Lung Nodule or Mass

Definitions

Lung Nodule

Lung Nodule is a Focal, Founded, <3 cm Radiographic Opacity Which May Be Solitary or Multiple (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- Solitary Pulmonary Nodule is Well-Circumscribed and Surrounded Completely by Aerated Lung
  - Absence of Associated Atelectasis, Hilar Enlargement, or Pleural Effusion
  - Typically Asymptomatic

Lung Mass

Lung Mass is a Lung Lesion Which is >3 cm in Diameter (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- Lung Mass >3 cm Should Be Presumed to Represent Bronchogenic Carcinoma (Lung Cancer) Until Proven Otherwise

Etiology

Developmental

Bronchogenic Cyst (see Bronchogenic Cyst)
Congenital Adenomatoid Malformation (see Congenital Adenomatoid Malformation)
Congenital Bronchial Atresia with Mucoid Impaction (see Congenital Bronchial Atresia with Mucoid Impaction)
Pulmonary Sequestration (see Pulmonary Sequestration)

Infection

Viral

Measles Virus (see Measles Virus)
Varicella-Zoster Virus (VZV) (see Varicella-Zoster Virus): miliary pattern

Bacterial

Actinomycosis (see Actinomycosis)
Legionellosis (see Legionellosis)
- Epidemiology: cases have been reported in patients with hematologic malignancies or prior hematopoietic stem cell transplant
- Clinical: indolent clinical course, mimicking that of fungal infection
Lung Abscess (see Lung Abscess)
Melioidosis (see Melioidosis)
Mycobacterium Avium Complex (MAC) (see Mycobacterium Avium Complex)
Nocardiosis (see Nocardiosis)
Rhodococcus Equi (see Rhodococcus Equi): nodular infiltrate, which may cavitate
Septic Embolism (see Septic Embolism)
Tuberculosis (see Tuberculosis): miliary or nodular pattern
Tularemia (see Tularemia)
- Pneumonic Tularemia: nodular infiltrates may occur in some cases

Fungal

Aspergilloma (see Aspergilloma)
Blastomycosis (see Blastomycosis)
Coccidioidomycosis (see Coccidioidomycosis)
Cryptococcosis (see Cryptococcosis)
Fusarium (see Fusarium)
- Clinical: may present as pneumonia, cavitary lesions, or lung nodules (with/without a halo sign)
Histoplasmosis (see Histoplasmosis)
Mucormycosis (see Mucormycosis)
Pneumocystis Jirovecii (see Pneumocystis Jirovecii)
Scedosporiosis (see Scedosporiosis)
Sporotrichosis (see Sporotrichosis)

Parasitic

Dirofilariasis (see Dirofilariasis)
Echinococcosis (see Echinococcosis)
Paragonimiasis (see Paragonimiasis)

Neoplasm

Lung Tumors

Adenoid Cystic Carcinoma (see Adenoid Cystic Carcinoma)
Benign Clear Cell Tumor (see Benign Clear Cell Tumor)
Blastoma (see Blastoma)
Bronchial Adenoma (see Bronchial Adenoma)
Bronchial Carcinoid (see Bronchial Carcinoid)
Bronchial Cystadenoma (see Bronchial Cystadenoma)
Carcinosarcoma (see Carcinosarcoma)
Chemodectoma (see Chemodectoma)
Chondroma (see Chondroma)
Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) (see Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia)
- Diagnosis
  - High-Resolution Chest CT (see High-Resolution Chest Computed Tomography): nodules and/or ground-glass infiltrates (or bronchiectasis in some cases)
  - Lung Biopsy (see Lung Biopsy): usually required for diagnosis
- Clinical: may present with cough, dyspnea, and/or wheezing
Endometrioma (see Endometrioma)
Fibroma (see Fibroma)
Fibrous Histiocytoma or Xanthoma (see Fibrous Histiocytoma or Xanthoma)
Glomus Tumor (see Glomus Tumor)
Granular Cell Myoblastoma (see Granular Cell Myoblastoma)
Hamartoma (see Hamartoma)
Hemangioma (see Hemangioma)
Hyalinizing Granuloma (see Hyalinizing Granuloma)
Leiomyoma (see Leiomyoma)
Lipoma (see Lipoma)
Lung Cancer (see Lung Cancer)
- Bronchioloalveolar Carcinoma (BAC) (see Lung Cancer)
Meningioma (see Meningioma)
Mucoid Pseudotumor (see Mucoid Pseudotumor)
Multiple Laryngeal Papillomatosis (see Multiple Laryngeal Papillomatosis)
Myxoma (see Myxoma)
Neurofibroma (see Neurofibroma and Neurofibromatosis)
Plasma Cell Granuloma (see Plasma Cell Granuloma)
Primary Pulmonary Hodgkin’s Disease (see Primary Pulmonary Hodgkins Disease)
Primary Pulmonary Lymphoma (see Primary Pulmonary Lymphoma)
Primary Pulmonary Melanoma (see Primary Pulmonary Melanoma)
Primary Pulmonary Plasmacytoma (see Primary Pulmonary Plasmacytoma)
Primary Pulmonary Sarcoma (see Primary Pulmonary Sarcoma)
Primary Pulmonary Waldenstrom’s Macroglobulinemia (see Primary Pulmonary Waldenstroms Macroglobulinemia)
Pseudolymphoma (see Pseudolymphoma)
Pulmonary Tumorlet (see Pulmonary Tumorlet)
Schwannoma (see Schwannoma)
Sclerosing Hemangioma (see Sclerosing Hemangioma)
Teratoma (see Teratoma)

