Solitary Pulmonary Lesions Research Articles

A Study of Clinical Investigations of Pulmonary Tuberculoma

Background A pulmonary tuberculoma is one of the most common causes of a solitary pulmonary lesion. Treating a tuberculoma is still controversial and there are few reports on antituberculosis chemotherapy. In this study, the clinical findings and changes in the size of tuberculomas on a radiograph after completing antiuberculosis chemotherapy was investigated. Methods The medical records, an chest radiographs of 18 pulmonary tuberculoma patients who were admitted to the Gachon medical school, Ghil medical center between April 1998 and August 2001, were reviewed. The symptomatic changes were recorded and the size of the tuberculomasl following treatment were compared. To compare the size, the long distance of each tuberculoma on the chest radiographs were measured and the additional radiological findings of calcification, satellite nodules and cavities were investigated. Results Fifteen patients were men and 3 were women. The median age was 46(24-74). Among these 18 patients, 14 patients had clinical symptoms. The other 4 patients were diagnosed incidentally as during a routine chest radiograph. The mean size of the tuberculomas on the initial plain chest film was 4.3±2.3cm(range : 1.7-10cm)and after 6 months treatment, it had decreased to 1.68±2.00cm(range : 1.5-6.5cm)(P<0.05). At least 6 months of antituberculosis chemotherapy resulted in the findings of a tuberculoma with a disappearance in 9, a decreased size in 4, and no change in 5 on the chest radiograph. Calcifications were found in 3 patients on the initial chest film and the chest CT and all calcified tuberculomas had disappeared after treatment. Conclusions A lthough a pulmonary tuberculoma can remain as an inactive lesion for a long time, if it is confirmed by pathological or bacteriological methods, antituberculosis chemotherapy will be beneficial despite the presence of calcification.

Solitary pulmonary lymphangioma

Lymphangioma is an abnormal collection of lymphatics that are developmentally isolated from the normal lymphatic system. Lymphangioma rarely presents as a solitary pulmonary lesion. We present a case of solitary pulmonary lymphangioma and review the literature on its pathogenesis, clinical features, and radiographic findings.

Fine needle aspiration of solitary pulmonary lesions

A 2-year experience using 25G sized needles for transthoracic fine needle aspiration (FNA) for solitary lung lesions under computed tomography (CT) guidance is documented with the main objective of reducing the postoperative complications through the use of a needle smaller than that previously routinely used. This study, in the hospital experience, demonstrated that FNAs became complication-free with the use of a smaller needle; whilst the sensitivity of the procedure was not much compromised. The duration of the hospitalization for the patients was reduced to under 24 h. The mandatory postoperative chest radiography can therefore be eliminated, provided no adverse clinical signs and symptoms are noted during the postoperative period. This is one of the first documented reports using 25G needles for FNAs. Further studies are needed on a wider scale to confirm the findings.

CT-guided marking of lung lesions before minimally invasive operation

Video-assisted thoracoscopic surgery (VATS) is an established method for resection of suspicious pulmonary lesions. However, there are problems to detect small subpleural lesions. A procedure for localization of such lesions will be demonstrated. Since may 2000 our experience includes 5 patients (4m, 1f) suffering from solitary pulmonary lesions. In preparation of VATS a CT-guided marking was carried out using both a lasermarker system as well as a special marker system for lung lesions. All 5 procedures were successful. With the laser system the pulmonary nodule was exactly marked and the special wire was placed without any complications. Consequently, the pulmonary nodule was fixed. During video-assisted wedge resection the nodule can be tracted outside. Operating time was reduced in comparison to time consuming search of unmarked lesions. The combined application of CT-guided marking, transthoracic fixation of pulmonary nodule and VATS is recommended preoperatively. It should apply in lesions, which are located subpleural and thoracoscopically not visible.

