eMedicine Specialties > Radiology > Chest

Solitary Pulmonary Nodule

Author: Sanjay Manocha, MD, Consulting Staff, Respirology and Critical Care Medicine, Department of Medicine, Humber River Regional Hospital
Coauthor(s): 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; Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Contributor Information and Disclosures

Updated: Apr 30, 2009

Introduction

Background

A solitary pulmonary nodule (SPN) is defined as a single discrete pulmonary opacity that is surrounded by normal lung tissue and is not associated with adenopathy or atelectasis.

Solitary pulmonary nodule. Cavitating nodule seco...

Solitary pulmonary nodule. Cavitating nodule secondary to an abscess.

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Solitary pulmonary nodule. Cavitating nodule seco...

Solitary pulmonary nodule. Cavitating nodule secondary to an abscess.


Solitary pulmonary nodule. Neurilemoma - Lung win...

Solitary pulmonary nodule. Neurilemoma - Lung window view.

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Solitary pulmonary nodule. Neurilemoma - Lung win...

Solitary pulmonary nodule. Neurilemoma - Lung window view.


The finding of an SPN on a chest radiograph is a diagnostic dilemma often faced by many clinicians. The differential diagnosis may be broad, but implications rest on whether the lesion is benign or malignant.

Radiographically, a nodule is defined as a lesion smaller than 3 cm. Anything larger than 3 cm is termed a mass.

Pathophysiology

Pathophysiology of pulmonary nodules depends on etiology.

Frequency

United States

Solitary pulmonary nodules (SPNs) are fairly common. Screening studies in adults reveal SPNs in 1-2 per 1000 chest radiographs. In the United States, an estimated 150,000 SPNs are detected annually. Overall, incidence of malignancy ranges from 10-70%. The higher incidence is largely the result of a selection bias, depending on the population under study (eg, age, smoking status, referral pattern, location of the study).

Mortality/Morbidity

Prognosis depends on whether the lesion is benign or malignant and the stage of the lung cancer on presentation.

Following resection of a solitary bronchogenic carcinoma (stage IA), the 5-year survival rate is approximately 80-90%.

Race

No racial difference in the prevalence and incidence of malignant nodules has been described. Geographic variations exist in the incidence of benign lesions, especially infectious granulomas.

Sex

No difference in incidence exists between males and females.

Age

Solitary nodules can occur at all age levels. Early on, they usually are secondary to a benign lesion. The risk of malignancy increases with age (see Clinical Details).

Presentation

Most solitary pulmonary nodules (SPNs) are asymptomatic. The goal of investigating an SPN is to differentiate a benign lesion from a malignant lesion as soon and as accurately as possible.

Important features in the patient history include the following:

  • Age - Risk of malignancy increases with age
    • Risk of 3% at age 35-39 years
    • Risk of 15% at age 40-49 years
    • Risk of 43% at age 50-59 years
    • Risk of greater than 50% in patients older than 60 years
  • Smoking history
  • Prior history of malignancy
  • Travel history - Travel to areas with endemic mycosis (eg, histoplasmosis, coccidioidomycosis, blastomycosis) or a high prevalence of tuberculosis
  • Occupational risk factors for malignancy - Exposure to asbestos, radon, nickel, chromium, vinyl chloride, and polycyclic hydrocarbons
  • Previous history of tuberculosis or pulmonary mycosis

Preferred Examination

Chest radiograph usually is the initial examination. Most solitary pulmonary nodules (SPNs) are discovered as an incidental finding. With recent studies examining the use of low-dose CT chest scans as a screening tool for lung cancer, more smaller nodules will be detected that require evaluation. As more large-scale studies become available, positron emission tomography (PET) and single-photon emission computed tomography (SPECT) will become important imaging tools in evaluating an SPN.1,2

Limitations of Techniques

Chest radiographs demonstrate poorer resolution than chest CT scans in determining degree of calcification or size. Visualization of some nodules may be difficult because of superimposed structures.

Chest CT scans are limited by expense and the need for intravenous contrast, which carries a risk of an adverse reaction. CT is not as available and portable as chest radiographs.

Nuclear medicine imaging (PET and SPECT scan) is considerably more expensive than a chest CT scan or MRI study. PET and SPECT are variably available.

Differential Diagnoses

Aspergillosis, Thoracic
Lung, Arteriovenous Malformation
Blastomycosis, Thoracic
Lung, Carcinoid
Bronchiolitis Obliterans Organizing Pneumonia
Lung, Metastases
Bronchogenic Cyst
Lung, Nontuberculous Mycobacterial Infections
Coccidioidomycosis, Thoracic
Lung, Postprimary Tuberculosis
Histoplasmosis, Thoracic
Lung, Primary Tuberculosis
Lung Cancer, Non-Small Cell
Pancoast Tumor
Lung Cancer, Small Cell
Sarcoidosis, Thoracic

Other Problems to Be Considered

Malignant lesions

Bronchogenic carcinoma - Small cell, large cell, adenocarcinoma, and squamous
Carcinoids
Solitary metastases