Metastases to Lung

Benign Metastasizing Leiomyoma (see Benign Metastasizing Leiomyoma)
Breast Cancer (see Breast Cancer): may cavitate
Cervical Cancer (see Cervical Cancer)
Cholangiocarcinoma (see Cholangiocarcinoma)
Choriocarcinoma (see Choriocarcinoma)
Colorectal Cancer (see Colorectal Cancer): may cavitate
Endometrioma (see Endometrioma)
Esophageal Cancer (see Esophageal Cancer)
Gastric Cancer (see Gastric Cancer)
Germ Cell Tumor (see Germ Cell Tumor)
Head and Neck Cancer (see Head and Neck Cancer)
Hepatocellular Carcinoma (see Hepatocellular Carcinoma)
Hodgkin’s Disease (see Hodgkins Disease)
Laryngeal Cancer (see Laryngeal Cancer)
Leukemic Infiltration (see Leukemic Infiltration)
Lymphoma (see Lymphoma)
Lymphomatoid Granulomatosis (see Lymphomatoid Granulomatosis)
Melanoma (see Melanoma)
Multiple Myeloma (see Multiple Myeloma)
Neuroblastoma (see Neuroblastoma)
Neurofibroma (see Neurofibroma and Neurofibromatosis)
Ovarian Cancer (see Ovarian Cancer)
Pancreatic Cancer (see Pancreatic Cancer)
Plasmacytoma (see Plasmacytoma)
Prostate Cancer (see Prostate Cancer)
Renal Cell Carcinoma (see Renal Cancer)
Sarcoma
- Chondrosarcoma (see Chondrosarcoma)
- Ewing Sarcoma (see Ewing Sarcoma)
- Kaposi Sarcoma (see Kaposi Sarcoma)
- Leiomyosarcoma (see Leiomyosarcoma): may cavitate
- Liposarcoma (see Liposarcoma)
- Osteosarcoma (see Osteosarcoma,)
- Rhabdomyosarcoma (see Rhabdomyosarcoma)
Testicular Cancer (see Testicular Cancer)
Thyroid Cancer (see Thyroid Cancer)
Urothelial Cell Carcinoma (Transitional Cell Carcinoma) (see Urothelial Cell Carcinoma)
- Bladder Cancer (see Bladder Cancer)
Uterine Cancer (see Uterine Cancer)
Waldenstrom’s Macroglobulinemia (see Waldenstroms Macroglobulinemia)
Wilm’s Tumor (see Wilms Tumor)

Rheumatologic

Behcet’s Disease (see Behcets Disease)
Churg-Strauss Syndrome (see Churg-Strauss Syndrome)
Giant Cell/Temporal Arteritis (see Temporal Arteritis)
Rheumatoid Arthritis (RA) (see Rheumatoid Arthritis)
Wegener’s Granulomatosis (see Wegeners Granulomatosis)

