1. What is a solitary pulmonary nodule (SPN)?

SPN is a solitary focal lesion in the lung that measures 3 cm or less. A solitary
focal lesion that is greater than 3 cm is considered to be a mass, and most
masses are malignant. Approximately 150,000 SPNs are detected annually in
the United States, often incidentally on imaging. About 60% are benign, but
40% can be malignant. The goal of radiologic evaluation of SPN is to
differentiate noninvasively whether it is benign or malignant as accurately as
possible. SPN is the initial radiographic finding in 30% of patients with lung
cancer, and the prognosis depends partly on the stage at presentation.
2. List some causes of pulmonary nodules.
Primary lung carcinoma is the most common cause of SPN; pulmonary
granuloma is the second most common overall
cause; and pulmonary hamartoma the third most common cause. Table 65-1
provides a more complete list. Many other
entities can cause SPNs or multiple pulmonary nodules, including tumors
(e.g., metastatic disease), infections, vasculitis,
and inflammatory diseases (e.g., sarcoidosis, rheumatoid arthritis, or
inhalational lung disease). Be careful about a
confluence of shadows or overlap of normal vascular and osseous structures
that appears to represent a nodule.
Nipple shadows can also appear as nodules, but are usually seen at a similar
level bilaterally.
3. What is the general approach to the evaluation of SPN?
The initial step is to determine whether a visualized nodule on chest
radiography is truly a pulmonary nodule or a
pseudolesion that mimics a nodule (some of the causes of a pseudolesion are
listed in Table 65-1). If a nodule is
actually a pseudolesion associated with bone, such as a rib fracture, it would
have the same anatomic relationship to
its bone of origin on radiographs with multiple views, whereas a true
pulmonary nodule that overlaps with osseous

structures on one view would appear to move apart from these osseous
structures on other views. Radiopaque nipple
markers can be used to distinguish pseudolesions that are actually nipples
from true pulmonary nodules. When a true
SPN has been confirmed, a more detailed investigation begins.
4. What further diagnostic steps may be implemented in the work-up of
indeterminate
pulmonary nodules?
Thin-section unenhanced computed tomography (CT), CT nodule
densitometry, fluorodeoxyglucose (FDG) positron
emission tomography (PET), short-term follow-up chest radiography or CT,
and tissue sampling are some of the options
available for the work-up of indeterminate pulmonary nodules. The choice is
based on several factors, including the
pretest probability of malignancy, the morphologic features of the nodules,
and the patients clinical history and current
status. Thin-section unenhanced CT is useful for the identification of fat or
certain patterns of calcification within
a nodule that indicate benignancy.
5. What are some potential blind spots on chest radiography and CT when
trying
to detect pulmonary nodules?
On chest radiography, potential blind spots include the lung apices where the
clavicles and ribs overlap, the hila and
retrocardiac region where superimposed cardiovascular structures are located,
and within the lung bases below the
level of the anterior portions of the hemidiaphragms where abdominal soft
tissue overlaps.
On CT, potential blind spots include the central portions of the lungs (e.g.,
the hilar regions and the azygoesophageal
recess) and the endoluminal portions of the trachea and bronchi.
6. List some morphologic imaging features of nodules assessed on chest
radiography
and CT.
Shape
Size/volume and change over time
Margins

 Internal architecture
Presence of fat
Presence and pattern of calcification