Management Of Solitary Pulmonary Nodules Research Articles

Advancements in Diagnosis, Follow-up, and Management of Solitary Pulmonary Nodules: A Comprehensive Review

Advancements in Diagnosis, Follow-up, and Management of Solitary Pulmonary Nodules: A Comprehensive Review

Solitary pulmonary nodule update of its diagnosis, molecular biology and treatment

Solitary Pulmonary Nodule (SPN) is a term used to describe a single, isolated lesion or abnormality in the lung parenchyma that appears as a discrete spot on radiological imaging. SPNs are frequently encountered in clinical practice, often as incidental findings on chest X-rays or CT scans. The management of SPNs is a critical aspect of pulmonary medicine and oncology, as these nodules can be benign or malignant. This abstract provides an overview of the characteristics, evaluation, and diagnostic approach to SPNs, highlighting the importance of distinguishing between benign and malignant nodules through imaging, biopsy, and molecular analysis. It discusses the significance of early detection, personalized treatment strategies, and the impact of recent advancements in molecular biology and genetics on SPN management. Accurate assessment and timely intervention are essential in improving outcomes for patients with SPNs, as early-stage lung cancer presents a better prognosis compared to advanced disease.

How Bronchoscopic Dye Marking Can Help Minimally Invasive Lung Surgery.

In the era of increasing availability of high-resolution chest computed tomography, the diagnosis and management of solitary pulmonary nodules (SPNs) has become a common challenging clinical problem. Meanwhile, surgical techniques have improved, and minimally invasive approaches such as robot- and video-assisted surgery are becoming standard, rendering the palpation of such lesions more difficult, not to mention pure ground-glass opacities, which cannot be felt even in open surgery. In this article, we explore the role of bronchoscopy in helping surgeons achieve successful minimally invasive resections in such cases.

Narrative review of classification and management of solitary pulmonary nodule: the state of art

Narrative review of classification and management of solitary pulmonary nodule: the state of art

Solitary pulmonary nodule malignancy predictive models applicable to routine clinical practice: a systematic review

BackgroundSolitary pulmonary nodule (SPN) is a common finding in routine clinical practice when performing chest imaging tests. The vast majority of these nodules are benign, and only a small proportion are malignant. The application of predictive models of nodule malignancy in routine clinical practice would help to achieve better diagnostic management of SPN. The present systematic review was carried out with the purpose of critically assessing studies aimed at developing predictive models of solitary pulmonary nodule (SPN) malignancy from SPN incidentally detected in routine clinical practice.MethodsWe performed a search of available scientific literature until October 2020 in Pubmed, SCOPUS and Cochrane Central databases. The inclusion criteria were observational studies carried out in low-risk population from 35 years old onwards aimed at constructing predictive models of malignancy of pulmonary solitary nodule detected incidentally in routine clinical practice. Studies had to be published in peer-reviewed journals, either in Spanish, Portuguese or English. Exclusion criteria were non-human studies, or predictive models based in high-risk populations, or models based on computational approaches. Exclusion criteria were non-human studies, or predictive models based in high-risk populations, or models based on computational approaches (such as radiomics). We used The Transparent Reporting of a multivariable Prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement, to describe the type of predictive model included in each study, and The Prediction model Risk Of Bias ASsessment Tool (PROBAST) to evaluate the quality of the selected articles.ResultsA total of 186 references were retrieved, and after applying the exclusion/inclusion criteria, 15 articles remained for the final review. All studies analysed clinical and radiological variables. The most frequent independent predictors of SPN malignancy were, in order of frequency, age, diameter, spiculated edge, calcification and smoking history. Variables such as race, SPN growth rate, emphysema, fibrosis, apical scarring and exposure to asbestos, uranium and radon were not analysed by the majority of the studies. All studies were classified as high risk of bias due to inadequate study designs, selection bias, insufficient population follow-up and lack of external validation, compromising their applicability for clinical practice.ConclusionsThe studies included have been shown to have methodological weaknesses compromising the clinical applicability of the evaluated SPN malignancy predictive models and their potential influence on clinical decision-making for the SPN diagnostic management.Systematic review registrationPROSPERO CRD42020161559

Pre-surgical lung biopsy in management of solitary pulmonary nodules: a cost effectiveness analysis