Drug/Toxin/Exposure

All-Trans Retinoic Acid (ATRA) (see All-Trans Retinoic Acid)
Amiodarone (see Amiodarone)
Bacillus Calmette-Guerin (BCG) (see Bacillus Calmette-Guerin)
Bleomycin (see Bleomycin)
Carbamazepine (see Carbamazepine)
Chlorambucil (see Chlorambucil)
Chronic Berylliosis (see Beryllium)
Coal Worker’s Pneumoconiosis (see Coal Worker’s Pneumoconiosis)
Crack Cocaine (see Cocaine)
Cyclophosphamide (see Cyclophosphamide)
Fludarabine (see Fludarabine)
Foreign Body Granulomatosis (see Foreign Body Granulomatosis)
Gold (see Gold)
Interferon (see Interferon)
Lipoid Pneumonia (see Lipoid Pneumonia)
Methotrexate (see Methotrexate)
Minocycline (see Minocycline)
Mitomycin (see Mitomycin)
Nitrofurantoin (see Nitrofurantoin)
Nitrogen Dioxide (see Nitrogen Dioxide)
Paraffinoma (see Paraffinoma)
Phenytoin (Dilantin) (see Phenytoin)
Propylthiouracil (PTU) (see Propylthiouracil)
Silicosis (see Silicosis)
Ticlopidine (see Ticlopidine)
Vinblastine (see Vinblastine)

Other

Acute Pulmonary Embolism (see Acute Pulmonary Embolism)
Amyloidosis (see Amyloidosis)
Bronchocentric Granulomatosis (see Bronchocentric Granulomatosis)
Hereditary Hemorrhagic Telangiectasia (see Hereditary Hemorrhagic Telangiectasia)
Langerhans Cell Histiocytosis (see Langerhans Cell Histiocytosis)
Metastatic Calcification (see Metastatic Calcification)
Mucoid Impaction (see Mucoid Impaction)
Lymphangioleiomyomatosis (LAM) (see Lymphangioleiomyomatosis): complex pulmonary masses may occur in patients with have been treated with pleurodesis for recurrent pneumothorax [MEDLINE]
Pseudotumor (see Pseudotumor)
Pulmonary Arteriovenous Malformation (AVM) (see Pulmonary Arteriovenous Malformation])
Pulmonary Artery Pseudoaneurysm (see Pulmonary Artery Pseudoaneurysm)
Pulmonary Hematoma (see Pulmonary Hematoma
Pulmonary Vein Varicosity (see Pulmonary Vein Varicosity)
Radiation (see Radiation Pneumonitis and Fibrosis)
Rounded Atelectasis (see Rounded Atelectasis)
Sarcoidosis (see Sarcoidosis)

