Solitary Pulmonary Nodule 

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

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. See the images below.

A 1.5-cm coin lesion in the left upper lobe in a pA 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 abMediastinal windows of the patient in the image above.

Patients with solitary pulmonary nodules are usually asymptomatic; however, solitary pulmonary nodules pose a challenge to both clinicians 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.

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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).

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Epidemiology

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.

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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.

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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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