Objectives: Tissue diagnosis prior to thoracic surgery with curative intent is vital in thoracic lesions concerning for lung cancer. Methods of obtaining tissue diagnosis are variable within the United Kingdom.Methods: We performed a model-based analysis to identify the most efficient method of diagnosis using both a health care perspective. Our analysis concerns adults in the UK presenting with a solitary pulmonary nodule suspicious for a primary lung malignancy, patients with more advanced disease (for example lymph node spread) were not considered. Model assumptions were derived from published sources and expert reviews, cost data were obtained from healthcare research group cost estimates (2016–17). Outcomes were measured in terms of costs experienced to healthcare trusts.Results: Our results show that CT guided percutaneous lung biopsy using an ambulatory approach, is the most cost-effective method of diagnosis. Indeed, using this approach, trust experience approximately half of the cost of an approach of surgical lung biopsy performed at the time of potential resection (‘frozen section’).Limitations and conclusions: Whilst this analysis is limited to the specific scenario of a solitary pulmonary nodule, these findings have implications for the implementation of lung cancer screening in the UK, which is likely to result in increased numbers of patients with such early disease.

Solitary pulmonary nodule: Comparison of quantitative capability for differentiation and management among dynamic CE-perfusion MRI at 3 T system, dynamic CE-perfusion ADCT and FDG-PET/CT

PurposeTo prospectively compare the capability of dynamic first-pass contrast-enhanced (CE) perfusion MR imaging with ultra-short TE and area-detector CT (ADCT), analyzed with the same mathematical methods, and that of FDG-PET/CT for diagnosis and management of solitary pulmonary nodules (SPNs). Methods and materialsOur institutional review board approved this study and written informed consent was obtained from all subjects. A total 57 consecutive patients with 71 nodules prospectively underwent dynamic CE-perfusion ADCT and MR imaging with ultra-short TE, FDG-PET/CT, as well as microbacterial and/or pathological examinations. The nodules were classified into malignant nodules (n = 45) and benign nodules (n = 26). Pulmonary arterial, systemic arterial and total perfusions were determined by means of dual-input maximum slope models on ADCT and MR imaging and maximum values of standard uptake values (SUVmax) on PET/CT. Receiver operating characteristic (ROC) analysis was performed for each index, and sensitivity, specificity and accuracy were compared by McNemar's test. ResultsAreas under the curve (Azs) of total perfusion on ADCT (Az = 0.89) and MR imaging (Az = 0.88) were significantly larger than those of systemic arterial perfusion and MR imaging (p<0.05). Accuracy of total perfusion on ADCT (87.3% [62/71]) and MR imaging (87.3% [62/71]) was significantly higher than that of systemic arterial perfusion for both methods (77.5% [55/71] p = 0.02) and SUVmax (78.9% [56/71], p = 0.03). ConclusionDynamic CE-perfusion MR imaging with ultra-short TE and ADCT and have similar potential capabilities, and are superior to FDG-PET/CT in this setting.

Evaluation of the solitary pulmonary nodule.

The solitary pulmonary nodule represents a common diagnostic challenge for clinicians. While most are benign, a significant number represent early, potentially curable lung cancers. With the increased utilisation of chest computed tomography, solitary pulmonary nodules are increasingly being identified and with lung cancer screening programmes now on the horizon globally, it is crucial clinicians are familiar with the evaluation and management of solitary pulmonary nodules. Through the evaluation of patient risk factors combined with computed tomography characteristics of solitary pulmonary nodules, including size, growth rate, margin characteristics, calcification, density and location; a clinician can assess the risk of malignancy. This article provides an up to date review of the imaging features of both benign and malignant solitary pulmonary nodules to assist in the identification of nodules that require histological confirmation or ongoing surveillance. In addition, we summarise the newly updated Fleischner Society Guidelines that provide clinicians with a framework for the evaluation and management of solitary pulmonary nodules.

Does aggressive management ofsolitary pulmonary nodulespay off?

Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental radiological findings. The ever-growing use of modern imaging has increased their detection. The majority of those nodules are benign; however, the possibility of diagnosing early-stage lung cancer still stands. Guidelines for the management of SPNs have never been validated in prospective comparative studies.Positron emission tomography (PET) is a useful tool to provide functional information on SPNs. However, overall sensitivity and specificity of PET in detecting malignant SPNs of at least 10 mm in diameter are about 90% and false-negative results are reported.The development of video-assisted thoracic surgery has provided minimally invasive diagnosis and treatment of SPNs. In our series, 105 patients underwent surgery based on combined increased 18F-labelled 2-fluoro-2-deoxy-d-glucose (FDG) uptake on PET computed tomography and radiological features (morphology and density) without prior histological confirmation. We detected 26 false negatives (24.8%) and only nine false positives (8.57%). Therefore, our minimally invasive surgical approach prevented 25% of patients with lung cancer from a delayed treatment versus only 9% undergoing “overtreatment”.In our monocentric cohort, patients with SPNs with large diameter, irregular outline, no calcifications, central location, increased FDG uptake and/or subsolid aspect benefited from a primary surgical resection.

