RESP-Pulmonary Nodules – Flashcards
Unlock all answers in this set
Unlock answersquestion
What is the definition of a solitary pulmonary nodule?
answer
A lesion within and surrounded by pulmonary parenchyma.
question
What is the typical size of a solitary pulmonary nodule?
answer
Less than 3cm.
question
What is the prevalence of solitary pulmonary nodules?
answer
8-51% in populations at a high risk for lung cancer.
question
How are solitary pulmonary nodules most often detected?
answer
Often an incidental finding on a chest radiograph or CT scan.
question
What is the goal in the diagnosis of solitary pulmonary nodules?
answer
Identify and resect all malignant SPNs and avoid resection of all benign nodules that do not require therapy.
question
How effective are methods to achieve the goal of diagnosing solitary pulmonary nodules (2)?
answer
-Approaches that remove most malignant nodules result in frequent removal of benign nodules -Approaches that leave most benign nodules intact leave some malignant nodules unresected
question
Why is a more conservative approach to diagnosing solitary pulmonary nodules preferable (2)?
answer
-Patients who have had a stage 1A (T1N0M0) non-small cell lung cancer resected have up to 70-80 % 5-year survival rate but unresected lung cancer is fatal -The operative mortality rate is <1 % among patients with benign nodules or early stage lung cancer
question
List the different types of malignant primary bronchogenic neoplasms (5).
answer
-Adenocarcinoma -Squamous cell carcinoma -Small cell carcinoma -Large cell carcinoma -Pulmonary carcinoid
question
What is the commonality in clinical presentation shared by the malignant primary bronchogenic neoplasms?
answer
All types of primary lung cancer can present as a single pulmonary nodule (SPN).
question
Which malignant primary bronchogenic neoplasms present as a peripheral solitary pulmonary nodule (2)?
answer
Adenocarcinoma (50% of malignant SPNs) and large cell carcinoma present most commonly as a peripheral SPN.
question
Which malignant primary bronchogenic neoplasms present as a peripheral solitary pulmonary nodule (1)?
answer
Squamous cell carcinoma (20-25 % of malignant SPNs) presents more commonly as a central rather than a peripheral nodule.
question
Which malignant primary bronchogenic neoplasms have a more variable presentation (1)?
answer
Carcinoid tumors are usually centrally located endobronchial lesions, but about 20 % arise peripherally and present as a SPN.
question
How commonly do the other malignant primary bronchogenic neoplasms present as a solitary pulmonary nodule (2)?
answer
-Other malignant primary pulmonary neoplasms comprise <10 % of SPNs -Lymphomas can present as a SPN (rarely)
question
List the types of tumors that are commonly metastatic (8).
answer
-Breast -Head and neck -Melanoma -Kidney -Colon -Sarcoma -Germ cell tumor -Other
question
What is important to note about metastatic cancer in the lungs?
answer
Most metastatic cancers present as multiple pulmonary nodules.
question
Which extrapulmonary malignancies are most likely to produce a solitary pulmonary nodule due to metastasis (3)?
answer
-Malignant melanoma -Sarcomas -Carcinomas of the colon, breast, kidney, and testicle
question
How frequently do solitary pulmonary nodules detected on a chest radiograph in a patient with a history of extrathoracic malignancy turn out to be due to a metastasis?
answer
Approximately 25 % of SPNs.
question
List the types of benign neoplasms (3).
answer
-Hamartoma -Lipoma -Fibroma
question
List the types of vascular lesions that occur in the lungs (2).
answer
-Arteriovenous malformation -Pulmonary varix
question
What else can "popcorn calcifications" indicate?
answer
They may also represent calcifications in a malignant primary or metastatic tumor.
question
What does the presence of fat within a solitary pulmonary nodule indicate?
answer
It is a reliable sign of benignity.
question
List the benign fat-containing lesions (3).
answer
-Pulmonary hamartoma -Lipoid pneumonia -Lipoma
question
List the benign developmental conditions (1).
answer
Bronchogenic cyst.
question
List the benign inflammatory conditions (2).
answer
-Granulomatosis with polyangiitis (Wegener) -Rheumatoid nodule
question
List the infectious granulomatous inflammatory conditions (6).
