Solitary pulmonary nodule vp.pptx

imaging

1. SOLITARY PULMONARY NODULE  Presenter:Dr.Vishwanath patil

2. DEFINITION: A solitary pulmonary nodule (SPN) is a round or oval opacity a. Smaller than 3 cm in diameter that is completely surrounded by pulmonary parenchyma. b. Not associated with lymphadenopathy. c. Not associated with atelectasis, or pneumonia.

3. D/D of SPN 1.INFECTIVE CAUSES: GRANULOMA MYCETOMA. ASPERGILLOMA. ECHINOCOCCUS/HYDATID CYST. FOCAL ROUND PNEUMONIA. LUNG ABSCESS.

4. D/D of SPN 2.INFLAMMATORY: A. RHEUMATOID NODULES. B. SARCOIDOSIS. C.WEGENERS GRANULOMATOSIS .

5. D/D of SPN 3. CONGENITAL: A. BRONCHOGENIC CYST B. CCAM C. INTRAPULMONARY LYMPH NODE D. SEQUESTRATION 4. AIRWAY AND INHALATIONAL DISEASE: A.MUCOID IMPACTION B. BRONCHIAL ATRESIA C. CYSTIC FIBROSIS D. PROGRESSIVE MASSIVE FIBROSIS E. LIPOID PNEUMONIA  

6. D/D of SPN 5.VASCULAR LESIONS: A. HEMATOMA B. INFARCTION C. PULMONARY ARTERY ANEURYSM D. PULMONARY VEIN VARIX E. ARTERIOVENOUS FISTULA F. SEPTIC EMBOLISM

7. D/D of SPN 6. Neoplasms BENIGN AND NEOPLASM LIKE CONDITIONS MALIGNANT A. HAMARTOMA.  A. CARCINOMA. B. ENDOMETRIOMA. B. LYMPHOMA. C. MESENCHYMAL TUMOR. C. LYMPHOPROLIFERATIVE DISEASES. D. SOLITARY METASTATIC NEOPLASM. E. BRONCHIAL CARCINOID. F. SARCOMA.

8. D/D of SPN SPURIOUS LESIONS ON CXR NIPPLE SHADOW • PLEURAL BASED LESIONS • CHEST WALL LESIONS • SKIN NODULES • ARTIFACTS DUE TO CLOTHING • SCREEN ARTIFACTS Benign granuloma and primary bronchogenic carcinomas account for 80% of cases of SPN.

9. IMAGING OF SPN 1.CHEST RADIOGRAPH. 2. CT SCAN. 3. MRI. 4. FDG-PET / SPECT.

10. CT: Benign versus malignant Size. Shape. Margin. Growth. Calcification. Air Bronchogram sign. Solid and Ground-glass components. Contrast enhancement.

11. CT: Benign versus malignant SIZE: 20-30mm-80% chance of malignancy.

12. CT: Benign versus malignant Shape: MALIGNANT : IRREGULAR/LOBULATED/NOTCHED Lobulation occurs in 25% of benign nodules . BENIGN : ROUND/OVAL/SMOOTH (SCARS/AREAS OF ATELECTASIS MAY APPEAR LINEAR OR ANGULAR).

13. CT: Benign versus malignant Shape: -Japanese screening studies showed that a polygonal shape and a three-dimensional ratio > 1.78 was a sign of benignity.   -The three-dimensional ratio is measured by obtaining the maximal transverse dimension and dividing it by the maximal vertical dimension.

14. CT: Benign versus malignant Margin Corona radiata sign  - highly associated with malignancy (figure) Lobulated or scalloped margins  - intermediate probability Smooth margins  - more likely benign unless metastatic in origin

15. CT: Benign versus malignant

16. CT: Benign versus malignant

17. CT: Benign versus malignant Growth Comparison with prior imaging studies is often the most useful procedure to determine the importance of the finding of a SPN. Stability Solid – 2 years. Subsolid – 3 years. Malignancy doubling time-20 to 400days Very rapid, or slow- less likely to be malignant.

18. CT: Benign versus malignant Calcification a.Diffuse , b.Central , c.Laminated or popcorn calcifications are benign patterns of calcification. These types of calcification are seen in granulomatous disease and hamartomas.

19. CT: Benign versus malignant

20. CT: Benign versus malignant

21. CT: Benign versus malignant Calcification a.Reticular b.punctate C.eccentric d.amorphous .

22. CT: Benign versus malignant

23. CT: Benign versus malignant Air Bronchogram sign Recent studies have showed that an air bronchogram is more commonly seen in malignant pulmonary nodules. It is most commonly seen in BAC ( bronchoalveolar cell carcinoma) and adenocarcinoma .

24. CT: Benign versus malignant Solid and Ground-glass components Another result from screening studies is that nodules containing a ground-glass component are more likely to be malignant . Partly solid lesions with ground-glass components had a malignancy rate of 63%. Nonsolid - only ground-glass lesions had a malignancy rate of 18%. Only solid lesions had a malignancy rate of only 7%.

25. CT: Benign versus malignant Contrast enhancement less than 15 HU has a very high predictive value for benignity (99%). After a baseline scan, 4 consecutive scans at 1 minute interval are performed. This applies only for nodules with the following selection criteria: Nodule > 5mm Relatively spherical Homogeneous, no necrosis, fat or calcification No motion or beam hardening artifacts

26. PET-CT: benign versus malignant PET-CT plays an increasingly important role in the evaluation of solitary nodules. When you perform PET-CT, you have to realize the following: PET has a very high sensitivity 95%, but a lesser specificity of only 81% PET is false positive in granulomatous disease PET is usually false negative in size With these specificity numbers, there will be false positives in about 20%, depending on the background prevalence of granulomatous disease. On the left a patient with an adenocarcinoma, that was not hypermetabolic on the PET, so it is a false negative PET.

27. The  Fleischner Society pulmonary nodule recommendations (2017)   Pertain to the follow-up and management of indeterminate pulmonary nodules detected incidentally on CT and are published by the  Fleischner Society. The guideline does not apply to lung cancer screening, patients younger than 35 years, or patients with a history of primary cancer or immunosuppression.

28. The  Fleischner Society pulmonary nodule recommendations

29. The  Fleischner Society pulmonary nodule recommendations

30. The  Fleischner Society pulmonary nodule recommendations

31. The  Fleischner Society pulmonary nodule recommendations

32. Thank you