Differentiation of malignant from benign solitary pulmonary lesions using chest radiography, spiral CT and HRCT

Objective: The aim of this prospective study was to summarize all of the qualitative and quantitative imaging criteria for the differentiation of solitary pulmonary lesions (SPLs) as malignant (MSPLs) or benign (BSPLs) described in the literature and to critically analyze the different characteristics in order to evaluate their clinical importance and usefulness as criteria for a discrimination during the primary diagnostic assessment of SPLs using chest radiography, spiral computed tomography (SCT) and high-resolution computed tomography (HRCT). Materials and methods: SPLs were examined, evaluated and then completely removed by surgery in 104 consecutive patients (MSPLs n=81, BSPLs n=23). No SPL was excluded by size. Chest radiography was performed with frontal and lateral views, SCT was carried out with a slice thickness of 8 mm and HRCT with a slice thickness of 1 mm and a 12-cm field of view. Results: All the characteristics which enabled a reliable differentiation of MSPLs from BSPLs were characteristics which were observed significantly more frequently in MSPLs than BSPLs. Useful characteristics for the differentiation of MSPLs from BSPLs (1) using chest radiography were the indistinct edge ( P<0.0001) and a ground-glass opacity of the lung parenchyma adjacent to the SPL ( P<0.05); (2) using SCT the presence of spicules ( P<0.0005), the vessel sign ( P<0.0005), necrotic areas ( P<0.001), spicules extending to the visceral pleura ( P<0.005), circumscribed pleural thickening ( P<0.005), inhomogeneity ( P<0.01), a ground-glass opacity of the lung parenchyma adjacent to the SPL ( P<0.01), the lesion density ( P<0.05), pleural retraction ( P<0.05) and the bronchus sign ( P<0.05); and (3) using HRCT the presence of spicules ( P<0.00005), spicules extending to the visceral pleura ( P<0.0005), the vessel sign ( P<0.0005), pleural retraction ( P<0.001), circumscribed pleural thickening ( P<0.001), the bronchus sign ( P<0.005), a ground-glass opacity of the lung parenchyma adjacent to the SPL ( P<0.01), the lesion density ( P<0.05) and the length of spicules ( P<0.05). Using any one of the characteristics with a significance level of P<0.01, the identification of MSPLs (1) using chest radiography showed a sensitivity of 64.2% and a specificity of 82.6% (accuracy of 68.3%); (2) using SCT a sensitivity of 88.9% and a specificity of 60.9% (accuracy of 82.7%); and (3) using HRCT a sensitivity of 91.4% and a specificity of 56.5% (accuracy of 83.7%). Conclusions: Using chest radiography, SCT and HRCT, a precise morphological assessment of the periphery of the pulmonary lesion and the adjacent visceral pleura is necessary to distinguish MSPLs from BSPLs. In this respect SCT and HRCT are useful in differentiation of MSPLs from BSPLs. However, metastases strongly resembled benign lesions in terms of size and edge type and chronic inflammatory pseudotumors as a group mimic MSPLs.

CT bronchus sign in malignant solitary pulmonary lesions: value in the prediction of cell type.

The aim of this study was to evaluate differences in the prevalence of patterns of CT bronchus sign in malignant solitary pulmonary lesions (SPLs), according to their histologic cell types and with respect to size, location, and degree of cell differentiation. Computed tomography scans of 78 patients, in whom pathologically confirmed malignant SPLs with CT bronchus sign were present, were randomly selected and reviewed by two radiologists under consensus. All 78 were CT scans done using spiral technique with 10-mm collimation and 10-mm reconstruction intervals with enhancement, and 75 included additional high-resolution CT scans. Lesions were classified into four cell types as squamous cell carcinoma (n = 24), small cell carcinoma (n = 12), adenocarcinoma (n = 23), bronchioloalveolar carcinoma (BAC; n = 9), and others (n = 12), into three degrees of differentiation, into three size groups, and according to location (central or peripheral). Patterns of CT bronchus sign were classified into abruptly obstructing (I), patent (II), displacing (III), or tapered narrowing (IV) types. The relationships between the patterns of CT bronchus sign and cell type and degree of cell differentiation were evaluated. Eighty patterns of CT bronchus sign were observed in 78 patients. According to cell type, squamous cell carcinoma showed most often type-I pattern (45.8%) but no type-II pattern, which was the most common pattern observed in BAC (77.8%) and adenocarcinoma (34.8%; p<0.01). Small cell carcinoma showed a varied distribution among the four patterns of CT bronchus sign. According to location, in central squamous cell carcinomas, type-I pattern was more common(55%; p<0.01). Bronchioloalveolar carcinoma showed more peripheral lesions and in both central and peripheral lesions, type-II pattern was significantly more common (100 and 66.7%; p<0.01). In SPLs with CT bronchus sign of obstructing pattern, especially if central location, squamous cell carcinoma should be suspected, whereas in SPLs with patent CT bronchus sign, regardless of the location, the strong possibility of BAC should be considered.

