A radiology and imaging approach to solitary pulmonary (lung) nodule (SPN)

1. Solitary Pulmonary Nodule
Dr. Bhavin Jankharia
Radiologist, Jankharia Imaging, Mumbai, India

2. Algorithm using a typical case

3. 52-years old lady went for a health check-up

4. Please identify the lesion

5. SPN
Lesion Detection
• Pickup - this is a variable factor depending on the
radiology’s experience
• Experience & Expertise
– The “Ten-Thousand” hours rule
• Overreading / underreading
• High kV - better rate of detection
• Digital radiograph - these allow manipulation on a
computer monitor and a higher rate of detection

6. She has a 2.2 cm sized nodule in the right mid-zone

7. Next Steps
• A – Do nothing - old granuloma
• B – Aggressive - suspected malignancy
• C – Give antibiotics or AKT
• D – Investigate further

8. Confirm intra pulmonary location

9. This lesion is intra-pulmonary – seen on both
frontal and lateral radiographs in the lung

10. This lesion is pleural – in the minor fissure and
ovoid and calcified and hence not significant

11. This lesion also pleural – probably an old calcified
hematoma and hence not an SPN

12. This patient had neurofibromatosis 1 and came
for a CT guided biopsy of a left upper lobe mass

13. Classic example of “hyposkilia” – the patient had
never been examined

14. This lady also came for a CT guided biopsy of a
left mid-zone lesion

15. Rib fracture callus

16. In our 52-years old lady, a CT scan show the lesion to
be in the right upper lobe – intra-pulmonary

17. Next Steps
• A – Do nothing - old granuloma
• B – Aggressive - suspected malignancy
• C – Give antibiotics or AKT

18. Is this benign or malignant?

19. Criteria for benignity
• A - Calcification
• B - Absence of enhancement
• C - No growth in 2 years

20. Completely calcified - benign Engulfed calcific focus by a malignant
lesion

21. April 06 June 08
A B C
Completely calcified and no growth in 2
years - benign

22. plain post-contrast
No enhancement whatsoever - benign

23. July
Our 52-years old lady

24. May July
She shows a significant increase in size
over 2 ½ months

25. Plain Post-contrast
Contrast-enhanced study shows
enhancement

26. Possible etiology
• A - Granuloma
• B - Malignancy
• C - Other

27. This does not show any criteria of
benignity and hence is of
indeterminate etiology

28. Next steps
• A - Trial of therapy
• B - CT guided biopsy
• C - Bronchoscopy guided biopsy
• D - Lobectomy

29. CT – guided biopsy

30. Tips during biopsy
• Biopsy not FNAC
• At least 5 cores
• Material for EGFR mutation studies

31. Gun-cannula technique – stylet in cannula and gun

32. Gun-cannula technique – stylet outside cannula and gun

33. Gun-cannula technique – gun in cannula – allowing multiple
biopsies to be obtained with a single puncture of the cannula

34. Foot pedal and in-room monitor allow accurate control along with
CT fluoroscopy

35. Diagnosis
Adenocarcinoma

36. Next steps
• A - Lobectomy
• B - PET/CT
• C - Chemotherapy
• D - Radiotherapy

37. PET/CT and Contrast-MRI of Brain for
Staging

38. Lung Cancer
Staging
• Nodes
• Metastases
• Local staging

39. A 52-year old with bronchogenic carcinoma – operable (T2N0M0)

40. A 68-year old with bronchogenic carcinoma – operable (N1M0)

41. A 57-year old with bronchogenic carcinoma – non-operable (N2M0)

42. A 52-year old doctor with bronchogenic carcinoma and solitary
focus of uptake in the left humeral head

43. A 52-year old doctor with bronchogenic carcinoma – nonoperable
(N0M1)

44. The fundamental idea when dealing
with a solitary pulmonary nodule >
8mm is to not miss malignancy

45. If a lesion has definite criteria for
benignity (no growth over 2 years,
diffuse calcification and/or no
enhancement whatsoever), then you
can forget about it

46. Else, the lesion should be assumed
to be malignant unless proved
otherwise and should be biopsied

47. SPN
PA radiograph
BENIGN
INDETERMINATE
Calcification
Old X-rays
Lesion external or extra-pulmonary
BENIGN INDETERMINATE
No change over 2 years CT scan / PET/CT
BENIGN
No enhancement or uptake INDETERMINATE
Calcification
BIOPSY

48. Sometimes, some lesions are
characteristic

50. Fungal Ball
Crescent sign in relation to the right upper lobe
SPN due to a fungal ball in a cavity

52. AVM
Nodule showing
curvilinear vessel
density on the lateral
radiograph (red arrow).
The CT shows the
typical appearance

53. Rounded Atelectasis
Mass of atelectasis due to previous pleural effusion (documented)
showing air bronchograms within and peripheral curving and
displacement of the bronchovascular bundles (red arrow)

54. Rounded Atelectasis
Mass of atelectasis due to previous pleural effusion (documented)
showing air bronchograms within and peripheral curving and
displacement of the bronchovascular bundles (red arrow)

55. Email: bhavin@jankharia.com
Twitter: @bhavinj
FB: www.facebook.com/bhavinjankharia