The problem of solitary pulmonary nodule

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the lecture approaches the problem of solitary pulmonary nodule in terms of variable imaging findings,differential diagnosis and algorithm of follow up .

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  • 1. The problem of Solitarypulmonary nodule Dr/Ahmed A. BahnassyConsultant radiologist (MBCHB-MD-FRCR (London UK

2. DD of Solitary pulmonary nodule 3. SPN Ii is defined as a focal opacity ,visible on chestradiograph or CT ,with the following criteria :1.Relatively well defined .2.Surrounded-at least partially - by lung .3.Roughly spherical in shape.4.3 cm or less in diameter (more than 3 cm istermed mass ) 4. Clinical evaluation Hx of smoking. Age over 40. Occupational exposure. Lung fibrosis. COPD. Family Hx of Lung cancer. Travel History TB skin test. Other diseases (Rheumatoid arthritis ) Malignancy .(solitary metastasis or increased likelihood of 1rybronchogenic Ca for H & N breast ,bile ducts ,oes. ,cervix,bladder ,prostate ,etc up to 3 folds ) 5. Radiographic evaluation Morphological Characteristics. Density. Growth rate . 6. I-Morphological Characteristics Size : Diameter Malignancy The likelihood ofratemalignancy is directly 1cm> 35%related to size reachingmore than 85 % for SPNmore than 2 cm . cm 1-2 50% cm 2-3 80% 7. Location : 2/3 of lung cancers occur in upper lobes. 60% seen in lung periphery .Only 10 % seen in medial third .Mets tend to be subpleural or outer 1/3 oflung.2/3 of mets are in lower lobes. 8. Edge Appearance :90% of lesions with irregular or spiculated edgesare malignant.20% only of well defined lesions are malignant(e.g.: Mets or carcinoid tumor )Corona Maligna or radiata represent eitherdesmoplastic reaction around the tumor oractual invasion of surrounding lung commonwith BAC and adenocarcinoma 9. CarcinomaFocal scarringBrncioalveolar cell carcinoma 10. Pleural tail in adenocarcinomaPleural tag refers to linear density (fibrosis)extending to pleural surface . 11. Pleural tag in adenocarcinoma 12. GranulomaHamartoma.Metastasis 13. Benign lesion-smooth edges 14. Mets 15. Hamartoma 16. Halo sign Halo of ground glass opacity surrounding anodule .Commonly present in Leukemic patient withinvasive aspergillosis (represent hemorrhagicinfarction )Can occur with any other infections .Can be seen with BAC and adenocarcinoma(representing lepidic growth ) 17. Causes of Halo signInvasive aspegillosis.Wegener Granulomatosis.BAC.Kaposi sarcoma.Mets.TB, nocardiosis.CMV infectionPCPBOOP 18. Invasive aspergillosis 19. BAC 20. Shape :Lung Ca tends to be irregular , lobulated ornotched.Granuloma are rounded.Hamartoma and metastasis are round ,oval orlobulated.Scars , atelectasis may appear linear .AVM and mucous plugs are particular in shape 21. Air bronchogram and pseudocavitation. 22. Cavitation 23. Air crescent sign 24. Air-Fluid level 25. Satellite nodules ..GALAXY sign 26. Feeding vessel signShowing a vessel ending into and feeding a lesionAssociated with infarction ,AVM , metastasis ,septic emboli . 27. II-Density Ground Glass opacity 28. CalcificationCauses 29. Benign Vs malignant patterns of calcifications 30. Bull eye calcification 31. Target calcification -Histoplasmoma 32. POP corn calcification -hamartoma 33. Eccentric calcification in adenoCa 34. Water density 35. Fat density 36. Contrast enhancementHRCT Malignant looking Increase 40 HU (>15 ) mass post contrast. .typical ofmalignancy (77%accuracy) 37. Contrast opacificationAVMPulmonary vein varix.Pulmonary artery aneurysm 38. III-Growth Doubling time is the time required for a lesionto double its volume . 26% increase in nodule diameter is one doubling Doubling of diameter is 3 volume doublings. Range of doubling time of carcinomas is 1week to 16 months. Doubling time 200 days is likelyto be benign . No growth over 2 years most likely benign. 39. ?How to evaluate.See prior examinationsIf not availableSmall lesions follow up is at 3,6 months ,1 and 2.yearVery small lesions (3mm)..yearly follow up 40. SPECT & PET Scan additions Using FDG high activity in PET is associatedwith malignancy 41. .Biopsy taking FOB =fiber opticbronchoscopy..for central lesions. TNB =Trans thoracic needlebiopsy ..For peripheral lesions. 42. Strategy for nodule evaluation