Diagnosis

Evaluation of Pulmonary Nodules

Recommendations-General (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- In Patient with Indeterminate Pulmonary Nodule, Prior Imaging Studies Should Be Reviewed (Grade 1C Recommendation)
- In Patient with Indeterminate Pulmonary Nodule on CXR, Chest CT (Preferably with Thin Sections Through the Nodule) is Recommended for Evaluation (Grade 1C Recommendation)
- With Solid, Indeterminate Nodule that Has Been Stable for at Least 2 Years, No Additional Diagnostic Evaluation is Recommended (Grade 2C Recommendation)
Recommendations-Solid Nodules >8 mm (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- Pretest Probability Should Be Estimated Qualitatively Using Clinical Judgment or Quantitatively Using a Validated Model (Grade 2C Recommendation)
- With Solid, Indeterminate >8 mm Nodule and Low-Moderate Pretest Probability of Malignancy (5-65%), PET Scanning is Recommended to Characterize the Nodule (Grade 2C Recommendation)
- With Solid, Indeterminate >8 mm Nodule and Pretest Probability of Malignancy (>65%), PET Scan is Not Recommended to Characterize the Nodule (Grade 2C Recommendation)
  - However, PET Scan May Be Indicated for Pre-Treatment Staging When Malignancy is Strongly Suspected or Confirmed
- With Solid, Indeterminate >8 mm Nodule, Serial Chest CT Surveillance is Recommended Under the Following Circumstances (Grade 2C Recommendation): serial CT scans should be performed at 3, 6, 9, 12, 18, and 24 mo using thin-sections and non-contrast, low-dose CT technique (preferably with computer-assisted measurements of area/volume/mass to facilitate early detection of nodule growth) (Grade 2C Recommendation)
  - Clinical Probability of Malignancy is Very Low (<5%)
  - Clinical Probability of Malignancy is Low (<30-40%) and Functional Tests are Negative (PET-Negative, Lack of Enhancement of >15 Hounsfield Units on Dynamic Contrast CT) -> Resulting in a Very Low Post-Test Probability of Malignancy
  - Non-Diagnostic Needle Biopsy and PET-Negative
  - When Informed Patient Prefers this Non-Aggressive Approach
- With Solid, Indeterminate >8 mm Nodule with Clear Evidence of Malignant Growth on Serial Imaging, Non-Surgical Biopsy or Surgical Resection is Recommended (Grade 1C Recommendation)
- With Solid, Indeterminate >8 mm Nodule, Non-Surgical Biopsy (by an Appropriate Technique, Given Nodule Location and Size) is Recommended for the Following Indications (Grade 2C Recommendation)
  - Clinical Pretest Probability and Findings on Imaging Tests are Discordant
  - Low-Moderate Probability of Malignancy (10-60%)
  - When a Benign Diagnosis Requiring Specific Medical Treatment is Suspected
  - When an Informed Patient Desires Proof of Malignancy Prior to Surgery (Especially When the Risk of Surgical Complications is High)
- With Solid, Indeterminate >8 mm Nodule with Plan for Surgical Diagnosis, Thoracoscopy with Diagnostic Wedge Resection is Recommended (Grade 1C Recommendation)
Recommendations-Solid Nodules ≤8 mm (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- With Solid ≤8 mm Nodule and No Risk Factors for Lung Cancer, Frequency/Duration of Serial Chest CT Surveillance Should Be Chosen Based on Size of the Nodule (Grade 2C Recommendation): with thin sections and non-contrast, low-dose CT technique
  - Nodule ≤4 mm: no need for follow-up imaging, but patient should be informed of risk/benefits of this approach
  - Nodule ≤4 mm: repeat imaging at 12 mo
  - Nodule 6-8 mm: repeat imaging between 6-12 mo and again between 18-24 mo (if unchanged)
  - Multiple Small Solid Nodules: frequency/duration of follow-up should be determined by the size of the largest nodule
- With Solid ≤8 mm Nodule and One or More Risk Factors for Lung Cancer, Frequency/Duration of Serial Chest CT Surveillance Should Be Chosen Based on Size of the Nodule (Grade 2C Recommendation): with thin sections and non-contrast, low-dose CT technique
  - Nodule ≤4 mm: repeat imaging at 12 mo
  - Nodule ≤4 mm: repeat imaging between 6-12 mo and again between 18-24 mo
  - Nodule 6-8 mm: repeat imaging between 3-6 mo, again between 9-12 mo, and again at 24 mo
  - Multiple Small Solid Nodules: frequency/duration of follow-up should be determined by the size of the largest nodule
Recommendations-Non-Solid (Pure Ground Glass) Nodule (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- With Non-Solid, (Pure Ground Glass) ≤5 mm Nodule, No Further Evaluation is Recommended (Grade 2C Recommendation)
- With Non-Solid, (Pure Ground Glass) >5 mm Nodule, Annual Surveillance for at Least 3 Years is Recommended (Grade 2C Recommendation): thin sections and non-contrast, low-dose CT technique
  - Non-Solid Nodules Which Grow or Develop a Solid Component are Often Malignant
- With Non-Solid, (Pure Ground Glass) >10 mm Nodule , Repeat Imaging at 3 mo is Probably Indicated: non-surgical biopsy and/or surgical resection may be required for nodules which persist
Recommendations-Part-Solid (>50% Ground Glass) Nodule (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- With Part-Solid (>50% Ground Glass) ≤8 mm Nodule, Repeat Imaging at 3, 12, and 24 mo (Followed by Annual Surveillance for 1-3 yrs) is Recommended (Grade 2C Recommendation): thin sections and non-contrast, low-dose CT technique
  - Part-Solid Nodules Which Grow or Develop a Solid Component are Often Malignant
- With Part-Solid (>50% Ground Glass) >8 mm Nodule, Repeat Imaging at 3 mo is Recommended (Grade 2C Recommendation): PET scan, as well as non-surgical biopsy and/or surgical resection may be required for nodules which persist
  - PET San Should Not Be Used to Evaluate Nodules with a Solid Component Measuring ≤8 mm
- With Part-Solid (>50% Ground Glass) >15 mm Nodule Should Proceed Directly to PET Scan, Non-Surgical Biopsy, and/or Surgical Resection
Recommendations-Multiple Nodules (American College of Chest Physicians Lung Cancer Guidelines; Chest, 2013) [MEDLINE]
- With a Dominant Nodule and ≥1 Additional Nodules, Each Nodule Should Be Evaluated Individually and Curative Treatment Not Be Denied Unless there is Pathologic Confirmation of Metastasis (Grade 2C Recommendation)

Clinical Manifestations

Pulmonary Manifestations

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References

Imaging features of lymphangioleiomyomatosis: diagnostic pitfalls. AJR Am J Roentgenol. 2011;196(4):982 [MEDLINE]
Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e93S-120S. doi: 10.1378/chest.12-2351 [MEDLINE]