Management of lung nodules in Brazil-assessment of realities, beliefs and attitudes: a study by the Brazilian Society of Thoracic Surgery (SBCT), the Brazilian Thoracic Society (SBPT) and the Brazilian College of Radiology (CBR).

Pulmonary nodules are common; some are inconsequential while others are malignant. Management of solitary pulmonary nodule (SPN) in Brazil appears to be highly variable, potentially leading to suboptimal outcomes. Assessment of the variability and the association with the degree of availability of resources can provide a foundation for development of clinical guidelines for management of SPN specific for the Brazilian setting. A web-based survey was developed by thoracic surgeons, pulmonologists and radiologists to evaluate SPN perception and management. This survey was sent to their respective national societies members and answers collected between August and December 2016. That included multiple choice questions regarding age, specialty, SPN management, accessibility to exams and interventional procedures characterizing public (SUS) and supplementary private working settings. A total of 461 questionnaires were answered. More than half of participants live in cities with over one million people. Specialties were reasonable equilibrated with 43.5% radiologists, 33.5% thoracic surgeons, 20.3% pulmonologists and 2.6% others. Most of the respondents work in both public and private sector (72.7%). Private has a similar reality compared to well-developed nations regarding exams accessibility and interventions. SUS setting has a significant variability access according to the participants. CT is only easily available in 31.9% of cases, PET-CT is easily available in 24.4%, bronchoscopy is easily available for 42.8%, transthoracic needle biopsy is only easily available in 13.9% and video-assisted thoracoscopic surgery (VATS) biopsy is not available in 19.5%. When there is a probability of malignancy of 50% or higher, 46.5% of participants would be comfortable recommending surgical biopsy. When the probability is higher than 10%, only 36.9% would be comfortable following up radiologically. Brazil has a very different setting for public and private patients regarding exams accessibility and management options. That might explain why participants have a higher tendency to choose interventional diagnosis and explains why current guidelines may not be applicable to developing countries reality.

Diagnostic performance of fluorine-18 fluorodeoxyglucose positron emission tomography in the management of solitary pulmonary nodule: a meta-analysis.

In the setting of solitary pulmonary nodules (SPNs), fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) is considered a useful non-invasive diagnostic tool though false positive (FP) and false negative (FN) results affects accuracy due to different conditions, such as inflammatory diseases or low-uptake neoplasms. Aim of this study is to evaluate overall diagnostic performance of 18F-FDG-PET/CT for malignant pulmonary nodules. A computerized research, including published articles from 2012 and 2017, was carried out. 18F-FDG-PET/CT overall sensitivity (Se), specificity (Spe), positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV), diagnostic index and odds ratio were pooled. No selection-bias were found according to asymmetry test. A total of twelve studies were included in the meta-analysis. The pooled Se, Spe, PLR, NLR, PPV, NPV and accuracy index (AI) with relative 95% confidence intervals (CI) were 0.819 (95% CI: 0.794-0.843), 0.624 (95% CI: 0.582-0.665), 2.190 (95% CI: 1.950-2.440), 0.290 (95% CI: 0.250-0.330), 0.802 (95% CI: 0.783-0.819), 0.652 (95% CI: 0.618-0.684) and 0.649 (95% CI: 0.625-0.673), respectively. The diagnostic odds ratio (DOR) was 7.049 with a relative 95% CI between 5.550 and 8.944. The results suggest 18F-FDG-PET/CT has good diagnostic accuracy in SPNs evaluation; but, it should not be considered as a discriminatory test rather than a method to be included in a clinical and diagnostic pathway.

Management pathways for solitary pulmonary nodules.

Pulmonary nodules are often detected during the clinical course of several diseases or through routine screening. Various guidelines have proposed management algorithms for suspicious solitary nodules in lung cancer. Generally, solitary pulmonary nodules are managed according to nodule appearance and risk of lung cancer using low-dose, thin section computed tomography (CT). Liquid biopsy is promising for diagnosis, therapeutic-monitoring and follow-up in lung cancer; however, diagnosis and management pathways based on genetic examination alone have not been established. Management of solitary pulmonary nodules should be carried out by a multidisciplinary team and tissue biopsy is necessary for the diagnosis of lung cancer. Genetic analysis via liquid biopsy is warranted in addition to more established techniques in pulmonary nodule management.

