Pocket Medicine

PULMONARYQ

SOLITARY PULMONARY NODULE

Principles

•  Definition: single, <3 cm, surrounded by normal lung, no LAN or pleural effusion

•  Often “incidentalomas,” esp with ↑ CT use, but may still be early, curable malignancy

Initial evaluation

•  History: h/o cancer, smoking, age (<30 y = 2% malignant, +15% each decade >30)

•  CT: size/shape, Ca2+, LAN, effusions, bony destruction, compare w/ old studies

Ø Ca → ↑ likelihood malignant; laminated → granuloma; “popcorn” → hamartoma

•  High-risk features for malignancy: ≥2.3 cm diameter, spiculated, >60 yo, >1 ppd current smoker, no prior smoking cessation (NEJM 2003;348:2535)

Diagnostic studies

•  PET: detects metab. activity of tumors, 97% Se & 78% Sp for malig. (esp. if >8 mm) also useful for surgical staging b/c may detect unsuspected mets (JAMA 2001;285:914) useful in deciding which lesions to bx vs. follow w/ serial CT (  J Thor Oncol 2006;1:71)

•  Transthoracic needle biopsy (TTNB): if tech. feasible, 97% will obtain definitive tissue dx (AJR 2005;185:1294); if noninformative or malignant → resect

•  Video-assisted thoracoscopic surgery (VATS): for percutaneously inaccessible lesions; highly sensitive and allows resection; has replaced thoracotomy

•  Transbronchial bx (TBB): most lesions too small to reliably sample w/o endobronchial U/S (Chest 2003;123:604); bronch w/ brushings low-yield unless invading bronchus; navigational bronchoscopy w/ 70% yield, ↑ sens w/ larger nodules (Chest 2012;142:385)

•  PPD, fungal serologies, ANCA

Management (for solid SPN >8 mm; if ≤8 mm, serial CT) (Chest 2013;143:840)

•  Low risk (<5%, see ref): serial CT (freq depending on risk); shared decision w/ Pt re: bx

•  Intermediate risk (5–60%): PET, if  → follow low-risk protocol; if  → high-risk protocol

•  High risk (and surgical candidate): TBB, TTNB, or VATS → lobectomy if malignant

•  Ground-glass nodules: longer f/u b/c even if malignant can be slow-growing and PET