Solitary pulmonary nodules: Part II. Evaluation of the indeterminate nodule.

Various strategies may be used to evaluate indeterminate solitary pulmonary nodules. Growth rate assessment is an important and cost-effective step in the evaluation of these nodules. Clinical features (eg, patient age, history of prior malignancy, presenting symptoms, smoking history) can be useful in suggesting the diagnosis and aiding in management planning. Bayesian analysis allows more precise determination of the probability of malignancy (pCa). Decision analysis models suggest that the most cost-effective management strategy depends on the pCa for a given nodule. At contrast material-enhanced computed tomography, nodular enhancement of less than 15 HU is strongly predictive of a benign lesion, whereas enhancement of more than 20 HU typically indicates malignancy. At 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography, lesions with low FDG uptake are typically benign, whereas those with increased FDG uptake are typically malignant. Results of transthoracic needle aspiration biopsy influence management in approximately 50% of cases and, in indeterminate lesions with a pCa between 0.05 and 0.6, is the best initial diagnostic procedure. It is optimally used in peripheral nodules and has been reported to establish a benign diagnosis in up to 91% of cases. Although there is no one correct management approach, the ability to distinguish benign from malignant solitary pulmonary lesions has improved with the use of these strategies.

An evaluation of the tumour markers, carcinoembryonic antigen (CEA), cytokeratin marker (CYFRA 21-1) and neuron-specific enolase (NSE) in the differentiation of malignant from benign solitary pulmonary lesions

Purpose: The aim of this prospective study was to assess the diagnostic value of the tumour markers carcinoembryonic antigen (CEA), cytokeratin 19 fragment marker (CYFRA 21-1) and neuron-specific enolase (NSE) in the differentiation of malignant (MSPLs) from benign solitary pulmonary lesions (BSPLs). Methods: Solitary pulmonary lesions (SPLs) were diagnosed using plain radiography and spiral computed tomography (SCT) and then completely removed by surgery in 104 consecutive patients (MSPLs; n=81, BSPLs; n=23). The serum concentrations of the tumour markers were determined 1–3 days prior to surgery by ELISA for CEA and CYFRA 21-1 and by IRMA for NSE using commercially available assay kits. The cut-off values were set at 3 ng/ml (for non-smokers) and 5 ng/ml (for smokers) for CEA, at 3.3 ng/ml for CYFRA 21-1 and at 12.5 ng/ml for NSE. Results: MSPLs were identified with a sensitivity between 13.6 and 45.7%, a specificity between 87.0 and 100% and an accuracy between 32.7 and 54.8%. Using the tumour markers alone, the highest sensitivity (27.2%) and accuracy (40.4%) was found with CEA, the highest specificity (100%) with CYFRA 21-1 and with NSE. Primary lung cancers ( n=39) were identified with a sensitivity between 17.9 and 61.5%, a specificity between 87.0 and 100% and an accuracy between 48.4 and 71.0%. Using the tumour markers alone, the highest sensitivity (35.9%) and accuracy (59.7%) was found with CYFRA 21-1, the highest specificity (100%) with CYFRA 21-1 and with NSE. The combination of all three tumour markers resulted in a greater sensitivity and greater diagnostic accuracy but a loss in specificity compared with CYFRA 21-1 and NSE. Conclusion: The use of the tumour markers alone or in combination showed a low sensitivity and low accuracy for the diagnostic differentiation of MSPLs from BSPLs and primary lung cancers from BSPLs. However, both CYFRA 21-1 and NSE exhibited a specificity of 100% and may be useful complements to standard clinical imaging methods.

Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis.

Persisting controversy surrounds the use of transthoracic needle aspiration biopsy (TNAB) stemming from its uncertain diagnostic accuracy. A systematic review and meta-analysis was therefore conducted to evaluate the accuracy of TNAB for the diagnosis of solitary or multiple localised pulmonary lesions. Searches for English literature papers in Index Medicus (1963-1965) and Medline (1966-1996) were performed and the bibliographies of the retrieved articles were systematically reviewed. Articles evaluating the accuracy of TNAB in series of consecutive patients presenting with solitary or multiple pulmonary lesions were considered. Only papers in which >/=90% of patients were given a final diagnosis according to an appropriate reference standard were included in the meta-analysis. A total of 48 studies were included and five meta-analyses were conducted according to four diagnostic thresholds. From the pooled sensitivity and specificity corresponding to each diagnostic threshold, associated likelihood ratios (LRs) were derived for malignant disease as follows: (1) malignant versus all other categories, LR = 72; (2) malignant or suspicious versus all others, LR = 49; (3) suspicious versus all categories but malignant, LR = 15; (4) benign versus all others, LR = 0.07; and (5) specific benign diagnosis versus all others, LR = 0.005. Differences in methodological quality of the studies, needle types, or whether a cytopathologist participated in the procedure failed to explain the heterogeneity of the results found in almost every meta-analysis. Given a 50% probability of malignancy prior to the TNAB, post-test probabilities of malignancy upon receiving the results would be malignant, 99%; suspicious, 94%; non-specific benign, 7%; and benign with a specific diagnosis, 0.6%. Given the intermediate pre-test probabilities that would probably lead to performing TNAB, findings of "malignant" or of a specific diagnosis of a benign condition provide definitive results. Findings of "suspicious" markedly increase the probability of malignancy, and "benign" markedly decreases it but may not be considered definitive.

Surgical resection of pulmonary metastases from gastric cancer.

There are no reports concerning surgical treatment on pulmonary metastases from gastric cancer. The aims of this study were to characterize patients with pulmonary metastasis from gastric cancer and to determine the efficacy of surgical therapy. Between 1977 and 1993, 3,076 patients underwent curative resection for gastric cancer. Among them, four patients (0.1%) with pulmonary metastases from gastric cancer underwent pulmonary resection. All four patients had advanced gastric cancers involving regional lymph nodes far from the primary gastric lesion. The median tumor-free interval after the initial gastrectomy was 32.0 months (range: 19-48 months). All patients underwent a lobectomy for a solitary pulmonary lesion. Although transthoracic fine-needle aspiration cytology revealed adenocarcinoma in all cases, none of them were definitely diagnosed as metastasis from gastric cancer preoperatively. The diagnosis was obtained after pulmonary resection. All patients received postoperative chemotherapy or radiotherapy, or both. However, they all subsequently developed systematic metastases. The time interval to recurrence after pulmonary resection ranged from 6 to 36 months and they were all dead at a median follow-up of 24.3 months after the pulmonary resection. An aggressive surgical approach was not warranted in patients with isolated resectable pulmonary metastases from gastric cancer. However, the possibility of surgical treatment could not be eliminated because surgery is the only diagnostic method for a solitary pulmonary nodule when there is some doubt about the diagnosis of primary or secondary lung cancer in patients with gastric cancer.

Catamenial Hemoptysis: Diagnosis With MRI

Thoracic endometriosis is a rare disorder. We report a case of a 26-year-old woman with a 4-year history of catamenial hemoptysis due to thoracic endometriosis which was diagnosed by MRI and treated successfully by means of video-assisted thoracoscopic wedge-resection of the solitary pulmonary lesion. Medical therapy with hormones was not necessary. There is no evidence of recurrence 10 months after the operation. This case demonstrates that MRI of the chest may be considered for the diagnostic work-up of patients with catamenial hemoptysis. It also shows that wedge-resection of pulmonary endometriosis foci by means of video-assisted thoracoscopy-an approach that has not been described in the literature thus far-is an effective therapy in localized peripheral pulmonary parenchymal endometriosis.