Multiple pulmonary nodules in malignancy

Multiple pulmonary nodules are a common finding especially with the implementation of lung cancer screening. Available guidelines address the management of solitary pulmonary nodules. The management of the multiple pulmonary nodules would differ based on the characteristic of the nodules, their distribution, and the history of the patients as well. Most of the recent publications on multiple pulmonary nodules consist of individual case reports or case series. Robust population studies are lacking. In this article, we propose an approach for management of multiple pulmonary nodules which needs to be validated.

P1.03-078 Size Matters...but Don't Underestimate the Power of Morphology

The detection of solitary pulmonary nodules has increased due to the widespread use of Computed Tomography (CT) and will increase even more in the future when lung cancer screening will be embedded in daily practice. In addition to the clinical information, size is one of the most important parameters to assess the likelihood of malignancy. Although there is a considerable overlap in imaging characteristics of benign and malignant solitary pulmonary nodules, the power of morphology –even in small nodules- should not be underestimated. The aim of this pictorial essay is to give an overview of the wide range of morphologic characteristics and to address the available evidence on sensitivity and specificity of these characteristics. Cases presented were collected during the Multidisciplinary Thoracic Oncology Tumor Board between January 2014 and May 2016. All malignant cases have histopathologic proof, whereas benign lesions were included when the benign nature was suggested after follow-up, negative PET-scan and/or multidisciplinary consensus. With regard to margin characteristics, spiculation is highly suggestive of a malignant nature. It is the only feature that is incorporated as ‘morphologic’ variable in most risk prediction models. Other features however may also be strong indicators of malignancy. Lobulation, halo sign, pleural indentation, vascular convergence sign and pitfall sign are frequently encountered in malignant nodules. The nodule-bronchus relationship can give additional information regarding the nature of the nodule, with signs such as air bronchogram, bubble like lucencies and bronchus cutoff sign being indicative of a malignant nature. In cavitated nodules, a very thin wall might indicate a benign cause, whereas a very thick wall is more common in malignant nodules. Calcification is typically seen in benign nodules, but depending on the calcification pattern a malignant etiology cannot be excluded. The presence of fat is a relative reliable sign of benignity. Thin-section CT will enable detection of subtle findings. Nodules rarely present with only one characteristic and combination of findings can definitely increase the likelihood of a correct diagnosis. The management of solitary pulmonary nodules involves both clinical and imaging assessment. Although a great overlap exists in morphologic features of benign and malignant nodules, thorough knowledge and recognition of subtle morphologic findings will aid in early detection of nodules with a high likelihood of malignancy and will avoid unnecessary follow-up and delay in diagnosis and treatment.

Novel Methods of Intraoperative Localization and Margin Assessment of Pulmonary Nodules

Lung cancer screening has lead to frequent diagnosis of solitary pulmonary nodules, many of which require surgical biopsy for diagnosis and intervention. Subcentimeter and central nodules are particularly difficult to visualize or palpate during surgery, thus nodule localization can be a difficult problem for the thoracic surgeon. Although minimally invasive techniques including transthoracic computed tomography and bronchoscopic-guided biopsy may establish a diagnosis, these methods do not help locate nodules during surgery and can lead to inadequate tissue sampling. Therefore, surgical biopsy is often required for diagnosis and management of solitary pulmonary nodules. Additionally, after an excision, intraoperative margin assessment is important to prevent local recurrence. This is important for bronchial margins following lobectomy or parenchymal margins following sublobar resection. First, we examine methods of preoperative lesion marking, including wire placement, dye marking, ultrasound, fluoroscopy, and molecular imaging. Second, we describe the current state of the art in intraoperative margin assessment techniques.

Management of solitary pulmonary nodules

Der solitare pulmonale Rundherd ist eine radiologische Verschattung, die ganz oder teilweise von Lungengewebe umgeben ist. Intrapulmonale Rundherde sind haufig, in den allermeisten Fallen klinisch blande und werden meist nur zufallig entdeckt. Lesen Sie hier, woran Sie differenzialdiagnostisch denken mussen und welche Untersuchungen Sie vornehmen sollten.

