Solitary Lung Nodule Research Articles

Diagnosis of Solitary Lung Nodule Using Texture e Geometry in Computerized Tomography Images: Preliminary Results

Diagnosis of Solitary Lung Nodule Using Texture e Geometry in Computerized Tomography Images: Preliminary Results

Pathologic quiz case: solitary lung nodule in a 77-year-old male smoker. Pulmonary cryptococcoma.

Pathologic quiz case: solitary lung nodule in a 77-year-old male smoker. Pulmonary cryptococcoma.

Effect of high sensitivity in a computerized scheme for detecting extremely subtle solitary pulmonary nodules in chest radiographs: observer performance study 1

Rationales and Objectives. This study investigated the effect of a high sensitivity in computer-aided diagnosis (CAD) for detecting lung nodules in chest radiographs when extremely subtle cases were presented to radiologists. Material and Methods. The chest radiographs used in this study consisted of 36 normal images and 54 abnormals containing solitary lung nodules, of which 25 were extremely subtle and 29 were very subtle. Receiver operating characteristic analysis for detecting lung nodules was performed without and with CAD. The levels of CAD output were simulated with a hypothetical ideal performance of 100% sensitivity, but with three or four false positives per image. Six radiologists participated in an observer study in which cases were interpreted first without and then with the use of CAD. Results. The average A Z values for radiologists without and with CAD were 0.682 and 0.808, respectively. The performance of radiologists was improved significantly when high sensitivity was used ( P = .0003). However, the radiologists were not able to recognize some extremely subtle nodules (5 of 54 nodules by all radiologists), even with the correct CAD output; these nodules were then considered as non-actionable. None of 306 computer-false positives was incorrectly regarded as a nodule by all radiologists, but 63 false positives were incorrectly identified by one or more radiologists. Conclusion. The accuracy of radiologists in the detection of some extremely subtle solitary pulmonary nodules can be improved significantly when the sensitivity of a CAD scheme can be made to be at an extremely high level. However, all of the six radiologists failed to identify some nodules (about 10%), even with the correct output of the CAD.

Bronchioloalveolar carcinoma: myths and realities in the surgical management.

Bronchioloalveolar carcinoma (BAC) of the lung is a subtype of adenocarcinoma with pure bronchoalveolar growth pattern and no evidence of stromal, vascular or pleural invasion (1999 WHO criteria), that seems to increase in incidence actually. BAC has its proper clinical spectrum, occurring more frequently in women and in younger patients. BAC also seems to be less dependent on tobacco exposure. Furthermore, original feature of this type of lung cancer is its intrapulmonary spreading and being infrequently systemic. Thus, surgical resection appears to have a pivotal role. This review of the literature attempted to assess whether or not patients with BAC should be treated according to the same oncological principles as those recommended for other non-small cell lung cancers, i.e. performance of anatomical resection combined with lymphadenectomy, and development of multimodality therapeutic strategies. Unilateral multinodular or pneumonic forms are best removed by lobectomy, or pneumonectomy when appropriate, combined with lymphadenectomy. Segmentectomy or wedge resection is a valuable option for the treatment of solitary lung nodules with pure pathological BAC patterns, provided specific conditions based upon computed tomography scan findings are present. The place of multimodality strategies is still unexplored. Treatment of bilateral BAC is challenging. Incomplete resection may be performed to palliate a severe intrapulmonary shunting. However, one hope of cure is provided by lung transplantation, even though disappointing results with disease recurrence on the grafts have been reported. The lack of large studies including only pure BAC gives a place for future biological and clinical research on this cancer.

Tumoral non‐amyloidotic monoclonal immunoglobulin light chain deposits (‘aggregoma’): presenting feature of B‐cell dyscrasia in three cases with immunohistochemical and biochemical analyses

Tumoral monoclonal immunoglobulin (Ig) light chain non-fibrillar deposits ('aggregomas'), which can be considered analogous to solitary light chain amyloidomas, are a rare presenting feature of B-cell dyscrasias. It is not certain if they are truly localized or if in reality they represent an initial expression of a silent systemic non-amyloid light chain deposition disease (LCDD). This report describes three patients, two of whom presented with cervical masses and the third with a solitary lung nodule, each comprising granular aggregates of monoclonal kappa light chain. Extracted deposits from the lymph node of one patient were shown by N-terminal amino acid sequence analysis to belong to the variable-region kappa I (Vkappa I) light chain subgroup, the first reported kappa-LCDD protein encoded by the L9 gene and the first report of an expressed protein related to this gene. Extracted deposits from the lung nodule of the second patient belonged to the Vkappa IV light chain subgroup encoded by the B3 germ line gene. The N-terminal amino acid sequences of the light chains from the aggregomas were compared with the related germ line sequences and to the N-terminal amino acid sequences of the nine other known kappa-LCDD light chains reported thus far from patients with systemic LCDD.