Evaluation of the air bronchogram sign on CT in solitary pulmonary lesions.

Our goal was to evaluate the presence and the significance of the air bronchogram sign in solitary pulmonary lesions (SPL) on CT. One hundred thirty-two patients with SPL who underwent chest CT scans and had histological diagnosis were studied retrospectively. We reviewed all chest CT scans to assess for the presence of the air bronchogram sign in the SPL and recorded the distribution of this sign in malignant and benign lesions. The morphology of the aerated bronchi in the lesion and its significance in differential diagnosis were also evaluated. Of 17 cases of benign lesions, only 1 (5.9%) had an air bronchogram; of 115 lung cancers, 33 (28.7%) had this sign (p < 0.05). The encased bronchi exhibited four morphologic patterns: normal, tortuous, ectatic, and cut-off. The morphology of the bronchus in the benign lesion was normal. However, bronchi in malignant lesions displayed all four types of morphology. The air bronchogram sign was seen in all histologic types of lung cancer (squamous cell 10, adenocarcinoma 9, bronchioloalveolar cell 12, small cell 1, non-small cell 1). Lesions of different sizes were noted to have air bronchograms, including those < 2 cm in diameter. The CT air bronchogram sign in SPL is significantly more common in malignant than in benign lesions. The sign is seen in all lung cancer cell types and demonstrates varied bronchial morphology.

Differentiation of solitary pulmonary coin lesions by high-resolution computerized tomography

The aim of this prospective study was not to describe individual morphological findings in benign and malignant solitary intrapulmonary nodules; it was instead to examine in a critical manner the indications for differentiation found in the literature in order to facilitate safe differential diagnosis of benign and malignant nodules. A total of 64 solitary pulmonary nodules were examined with high-resolution computed tomography and correlated with histological findings. Only lesions that had been removed by surgery were used. No lesion was excluded on the grounds of size. Useful characteristics for the differentiation of benign from malignant pulmonary nodules were: diameter and density of the lesion, air inclusion, unsharp and dystelectatic margin, the presence of spicules, length of spicules, spicules extending to the visceral pleura, pleural tail sign and cirumscribed pleural thickening. For the differentiation of benign and malignant solitary pulmonary nodules meticulous assessment of the margin of the nodule is necessary. Using the criteria mentioned, a sensitivity of 85% and a specifity of 78% can be achieved for the identification of malignant pulmonary nodules. Since it was not possible to differentiate between benign and malignant nodules with certainty using imaging methods, the chance of patient survival could only be promoted by early surgery.

Temporal Trends in the Prevalence of Malignancy in Resected Solitary Pulmonary Lesions

To determine whether there has been an increase in the prevalence of malignancy among resected, indeterminate solitary pulmonary lesions (SPL) over the past 14 years. A retrospective review of all thoracotomies for indeterminate SPLs from 1981 through 1994. A university-affiliated VA Medical Center. Three-hundred seventy resected indeterminate SPLs (all < or = 6 cm) in 360 patients. Virtually all patients were men with an average age of 63 +/- 9 years. The average lesion size was 2.5 +/- 1.4 cm; 71% were 3 cm or less. Overall, 79% of resected lesions were malignant; 94% of these were bronchogenic carcinomas. Granulomas accounted for more than 50% of benign lesions. The proportion of malignant diagnoses increased from 55 to 60% in 1981 to 1983 to 90 to 100% in 1990 to 1994 (p < 0.005). The increasing proportion of malignancy over time was independent of age at time of operation and lesion size. There was no significant difference in survival among patients with a malignant lesion resected in 1981 to 1983 compared with 1990 to 1994. We conclude that there has been a striking increase in the prevalence of malignancy among resected indeterminate SPLs over the past 14 years in our institution. We suspect that this trend reflects improvements in our ability to diagnose benign SPLs preoperatively, primarily through the use of CT. Our results should prompt other institutions to review their recent experience with the diagnosis of indeterminate SPLs to provide more timely information to physicians and their patients who are contemplating resection of SPLs.

