Solitary pulmonary nodules are usually incidental findings in chest x-ray photographs. Soft shadows not pulmonary origin may come through the nipples, warts or lump of skin and bone disorders materialize and are often mistaken for a lung nodule on the radiograph.
A solitary pulmonary nodule is defined as a single oven <3 cm in diameter, which is completely surrounded by lung parenchyma (z. B. not directly hilum, mediastinum or pleural borders) and is not accompanied by atelectasis or a pleural effusion. The examination of a mediastinal mass is discussed elsewhere. Solitary pulmonary nodules are usually incidental findings in chest x-ray photographs. Soft shadows not pulmonary origin may come through the nipples, warts or lump of skin and bone disorders materialize and are often mistaken for a lung nodule on the radiograph. Etiology Although cancer is the main reason usually solitary pulmonary nodules have many causes (see Table: Causes of solitary pulmonary nodules). Of these, the most common vary by age and risk factors, but usually are granulomas Pneumonia Bronchogenic cysts causes of solitary pulmonary nodules cause examples Malignant causes * Primary lung adenocarcinoma Small cell carcinoma Metastatic tumor breast cancer melanoma colon cancer head and neck cancer, renal carcinoma testicular cancer Sa rkom non-malignant causes autoimmune diseases granulomatosis with polyangiitis Atypical rheumatoid nodules Benign tumors fibroma lipoma hamartoma granulomatous infection mycobacterial infection blastomycosis coccidioidomycosis cryptococcosis histoplasmosis TB infection Askariasis Aspergilloma Bacterial abscess Dirofilariasis (dog heartworm) Echin ococcus cyst Pneumocystis jirovecii (Pulmonary vascular anomalies) Cavernous angioma hemangioma Pulmonary arteriovenous malformation Pulmonary telangiectasis Other amyloidosis Bronchialzyste hematoma Intrapulmonary lymph nodes Encapsulated liquid storage Mucoid Rounded atelectasis * The probability of malignant causes increases with age. Review The primary study objective is to diagnose cancer and active infections. History, the history may provide information that may indicate and include current or of past cigarette smoking Earlier cancer or autoimmune disease Occupational risk factors for cancer (eg. As exposure to asbestos, vinyl chloride, radon) travel or live in malignant and non-malignant causes of a solitary pulmonary oven (in areas n are endemic mycoses or a high prevalence of TB risk factors for opportunistic infections (eg., HIV, immune deficiency) increase Advanced age, smoking and earlier cancers all of developing the probability of cancer and) together with the diameter of the nodule to determine likelihood ratios for cancer (see table: assessment of cancer probability of a solitary pulmonary nodule) .Körperliche examination a thorough physical examiner ung may clues to the etiology (eg. B. nodular changes or skin lesions that may indicate cancer) provide a lung nodule, but the cause is not clear klären.Tests The aim of the initial diagnosis is to assess the malignant potential of solitary pulmonary nodule. The first step is a review of the summary record, then then is usually a CT. Radiological features help to define the malignant potential of a solitary pulmonary nodule: The growth rate is, if any, determined by comparisons with previous X-ray or CT images. A nodule showing no growth in ? 2 years is assessed as benign. Has the volume but doubled within 21 to 400 days, it is malignant likely. Small knots (<1 cm) should at 3 months and 6 months and then annually 2 years be controlled. Calcifications are an indication of a benign etiology if they are centrally located mainly (tuberculoma, histoplasmosis), concentric (healed histoplasmosis) or popcorn-like (hamartoma) are. Edge boundaries that jagged or irregular are (curved) suggest more attention to cancer. Diameter <1.5 cm suggests a benign etiology, diameter> 5.3 cm are strongly suspected of being carcinogenic. However, lung abscess, granulomatosis with polyangiitis and include hydatid cyst of the non-malignant exceptions. These characteristics are sometimes assessed on the chest x-ray image, however, usually a CT is needed. In addition, a CT also allows a better delineation of pulmonary pleural opacities. With respect to cancer diagnostics, the conventional CT has a sensitivity of 70% and a specificity of 60%. (.. Editor’s note .: Thanks to the development of the multi-row spiral CT technique is the sensitivity with appropriate reconstruction of the layers in the meantime, however, much higher.) Clinical Calculator: malignancy of solitary pulmonary nodules (prediction model by Cummings: Bayesian approach) assessment the cancer probability of a solitary pulmonary nodule I. It likelihood ratios are (LRS) * created for cancer using the following table: finding LR for cancer nodules in diameter (cm) <1.5 0.1 1.5-2.2 0.5 1.7 3.3-4.2 4.3 4.3 to 5.2 2.3-3.2 6.6 5, 3 to 6.0 29.4 patient age (years) ? 