Improved detection of lung nodules by using a temporal subtraction technique.

To evaluate the effect of a temporal subtraction technique for digital chest radiography with regard to the accuracy of detection of lung nodules. Twenty solitary lung nodules smaller than 30 mm in diameter, including 10 lung cancers and 10 benign nodules, were used. The nodules were grouped subjectively according to their subtlety. For non-nodular cases, 20 nodules without perceptible interval changes were selected. All chest radiographs were obtained by using a computed radiographic system, and temporal subtraction images were produced by using a program developed at the University of Chicago. The effect of the temporal subtraction image was evaluated by using an observer performance study, with use of receiver operating characteristic analysis. Observer performance with temporal subtraction images was substantially improved (A(z) = 0.980 and 0.958), as compared with that without temporal subtraction images (A(z) = 0.920 and 0.825) for the certified radiologists and radiology residents, respectively. The temporal subtraction technique clearly improved diagnostic accuracy for detecting lung nodules, especially subtle cases. The temporal subtraction technique is useful for improving detection accuracy for peripheral lung nodules on digital chest radiographs.

Three cases of Pulmonary Epithelioid Hemangioendothelioma

A pulmonary epithelioid hemangioendothelioma (PEH) is a rare tumor with a vascular origin. A PEH can arise in many organ systems, such as the lung, liver, bone and soft tissues. It is a borderline malignancy but the clinical course is usually benign. In this report, we describe three cases of PEH. Case 1, a 61-year-old man, had nonspecific chest discomfort and the chest X-ray showed a solitary lung nodule. This nodule was diagnosed by an open lung biopsy. The pathologic findings including abundant necrosis, mitosis and hyperchromatic and pleomorphic nuclei, indicated a malignancy. The electron microscopic study showed Weibel-Palade bodies and the immunohistochemical stain for CD31 showed a positive reaction in the tumor cells, and linear staining along the vascular lumina. Case 2, a 34-year-old man, was admitted for an evaluation of multiple small nodules, incidentally detected a screening chest X-ray. The nodules were diagnosed by a immunohistochemical stain for the factor VIII-related antigen. Case 3, a 34-year-old woman, complained of left pleuritic chest pain. A simple chest film and the chest CT scan revealed multiple bilateral nodules and a left pleural effusion. An immunohistochemical stain for the factor VIII-related antigen was used to diagnose the nodules. Forth-one months after the diagnosis, she died of pulmonary insufficiency.

Significance of a single pulmonary nodule in patients with previous history of malignancy.

To determine the diagnosis, treatment and follow-up in patients with a solitary lung nodule and a previous primary extrapulmonary neoplasm. The authors evaluated the charts of 45 patients with an extrapulmonary malignant neoplasm and a solitary pulmonary nodule. The histologic characteristics of the nodule were correlated with those of the extrapulmonary neoplasm. The histology of the nodule was not known preoperatively in 43 cases (93.5%); in the remaining three cases cytologic examination had shown the presence of atypical cells. The majority of pulmonary lesions (73.9%) were found during the follow-up of the previous tumour, but a significant percentage of nodules (17.4%) were found incidentally. Pre- or intraoperative localisation of the nodule was done in 19 cases (41.3%), and was successful in nine cases (47.4%). Thoracoscopy was performed in 44 patients (95.6%). The coincidence between the pathology of the previous tumour and that of the nodule was 41.3% (19/46). The coincidence rate was 100% for the tumours of ovary, prostate, and sarcomas. The advent of minimally invasive surgical techniques has made a definitive diagnosis likely, providing also therapy with a less painful engagement for the patient and a less cost for the community.

Solitary pulmonary nodules in patients with extrapulmonary neoplasms.