answer
-Histoplasmosis -Coccidioidomycosis -Tuberculosis -Atypical mycobacterial infection -Cryptococcosis -Blastomycosis
question
How frequently do benign pulmonary nodules turn out to be granulomas?
answer
80% of pulmonary nodules.
question
What are the most common infectious granulomas of the lung (4)?
answer
-Endemic fungi -Mycobacteria -Nontuberculous -Pneumocystis jirovecii
question
Which infectious granulomas of the lung are caused by endemic fungi (2)?
answer
-Coccidioidomycosis -Histoplasmosis
question
Which mycobacterial infection results in the development of infectious granulomas and what are the two presentations of these granulomas?
answer
-Tuberculosis -Cavitary or calcified
question
What are the common missteps made in diagnosing nontuberculous infectious granulomas (2)?
answer
-Most often not recognized as a granuloma, if presents as a solitary peripheral nodule -Typically presumed to be a primary lung (adeno)carcinoma and gets resected
question
Describe the presentation of Pneumocystis jirovecii.
answer
Infection can present as a SPN and may cavitate.
question
List the other benign, infectious lesions that can occur in the lungs (6)
answer
-Bacterial abscess -Dirofilaria immitis -Echinococcal cyst -Ascariasis -Pneumocystis carinii -Aspergilloma
question
List the other benign conditions that can affect the lungs (7).
answer
-Amyloidoma -Rounded atelectasis -Intrapulmonary lymph nodes -Hematoma -Pulmonary infarct -Pseudotumor (loculated fluid) -Mucoid impaction
question
How do you determine whether the presence of multiple pulmonary nodules are due to a metastatic or benign condition (2)?
answer
-Multiple pulmonary nodules ?1 cm in diameter or detected by conventional chest radiography are most likely due to metastatic disease -Multiple pulmonary nodules <5 mm in diameter located next to the visceral pleura or an interlobar fissure, and detected incidentally, are more likely to be benign lesions, such as granulomata, scars, or intraparenchymal lymph nodes
question
Why is the patient's age important for evaluating a solitary pulmonary nodule?
answer
-The probability of a SPN being malignant rises with increasing patient age -SPN should not be automatically assumed to be benign in a young patient
question
How frequently is a solitary pulmonary nodule malignant in patients younger than 50? Older than 50?
answer
-Age 50: 65%
question
What are risk factors for a solitary pulmonary nodule being malignant (4)?
answer
-History of smoking -Industrial exposure (e.g asbestos, radiation) -Previously diagnosed malignancy -Family history
question
How does size factor into whether a solitary pulmonary nodule is malignant?
answer
Larger lesions are more likely to be malignant than smaller lesions.
question
Relate the frequency of malignancy in increasing sizes of nodules (4).
answer
-0.2 % for nodules 20 mm
question
What can the border of a solitary pulmonary nodule tell you about the likelihood of its malignancy (2)?
answer
-Malignant lesions have more irregular and spiculated borders -Benign lesions have a relatively smooth and discrete border
question
What can the calcification of a solitary pulmonary nodule tell you about the likelihood of its malignancy (2)?
answer
-The presence of calcification does not exclude malignancy. -An "eccentric" calcification (ie, asymmetric calcification) is suspicious for carcinoma arising in an old granuloma (ie, a "scar" carcinoma)
question
What are the patterns of calcification in solitary pulmonary nodules that suggest benignity (5)?
answer
-"Popcorn" -Laminated (concentric) -Central -Diffuse -Homogeneous
question
What can the density of a solitary pulmonary nodule tell you about the likelihood of its malignancy (3)?
answer
-Increased density of a SPN- probably benign -Ground glass and solid components ("subsolid"): 20-60% malignancy rate -Pure ground glass: adenocarcinoma, most often adenocarcinoma in-situ (AIS) or minimally invasive adenocarcinoma (MIA), aka broncho-alveolar carcinoma (BAC)
question
What can the growth rate of a solitary pulmonary nodule tell you about the likelihood of its malignancy (3)?