35 0.1 36-44 0.3 45-49 0.7 50-59 1.5 60-69 2.1 70-83 5.7 Positive smoking history Never smoked 0.15 Only pipe or cigar 0.3 ex-cigarette smoker 1.5 Current smoker or someone who has stopped in the last 9 years (average number of cigarettes / day) 1-9 0.3 10-20 1, 0 21-40 2 , 0 ? 41 3.9 up smoking (years) ? 3 1.4 4-6 1.0 7-12 0.5 13 ? 0.1 overall prevalence Clinical Background 0.7 Community surveys 0.1 II The LR is multiplied by nodal diameter, age of the patient, positive history of smoking and cancer prevalence in order to obtain an estimate of the chances of cancer in a solitary pulmonary nodule (OddsCA). OddsCA = LR size × LR-age × LR-smoking × LR chance In the example: OddsCA = (1.5 x 2.1 x 1.0 x 0.7) = 2.21: 1 IIII. Chances are converted into a probability for cancer: probability of cancer (PCA) = odds / CA / (1 + OddsCA) x 100 =% In the example: PCA (in%) = 2.21 / (1 + 2.21) x 100 = 69% * the LR is a measure of how predictive is the finding of a disease and is defined as the probability of the presence of the lesion in a patient with the disease divided by the probability of the presence of the lesion in a patient without this disease defined; d. . H, it is the ratio of true positives to false positives or sensitivity to 1 - specificity. The example is a 65 year old who smokes 20 cigarettes per day, and has a node of 2.0 cm. Adapted from Cummings SR, Lillington GA, Richard RJ: "Estimating the probability of malignancy in solitary pulmonary nodules." The Bayes theorem. The American Review of Respiratory Disease 134 (3): 449-452, 1986. PET imaging can help distinguish malignant and benign lumps from each other. A PET is mostly used to represent nodules that have a medium or high likelihood of cancer. The discovery of cancer, the PET has a sensitivity of> 90% and a specificity of about 78%. The PET activity is quantified by the standardized uptake value (SUV) (18) F-2-deoxy-2-fluoro-D-glucose (FDG). SUV> 2.5 indicates, cancer out while nodules with SUV <2.5 are more benign. However, both false-positive and false-negative results occur. False-negative results are likely if nodules are <8 mm. Metabolically inactive tumors lead to false-negative test results can occur false-positive results in various infectious and inflammatory diseases while. Cultures may be useful when the history of an infectious cause (eg. As TB, coccidioidomycosis) hndeutet as a possible diagnosis. Invasive testing capabilities include CT or ultrasound-guided transthoracic puncture Fiberoptic bronchoscopy surgical biopsy Although cancers can be diagnosed by biopsy, there is a definitive treatment in a resection and so should patients with a high probability of cancer with a resectable lesion surgical resection undergo. However, the bronchoskopisch- endobronchial ultrasound-guided mediastinal lymph node biopsy is increasingly being used and recommended by some experts as a less invasive method for the diagnosis and staging of lung cancer before nodes are surgically removed. A transthoracic puncture is best suited for peripheral lesions and is particularly useful when strong assumed infectious causes, because a transthoracic access, as opposed to the bronchoscopy, avoiding the possibility of contamination of the sample with organisms of the upper respiratory tract. The main disadvantage of transthoracic puncture is the risk of a pneumothorax, that is about 10%. The fiberoptic bronchoscopy allows "endobronchial washing", "brushing", percutaneous needle aspiration and transbronchial biopsy. The results are better for larger, centrally gelegeneren lesions, but very experienced surgeons who use specially developed thin-vision devices can successfully biopsy of peripheral lesions <1 cm in diameter perform. In cases where nodes by these less invasive methods are not achieved, an open surgical biopsy is required. Sometimes therapy operation Sometimes observation If only a small suspicion of cancer exists, the flock of very small (<1 cm), or the patient rejects a resection or inoperability present course of observations are appropriate. Checks should be made after 3 and 6 months and then annually for 2 years. Has the nodule does not increase during> 2 years, he’s probably benign. If cancer is suspected or benign diseases unlikely the nodule should be resected, unless the surgery is contraindicated because of poor lung function, severe concomitant diseases or of rejection by the patient.