To determine the frequency of single lung metastasis, primary lung cancer, and benign lesions in patients with a solitary lung nodule and a primary extrapulmonary neoplasm. The authors evaluated the electronic charts of 149 patients with an extrapulmonary malignant neoplasm and a solitary pulmonary nodule. The histologic characteristics of the nodule were correlated with those of the extrapulmonary neoplasm and with patient age and smoking history. Patients with carcinomas of the head and neck, bladder, breast, cervix, bile ducts, esophagus, ovary, prostate, or stomach were more likely to have primary bronchogenic carcinoma than lung metastasis (ratio, 25:3 for patients with head and neck cancers; 26:8 for patients with other types of cancer combined). Patients with carcinomas of the salivary glands, adrenal gland, colon, parotid gland, kidney, thyroid gland, thymus, or uterus had fairly even odds (ratio, 13:16). Patients with melanoma, sarcoma, or testicular carcinoma were more likely to have a solitary metastasis than a bronchogenic carcinoma (ratio, 23:9). Thirty patients had a benign nodule. There was substantial overlap in age distribution among the patients with benign disease, lung cancer, and metastasis, although no patient younger than 44 years had a lung cancer. Smokers had a 3.5-fold higher chance of developing lung cancer compared with nonsmokers. The likelihood of a primary lung cancer versus a metastasis depends on the histologic characteristics of the extrapulmonary neoplasm and the patient's smoking history.

PET imaging in oncology

The role of positron emission tomography (PET) during the past decade has evolved rapidly from a pure research tool to a methodology of enormous clinical potential. Perhaps the most striking development is the use of PET in oncology. PET imaging is approved in the United States for lung, lymphoma, colon, and melanoma cancer imaging. Data are accumulating rapidly to attest the efficacy of Fluorine-18 fluorodeoxyglucose (FDG) imaging in a wide variety of malignant tumors with sensitivities and specificities often in the high 90s. FDG uptake has been shown in tumors of the head and neck, ovary, breast, musculoskeletal system, and neuroendocrine system as well. The major role of PET has emerged as a reliable method for evaluating and staging recurrent disease. But it also has an important role in differentiating benign and malignant primary tumors. This has been shown particularly well in the differential diagnosis of solitary lung nodules. Although FDG has emerged as the dominant radiopharmaceutical for PET imaging in oncology, numerous other compounds are being evaluated. It is likely that more specific and efficacious compounds will be introduced during the next decade. F-18, because of its highly favorable physical characteristics, is likely to become the technetium of PET imaging. The next decade will witness an explosive growth of PET technology in oncologic imaging.

Clinical evaluation of irreversible data compression for computed radiography of the chest.

Efficient data compression is essential for practical daily operation of computed radiography (CR) systems. In this study the clinical applicability of type III irreversible high data compression using an FCR 9501 chest unit (Fuji Photo Film, Tokyo, Japan) was evaluated. Sixty-eight normal and 93 various abnormal cases, with an additional 15 cases of lung cancers with solitary lung nodules, were selected from the file. A pair of hard copies of original images and images reconstructed using type III compression was made for each case. Six radiologists evaluated the image quality by visual rating and receiver operating characteristic (ROC) curve analysis. For all five anatomic regions of normal cases, "original equal to compressed" was the most common response, followed by "original significantly better than compressed." When abnormal cases were evaluated for diagnostic information, there was no significant difference between the compressed and original images. ROC curve analysis on lung nodules with lung cancer showed no significant difference between the two. Compressed CR images using the type III irreversible technique are clinically applicable and acceptable despite slight degradation of image quality.

Distinguishing second primary tumors from lung metastases in patients with head and neck squamous cell carcinoma.