Benign lesions

Benign neoplasms - Hamartomas, lipomas, and fibromas
Vascular lesions - Arteriovenous malformation
Infectious granulomas - Tuberculosis, atypical mycobacterial infection, histoplasmosis, coccidioidomycosis, and blastomycosis
Other infections - Aspergilloma, ascaris, dirofilariasis, echinococcal cyst, and bacterial abscess
Noninfectious granulomas - Rheumatoid arthritis, Wegener granulomatosis, and sarcoidosis
Developmental lesions - Bronchogenic cyst
Others conditions - Hematoma, bronchiolitis obliterans-organizing pneumonia, pseudotumor, pulmonary infarction, amyloidoma, rounded atelectasis, and mucoid impaction

More on Solitary Pulmonary Nodule

Overview: Solitary Pulmonary Nodule
Imaging: Solitary Pulmonary Nodule
Follow-up: Solitary Pulmonary Nodule
Multimedia: Solitary Pulmonary Nodule
References
Further Reading
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References

  1. Lee HY, Han J, Lee KS, Koo JH, Jeong SY, Kim BT, et al. Lung adenocarcinoma as a solitary pulmonary nodule: Prognostic determinants of CT, PET, and histopathologic findings. Lung Cancer. Mar 17 2009;[Medline].

  2. Lee HY, Lee KS, Han J, Kim BT, Cho YS, Shim YM, et al. Mucinous versus nonmucinous solitary pulmonary nodular bronchioloalveolar carcinoma: CT and FDG PET findings and pathologic comparisons. Lung Cancer. Dec 26 2008;[Medline].

  3. Lee HY, Goo JM, Lee HJ, Lee CH, Park CM, Park EA, et al. Usefulness of concurrent reading using thin-section and thick-section CT images in subcentimetre solitary pulmonary nodules. Clin Radiol. Feb 2009;64(2):127-32. [Medline].

  4. Nakagawa N, Tanino Y, Inokoshi Y, Sato S, Ishii T, Saito K, et al. [Solitary pulmonary nodule due to Mycobacterium intracellulare showing intense uptake on 18F-fluorodeoxyglucose-positron emission tomography]. Nihon Kokyuki Gakkai Zasshi. Feb 2009;47(2):122-7. [Medline].

  5. Stamatelopoulos A, Kadjianis F. Patient management with a solitary pulmonary nodule. J BUON. Oct-Dec 2008;13(4):479-85. [Medline].

  6. Bonetti A, Aubert JD. [The solitary pulmonary nodule]. Rev Med Suisse. Nov 19 2008;4(180):2506-10. [Medline].

  7. Itoh T, Kobayashi D, Rensha K, Minami K. [A case of sarcoidosis presenting as a solitary pulmonary nodule]. Nihon Kokyuki Gakkai Zasshi. Dec 2008;46(12):992-6. [Medline].

  8. Awai K, Murao K, Ozawa A, et al. Pulmonary nodules at chest CT: effect of computer-aided diagnosis on radiologists' detection performance. Radiology. Feb 2004;230(2):347-52. [Medline].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. Gould MK, Maclean CC, Kuschner WG, et al. 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. Jain P, Kathawalla SA, Arroliga AC. Managing solitary pulmonary nodules. Cleve Clin J Med. Jun 1998;65(6):315-26. [Medline].

  15. Klein JS, Zarka MA. Transthoracic needle biopsy. Radiol Clin North Am. Mar 2000;38(2):235-66, vii. [Medline].

  16. 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].

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

  18. 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].

  19. Poulos A. CT and nodules revisited. Postgrad Med. Dec 2003;114(6):8; author reply 8. [Medline].

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

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

  22. Swensen SJ, Silverstein MD, Ilstrup DM, et al. 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].

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Keywords

solitary pulmonary nodule, SPN, coin lesion, discrete pulmonary opacity, pulmonary mass, malignancy, lung cancer, solitary bronchogenic carcinoma, smoking, tobacco, cigarettes, mycosis, histoplasmosis, coccidioidomycosis, blastomycosis, tuberculosis, TB

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Contributor Information and Disclosures

Author

Sanjay Manocha, MD, Consulting Staff, Respirology and Critical Care Medicine, Department of Medicine, Humber River Regional Hospital
Sanjay Manocha, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Bruce Maycher, MD is a member of the following medical societies: American Roentgen Ray Society, Canadian Medical Association, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Medical Editor

Kitt Shaffer, MD, PhD, Director of Undergraduate Medical Education, Associate Professor, Department of Radiology, Cambridge Health Alliance
Kitt Shaffer, MD, PhD is a member of the following medical societies: American Roentgen Ray Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

W Richard Webb, MD, Professor, Department of Radiology, University of California at San Francisco
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Barry H Gross, MD, Professor, Department of Radiology, University of Michigan Medical School; Professor, University of Michigan Cancer Center
Barry H Gross, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Michigan State Medical Society, Physicians for Social Responsibility, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

 
 
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