Algorithmic Approach to the Diagnosis and Management of Solitary Pulmonary Nodules

Algorithmic Approach to the Diagnosis and Management of Solitary Pulmonary Nodules

S72 Clinical Prediction Models For Malignancy In Solitary Pulmonary Nodules - A Validation Study In A Uk Population

Background Management of solitary pulmonary nodules (SPNs) depends critically on the pre-test probability of malignancy. Several quantitative prediction models have been developed using clinical and radiological criteria. Three models include CT criteria (Mayo, Veterans Association, Brock University) with a fourth model (Herder) incorporating FDG avidity on CT-PET scan in addition. These models have not been validated in a UK population, and the current study aimed to compare their performance in a population of patients recruited from a UK teaching hospital. Methods Patients with SPNs (4–30 mm) were retrospectively identified from the lung cancer MDT and a nodule follow-up clinic (n = 246). All patients had a final diagnosis confirmed by histology or radiological stability on a 2-year follow up. For each patient, the probability of the pulmonary nodule being malignant was calculated using the four models described. The models were used both in a restricted cohort of patients based on their respective exclusion criteria, and in the total cohort of patients. The accuracy of each model was assessed by calculating the area under the receiver operating characteristic (ROC) curve. Results The median age of the patient population was 69 years (range 32–94) and 50% were male. The prevalence of malignancy was 40.6% (33.3% primary lung cancer, 7.3% metastatic disease). Figure 1 shows the distribution of the probabilities of malignancy according to the four different models. The areas under the ROC curves for the cohorts restricted by respective exclusion criteria were (AUC, 95% CI): Mayo 0.892 (0.847–0.937); VA 0.736 (0.672–0.801); Brock 0.901 (0.855–0.947) and Herder 0.924 (0.875–0.974). For the total cohort, the AUC values were Mayo 0.873, VA 0.736, Brock 0.867 and Herder 0.916. There was no statistical difference between the Mayo and Brock models, but both were significantly better than VA (AUC difference of 0.14 and 0.13 respectively, p ≤ 0.0001 for both). The Herder model performed significantly better than both Mayo and Brock models (AUC difference of 0.10 and 0.14 respectively, p ≤ 0.01). Conclusion Both the Mayo and the Brock models perform well in a UK population, but accuracy is improved by incorporating CT-PET findings using the Herder prediction model.

Apport de l’imagerie médicale fonctionnelle dans le diagnostic du nodule pulmonaire

The introduction into clinic of positron emission tomography (PET) with 18F-Flurorodesoxyglucose (FDG) and of hybrid cameras combining PET and computed tomography (PET/CT) has radically changed the management of solitary pulmonary nodules (SPN). Three meta-analyses have shown a high diagnostic accuracy of FDG PET for the diagnosis of cancer in SPN.Small pulmonary nodules (less than 5mm), respiratory movements and histology with low cell density and/or low metabolic activity are the most common cases of false negative FDG PET/CT. The majority of false positive cases are related to benign tumours, granulomatosis and infectious diseases.Likelihood ratio's (LR) of FDG PET/CT for overall prevalence of malignancy in SPN were published and are higher for malignancy diagnosis with PET scan in comparison with most clinical and radiological variables. Today, the Bayesian approach for SPN differential diagnosis must include information from FDG PET/CT.The increasing use of new radiotracers, such as octreotide derivates labeled with 68Gallium (68Ga) for diagnosis and staging of carcinoid tumours and the development of other radiotracers, will lead to an improvement in the management of solitary pulmonary nodules.

Guideline on Management of Solitary Pulmonary Nodule

The aim of the proposed recommendations is to be a tool to facilitate decision-making in patients with a solitary pulmonary nodule (SPN). For an optimal decision, accessibility to the different diagnostics techniques and patient preferences need to be incorporated.The first assessment, which includes a chest computed tomography scan, separates a group of patients with extrapulmonary neoplasm or a high surgical risk who require individualized management. Another two groups of patients are patients with SPN up to 8mm and those who have a subsolid SPN, for which specific recommendations are established.SPNs larger than 8mm are classified according to their probability of malignancy into low (less than 5%), where observation is recommended, high (higher than 65%), which are managed with a presumptive diagnosis of localized stage carcinoma, and intermediate, where positron emission tomography-computed tomography has high yield for reclassifying them into high or low probability. In cases of intermediate or high probability of malignancy, transbronchial needle aspiration or biopsy of the nodule may be an option.Radiologic observation with low radiation computed tomography without contrast is recommended in SPN with low probability of malignancy, and resection with videothoracoscopy in undiagnosed cases with intermediate or high probability of malignancy.