answer
-Malignant lesions double in volume in 20-400 days -Volume doubling of a nodule corresponds to an approximately 30% increase in diameter -SPN whose size has increased very rapidly or has remained stable for a long time is likely benign.
question
What are the steps for estimating the probability of cancer in a solitary pulmonary nodule (3)?
answer
-Find the appropriate values of likelihood ratios for overall prevalence of malignancy, diameter of the nodule, patient's age and smoking history -Multiply all of these likelihood ratios together -Convert these odds into a probability of cancer
question
What are the most common causes of a malignant solitary pulmonary nodule (3)?
answer
-Primary lung cancer -Carcinoid tumors -Lung metastases
question
What are the most common causes of a benign solitary pulmonary nodule (2)?
answer
-Infectious granulomas -Hamartomas
question
Which variables are used to determine whether there is a high, intermediate, or low probability that the nodule is malignant (3)?
answer
-Clinical features -Radiographic features -Occasionally quantitative models
question
What is the recommended management for solid and subsolid solitary pulmonary nodules that have clear evidence of growth on serial imaging studies?
answer
Surgical excision rather than following the lesion due to the high probability of malignancy.
question
When is no further diagnostic testing recommended for a solitary pulmonary nodule?
answer
SPNs that have been stable over two years and do NOT have a ground-glass (GG) morphologic appearance.
question
What is the recommended management for a solid nodule that has a high probability of being malignant (>60 %)?
answer
Surgical resection, it is the only intervention that is potentially curative.
question
What is the recommended management for a a nodule that has a low probability of being malignant (< 5 %)?
answer
Follow the nodule with serial CT scans rather than to surgically resect the nodule immediately.
question
What determines the frequency of serial CT scans when following a nodule?
answer
The frequency of CT scans varies according to the nodule's size and the patient's risk for lung cancer.
question
What is an alternative to serial CT scans when following a nodule?
answer
FDG-PET and sampling of the nodule are acceptable alternatives for patients who are uncomfortable with a strategy of observation.
question
When is evaluation of a solitary pulmonary nodule by FDG-PET preferred to CT?
answer
Nodules 8-10 mm or larger with an intermediate probability of being malignant (5-60 %) should be evaluated by FDG-PET, rather than followed with serial CT scans or surgically resected.
question
What is the protocol for solitary pulmonary nodules that are positive on FDG-PET?
answer
They should be excised.
question
What is the protocol for solitary pulmonary nodules that are negative on FDG-PET?
answer
They can be followed with serial CT scans.
question
What are the options for solitary pulmonary nodules that need to be biopsied when FDG-PET is unavailable (4)?
answer
-Percutaneous needle aspiration -Percutaneous needle biopsy -Thoracoscopy -Bronchoscopy
question
Why is follow-up with serial CT scans, rather than excision, sampling, or evaluation by FDG-PET is recommended for a nodule 8 mm or smaller with an intermediate probability of malignancy?
answer
The diagnostic yield of both sampling and FDG-PET is relatively poor for nodules <1 cm, and because of the risks associated with excision or sampling.
question
Does a subsolid nodule that has a purely ground glass (GG) appearance based on thin-slice (1-mm sections) chest CT and ?5 mm in diameter need further CT follow-up?
answer
No.
question
What is the recommended management of a solitary pulmonary nodule with a diameter >5 mm and a ground glass appearance unchanged at three months?
answer
It should be followed with serial CT scans, rather than resected immediately.
question
How frequently should CT scans be obtained for a solitary pulmonary nodule with a diameter >5 mm and a ground glass appearance unchanged at three months?
answer
12-month intervals for at least three years. After three years of stability, the need for further imaging is determined on a case by case basis.
question
What is the recommended management of a partly solid nodule that persists at three months and has a solid component <5 mm?
answer
Follow-up with serial CT scans at 12, 24, and 36 months, rather than immediate resection.
question
What is the recommended management of a partly solid nodule that persists at three months and has a solid component ?5 mm?
answer
Biopsy or excision of the nodule.
question
What is the purpose of an FDG-PET/CT scan for a solitary pulmonary nodule with an overall diameter of >8-10 mm?
answer
It may help with staging.