In patients with head and neck squamous cell carcinoma (HNSCC), a squamous cell carcinoma (SCC) in the lung represents either another primary tumor or a metastasis. This distinction greatly influences patient prognosis and could guide treatment strategies, but the nature of a solitary lung nodule is often difficult to discern by use of standard clinical and histologic parameters. Comparison of genetic alterations in the tumors could resolve this dilemma. We compared paired tumors from 16 patients with HNSCC and a solitary lung SCC for loss (i.e., deletion) of loci on chromosomal arms 3p and 9p. Losses at these loci occur early during neoplastic transformation of the respiratory tract. DNA from microdissected tumors and normal tissues was subjected to polymerase chain reaction-based microsatellite analysis. An effort was also made to distinguish primary lung cancers from lung metastases on the basis of clinical and histopathologic features. In most cases, comparison of genetic alterations clarified the relationship between the lung tumor and the primary HNSCC. The paired tumors from 10 patients had concordant patterns of loss at all loci suggesting metastatic spread, whereas three paired tumors had discordant patterns of loss at all loci suggesting independent tumor origin. These observations were supported by the clinical and pathologic findings. In patients with HNSCC and a solitary SCC in the lung, microsatellite analysis provides a rapid genetic approach for discerning clonal relationships. In such patients, we found that a solitary SCC in the lung more likely represents a metastasis than an independent lung cancer. Microsatellite analysis could potentially be applied to any patient with multiple tumors, where tumor relationships are not clear on clinical, radiographic, or even histopathologic grounds.

Temporal image database design for outcome analysis of lung nodule

This paper presents the design of a temporal image database system and its application in thoracic imaging. The design of this information system is based on the client/server architecture. The system consists of a chest imaging database server, a library of image processing modules, a link to the picture archiving and communication system (PACS) archive, and a low end client workstation with motif-based graphic user interface (GUI). The database system can be used to aid the radiologist in quantitating solitary or multiple lung nodules and in assessing effectiveness of therapeutic procedures for these lung cancers. The GUI allows a user to retrieve any patient study from PACS. After a nodule is visually identified, it will be segmented automatically to obtain relevant features, such as the center of mass, volume, and surface area. Such 3D nodule information, together with the patient textual information, is subsequently organized in the chest imaging database to facilitate outcome analysis.

Non-specific fluorescent whitener stains in the rapid recognition of pulmonary dirofilariasis: a report of 20 cases.

Solitary lung nodules in humans caused by the dog parasite Dirofilaria immitis are steadily increasing in number. The organisms can be easily missed in haematoxylin and eosin stained tissue when they are degenerated and pale staining. The value of Tinopal CBS-X (TCBS-X) and Calcofluor white (CFW), two rapid, inexpensive, simple non-specific fluorescent whitening stains, were assessed in the identification of these worms. Deparaffinised rehydrated tissue slides prepared from the pulmonary nodules were stained for one minute in 1% w/v aqueous solutions of TCBS-X or CFW, counterstained, coverslipped, and viewed with a fluorescent microscope. The stains demonstrated the intact worm and worm fragments in 20 cases of pulmonary dirofilariasis collected from hospitals in Houston. The filariae and fragments of filariae stained bright green while the background tissue stained red, delineating the internal structures of the worm. Dirofilariasis should be included in the differential diagnosis of subpleural masses, and non-specific fluorescent whitening stains can help in the rapid recognition of the fragmented organism in cytological or surgical material.

Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule

Traditional nonoperative diagnostic approaches to the indeterminate solitary pulmonary nodule include bronchoscopy and percutaneous needle biopsy. Although both methods are minimally invasive, the diagnosis of the small, peripheral nodule may remain elusive. Open thoracotomy is often required when these methods fail to obtain a diagnosis. Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopie stapler alone (72%), neodymium:yttriumaluminum garnet laser (18%), or both (10%). A definite diagnosis was obtained in all patients. Two patients required conversion to thoracotomy to locate the nodule (both malignant). A benign diagnosis was obtained in 127 patients (52%) and a malignant diagnosis in 115 (48%). Of the malignant nodules, 51 (44%) were primary lung cancer and 64 (56%) were métastases. All patients diagnosed with primary lung cancer having adequate pulmonary reserve (n = 29) underwent formal open lung resection during the same procedure. There was no mortality, and significant morbidity was limited to atelectasis in 3 patients (1.2%), pneumonia in 2 patients (0.8%), and prolonged air leak more than 7 days in 4 patients (1.6%). Average hospital stay for patients having thoracoscopy only (n = 213) was 2.4 days (range, 1 to 12 days). Thoracoscopy offers a minimally invasive approach for the diagnosis of the indeterminate solitary nodule. It has advantages over traditional diagnostic methods of being virtually 100% sensitive and 100% specific with no mortality and minimal morbidity. Based on these results, as well as the benefits of cost and time effectiveness, we anticipate a larger role for thoracoscopy in the diagnostic management of the indeterminate solitary pulmonary nodule.

