Lung cancer is the leading cause of cancer death in the United States, accounting for more deaths annually than breast, colon, and prostate cancers combined. Lung cancer survival rates remain dismally low at 14% at 5 years. Early lung cancer, when the primary tumor is less than 3 cm in diameter (stage 1A), may lead to 5-year survival rates of 70-80%. Therefore, prompt diagnosis and management of early lung cancer manifesting as solitary pulmonary nodule may be the only chance for cure.

Pathophysiology

A solitary pulmonary nodule is defined as a single, discrete pulmonary opacity that is less than 3 cm in diameter, surrounded by normal lung tissue, and not associated with adenopathy or atelectasis. Lesions larger than 3 cm are considered masses and are treated as malignancies until proven otherwise.

Generally, a pulmonary nodule must reach 1 cm in diameter before it can be identified on a chest radiograph. For a malignant nodule to reach this size, approximately 30 doublings would have occurred. The average doubling time for a tumor is 120 days (range 7-590 d). A lesion at this growth rate may be present for 10 years before discovery.

A solitary pulmonary nodule may be secondary to a wide differential of causes. However, greater than 95% are malignancies (most likely primary), granulomas (most likely infectious), or benign tumors (most likely hamartoma).

Frequency

United States

Solitary pulmonary nodules are one of the most common thoracic radiographic abnormalities. Approximately 150,000 cases are detected each year as an incidental finding, either on chest radiographs or thoracic CT scans.1 In lung cancer screening studies that enrolled people at high risk for lung cancer, the prevalence of solitary pulmonary nodules ranged from 8-51%.2
 
Approximately 40-50% of solitary pulmonary nodules are malignant. Gould et al reported after a review of the literature that most of these are adenocarcinoma (47%), followed by squamous cell carcinoma (22%); small cell lung cancer makes up only 4% of malignant solitary pulmonary nodules.3

Mortality/Morbidity

Most solitary pulmonary nodules are benign, but they may represent an early stage of lung cancer. Although lung cancer survival rates remain dismally low at 14% at 5 years, early lung cancer (ie, diagnosed when the primary tumor has a diameter <3 cm [stage 1A]) can be associated with a 5-year survival rate of 70-80%. Accordingly, the only chance for cure of early lung cancer manifesting as solitary pulmonary nodule is prompt diagnosis and management.

Age

Risk of malignancy increases with age. For individuals younger than 39 years, the risk is 3%. The risk increases to 15% for individuals aged 40-49 years, to 43% for persons aged 50-59 years, and to more than 50% for persons older than 60 years.

Clinical

History

Most patients with solitary pulmonary nodules are asymptomatic; the nodules are typically detected as an incidental finding. Approximately 20-30% of all bronchogenic carcinomas appear as solitary pulmonary nodules on initial radiographs. The following features are important when assessing whether the nodule is benign or malignant.

  • History of malignancy
  • History of smoking
  • Occupational risk factors for lung cancer: Exposure to asbestos, radon, nickel, chromium, vinyl chloride, and polycyclic hydrocarbons can lead to the development of a solitary pulmonary nodule.
  • Travel: Travel to areas with endemic mycosis (eg, histoplasmosis, coccidioidomycosis, blastomycosis) or to areas with a high prevalence of tuberculosis (TB) can lead to the development of a benign solitary pulmonary nodule.
  • History of TB or pulmonary mycosis

Causes

Bearing in mind that the major distinction that must be made is between neoplastic and inflammatory lesions, solitary pulmonary nodules may have the following causes:
  • Neoplastic (malignant or benign)
    • Bronchogenic carcinoma
      • Adenocarcinoma (including bronchoalveolar carcinoma)
      • Squamous cell carcinoma
      • Large cell lung carcinoma
      • Small cell lung cancer
    • Metastasis
    • Lymphoma
    • Carcinoid
    • Hamartoma
    • Connective-tissue and neural tumors - Fibroma, neurofibroma, blastoma, sarcoma
  • Inflammatory (infectious)
    • Granuloma - TB, histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis, nocardiosis
    • Lung abscess
    • Round pneumonia
    • Hydatid cyst
  • Inflammatory (noninfectious)
  • Congenital
  • Miscellaneous
    • Pulmonary infarct
    • Round atelectasis
    • Mucoid impaction
    • Progressive massive fibrosis

More on Solitary Pulmonary Nodule

Overview: Solitary Pulmonary Nodule
Differential Diagnoses & Workup: Solitary Pulmonary Nodule
Treatment & Medication: Solitary Pulmonary Nodule
Follow-up: Solitary Pulmonary Nodule
Multimedia: Solitary Pulmonary Nodule
References
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References

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Further Reading

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Keywords

solitary pulmonary nodule, SPN, early lung cancer, histoplasmosis, coccidioidomycosis, blastomycosis, pulmonary mycosis, tuberculosis, TB, bronchogenic carcinoma, nocardiosis, asbestos exposure, radon exposure, nickel exposure, chromium exposure, vinyl chloride exposure, polycyclic hydrocarbon exposure, chemical exposure, industrial exposure, bronchogenic cancer, bronchogenic malignancy, pulmonary mycosis, mycosis, lung nodule, malignant nodule, lung lesion, lung malignancy, neoplasm, primary neoplasm, lung neoplasm, granuloma, infectious granuloma, lung granuloma, benign lung lesion, hamartoma, lymphoma, carcinoid, fibroma, neurofibroma, blastoma, sarcoma, lung abscess, round pneumonia, hydatid cyst, rheumatoid arthritis, RA, Wegener granulomatosis, sarcoidosis, lipoid pneumonia, arteriovenous malformation, AVM, lung cyst, pulmonary infarct, round atelectasis, mucoid impaction, mucus impaction, progressive massive fibrosis

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Contributor Information and Disclosures

Author

Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Nader Kamangar, MD, FACP, FCCP, FAASM, 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.

Coauthor(s)

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.

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Sri R Navaratnam, MBBS, PhD, FRCPC, Assistant Professor, Department of Internal Medicine, Section of Hematology/Oncology, University of Manitoba; Consulting Medical Oncologist, Department of Hematology/Oncology, Cancer Care Manitoba
Disclosure: Nothing to disclose.

Medical Editor

Stephen P Peters, MD, PhD, Professor, Department of Medicine, Wake Forest University
Stephen P Peters, MD, PhD 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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

,, Kathy Roarty Placeholder
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint 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, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
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.

 
 
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