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Diagnostic evaluation and management of the solitary pulmonary nodule

Steven E Weinberger, MD
Shaunagh McDermott, MD
Section Editors
Nestor L Muller, MD, PhD
Talmadge E King, Jr, MD
David E Midthun, MD
Sanjeev Bhalla, MD
Deputy Editors
Geraldine Finlay, MD
Susanna I Lee, MD, PhD


A solitary pulmonary nodule (SPN) is a common clinical problem. Lung cancer screening studies of smokers at high risk for malignancy report a prevalence of SPNs as high as 50 percent with additional epidemiological studies reporting a prevalence of incidental nodules identified on computed tomography at 31 percent [1]. The major question that follows detection of a SPN is the probability of malignancy, with subsequent management varying accordingly.

The definition, differential diagnosis, initial evaluation, and management of a SPN are reviewed here. Radiologic evaluation of pulmonary nodules and differential diagnosis of multiple pulmonary nodules is discussed in greater detail separately. (See "Computed tomographic and positron emission tomographic scanning of pulmonary nodules" and "Differential diagnosis and evaluation of multiple pulmonary nodules".)


A solitary pulmonary nodule (SPN) is classically defined as a single, small (≤30 mm), usually well-circumscribed lesion that is surrounded completely by pulmonary parenchyma [2-4]. Patients are usually asymptomatic, and there are typically no associated features on imaging (eg, hilar lymphadenopathy, atelectasis, or pleural effusion) [5,6]. SPNs are further subclassified as solid or subsolid, as discussed separately. (See 'Computed tomography' below.)

Radiologically, lesions that measure ≤30 mm are considered nodules and those >30 mm are considered masses. The distinction between a SPN and a mass is important because it determines further work-up. When patients present with a SPN, the focus of the evaluation is the assessment of the probability of malignancy and the selection of patients for computed tomography (CT) scan surveillance, nonsurgical biopsy, or surgical biopsy. In contrast, when symptoms or associated imaging abnormalities occur in patients with a nodule or mass, work-up should proceed for suspected cancer, as discussed separately. (See "Overview of the initial evaluation, diagnosis, and staging of patients with suspected lung cancer".)

The increased use of CT scanning for benign pathologies has led to the identification of multiple pulmonary nodules on a single scan that are often small and nonspecific (<4 mm). In this setting, a SPN can refer to one "dominant" nodule among many when a single lesion is larger than others, appears to have malignant characteristics (eg, spiculated), or is growing. (See "Differential diagnosis and evaluation of multiple pulmonary nodules".)


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