Clinical evaluation of the small solitary pulmonary nodule

The diagnostic process for small solitary pulmonary nodules was retrospectively analyzed. Three hundred and forty-three patients, each with a solitary pulmonary lesion of less than 3 cm on chest radiography, were evaluated. The patients were seen at our hospital between September 1986 and December 1993. They consisted of 138 with malignant diseases (114 with lung cancer and 24 with metastatic tumors), and 205 with benign diseases. There were 146 patients (71%) with benign lesions of less than 2 cm. The diagnosis in 118 patients (86%) with malignant disease was made by lung biopsy. Of these 118 patients, 19 underwent biopsy of the lung through a thoracoscope or open lung biopsy via a thoracotomy. Benign diseases were diagnosed in 167 patients (81%) by various laboratory tests and imaging techniques, including chest radiography. Thinsection CT was done in 132 patients. In 72 of these 132 patients (16 with lung cancer, 23 with metastatic tumors, and 33 with benign tumors), a judgement regarding whether the lesion was malignant or not could not be made. Therefore, open lung biopsy was done in 5 patients. Twenty-four patients were only observed, 43 underwent biopsy, and 35 underwent surgery. A decision tree needs to be established to select therapeutic options for management of patients whose diagnoses remain indeterminate even after thin-section CT. Formulation of a decision tree based not only on clinical findings but also on the results of diagnostic imaging is necessary to improve clinical decision making regarding small solitary pulmonary nodules.

Solitary pulmonary metastasis of gestational choriocarcinoma.

Gestational choriocarcinoma is a highly malignant tumor which arises from the trophoblast of human pregnancy. This tumor develops early pulmonary metastasis and the most common pattern of pulmonary metastasis is discrete multiple nodules. But occasionally solitary pulmonary metastasis occurs. Authors presented three cases of choriocarcinoma presented with different types of solitary pulmonary metastases with review of literatures. We emphasize the importance of careful obstetric history taking and screening of serum gonadotropin level in differential diagnosis of solitary pulmonary lesion especially among women who are from areas of high prevalence of trophoblastic neoplasia.

Intraparenchymal pulmonary lymph node: case report and literature review

A case of a 44-year-old woman with a solitary pulmonary coin lesion is presented. Histologic study of this nodule revealed a normal intraparenchymal pulmonary lymph node. A review of the literature discusses the incidence and characteristics of this entity.

The Impact of Thoracic Computed Tomography in Clinically Staged T1, NO, MO Chest Lesions

We assessed the impact of thoracic computed tomography (CT) in 38 patients considered for thoracotomy for solitary pulmonary lesions characterized as T1, N0, M0 by clinical and roentgenographic staging. False-positive lymph nodes were identified by CT in four patients prompting additional surgical staging procedures in two cases. Two of three patients with false-negative clinical, roentgenographic, and CT findings had successful complete resections. The CT scan did not correctly advance the stage of, or alter the plan for, these lesions in any patient. We conclude that CT is not helpful in patients considered for diagnostic and therapeutic thoracotomy for clinical and roentgenographic T1, N0, M0 lesions.

The Evaluation of Lung Tuberculosis Appearing as a Solitary Pulmonary Lesion

The Evaluation of Lung Tuberculosis Appearing as a Solitary Pulmonary Lesion

Solitary coin lesion in patients with malignant melanoma: an indication for thoracotomy?

In five patients solitary pulmonary lesions were detected radiographically during routine follow up after malignant melanoma. Surgical removal was done in each case under the tentative diagnosis of metastases. Histologically, two lesions turned out as benign chondroma, one as organized pulmonary infarction and one as bronchogenic carcinoma. Only in one patient was a melanoma metastasis present. The findings underline the usefulness also in malignant melanoma of a surgical approach in suspected solitary pulmonary metastases.