Transient solitary pulmonary nodule caused by Dirofilaria immitis

The second described case of solitary transient lung nodule caused by Dirofilaria immitis is reported. Diagnostic thoracotomy can be avoided with the use of enzyme-linked immunosorbent assay (ELISA), and hence a conservative serological follow-up is warranted in endemic areas.

Pulmonary metastases in gestational trophoblastic disease: A review of 97 cases

Metastatic gestational trophoblastic disease poses problems in diagnosis and management and has a poorer prognosis than the non-metastatic variant. The lung is the most common site of metastases. This paper reviews 97 patients with pulmonary metastasis developing after gestational trophoblastic disease who were seen at one centre over 26 years. Most patients had an antecedent molar pregnancy but an associated choriocarcinomatous lesion in the uterus was absent in the majority. In many patients the pulmonary lesion was asymptomatic. Whilst chemotherapy was the treatment of choice, selective thoracotomy in cases with solitary lung nodules reduced the treatment time and need for aggressive multi-drug combination regimens. The overall survival rate at 2 years after diagnosis was 65%. A higher mortality was found when the antecedent pregnancy ended at term, when the time interval between the preceding pregnancy and diagnosis of pulmonary metastases was greater than 1 year, when multiple pulmonary secondaries were present or when cerebral metastases occurred. The main causes of death were cerebral haemorrhage, respiratory failure and pulmonary embolism.

Pulmonary metastases in gestational trophoblastic disease: a review of 97 cases.

Metastatic gestational trophoblastic disease poses problems in diagnosis and management and has a poorer prognosis than the non-metastatic variant. The lung is the most common site of metastases. This paper reviews 97 patients with pulmonary metastasis developing after gestational trophoblastic disease who were seen at one centre over 26 years. Most patients had an antecedent molar pregnancy but an associated choriocarcinomatous lesion in the uterus was absent in the majority. In many patients the pulmonary lesion was asymptomatic. Whilst chemotherapy was the treatment of choice, selective thoracotomy in cases with solitary lung nodules reduced the treatment time and need for aggressive multi-drug combination regimens. The overall survival rate at 2 years after diagnosis was 65%. A higher mortality was found when the antecedent pregnancy ended at term, when the time interval between the preceding pregnancy and diagnosis of pulmonary metastases was greater than 1 year, when multiple pulmonary secondaries were present or when cerebral metastases occurred. The main causes of death were cerebral haemorrhage, respiratory failure and pulmonary embolism.

Solitary nodular sarcoidosis

Three patients, each with a solitary lung nodule consisting of sarcoid tissue, are described. With the exception of one case where a submandibular lymph node was palpable, clinical and pathological involvement was limited to the thorax and the prognosis was highly favourable. In spite of atypical features, the absence of other causes of granulomatous inflammation suggests that these patients had sarcoidosis. What factors account for limited granulomatous reaction in this form of sarcoidosis are unknown. Previous use of corticosteroids and an age of over 40 years are two possible causes suggested by these cases.

Review of smooth muscle tumours of the lower respiratory tract

A case of leiomyoma of the lung was described by our department 17 years ago. We now report three new cases of smooth muscle tumours of the lower respiratory tract: a leiomyoma of the lung, a leiomyosarcoma of the right main bronchus, and a leiomyoma of the trachea. Whereas in the previous case the tumour was bronchoscopically removed, all the recent tumours were surgically resected. All the patients have done well, including the one with the leiomyosarcoma who underwent surgery 7.5 years ago. One hundred and eighty cases of leiomyoma and leiomyosarcoma of the lung and trachea have been reported to date. Pulmonary leiomyoma most commonly presents as an asymptomatic solitary lung nodule. The endobronchial variety may cause cough, haemoptysis, or shortness of breath. Most of these tumours were dealt with by major pulmonary resection, although a lesser resection would have sufficed in many cases if a histological diagnosis had been established prior to surgery. Pulmonary leiomyosarcoma may occur at any age, and is much more common in females. The majority of the patients have thoracic symptoms. These neoplasms seem resistant to chemotherapy or radiotherapy and should be treated by radical resection whenever possible, which results in a 45% 5-year survival rate. Only seven cases of leiomyosarcoma and 12 cases of leiomyoma of the trachea have been reported. These usually cause respiratory obstruction and/or haemoptysis. The malignant as well as the benign tumour is probably best treated by complete surgical resection.