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Diagnostic evaluation of the incidental pulmonary nodule

Authors
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
Susanna I Lee, MD, PhD
Geraldine Finlay, MD

INTRODUCTION

Pulmonary nodules may be detected on cross-sectional imaging studies performed for an unrelated reason (ie, incidental pulmonary nodule). The major question that follows detection of a pulmonary nodule is the probability of malignancy, with subsequent management varying accordingly. The approach in this topic applies to nodules found incidentally in patients ≥35 years old without signs or symptoms attributable to the lesion and with a baseline risk of lung cancer equivalent to that of the general population. Separate strategies and individual adjustments are needed for other populations including patients who are undergoing lung cancer screening and for those who are immunocompromised, have a history of malignancy actively under treatment or follow-up, or are presenting with pulmonary symptoms (ie, suspected lung cancer).

The approach to patients with suspected lung cancer and indications for lung cancer screening are discussed separately. (See "Overview of the initial evaluation, diagnosis, and staging of patients with suspected lung cancer" and "Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer" and "Screening for lung cancer".)

DEFINITIONS

A pulmonary nodule is defined on imaging as a small (≤30 mm), well defined lesion completely surrounded by pulmonary parenchyma [1-4]. Morphologically, nodules are classified as solid (image 1) or subsolid; subsolid nodules are subdivided into pure ground-glass nodules (ie, no solid component) (image 2) and part-solid nodules (ie, both ground-glass and solid components) (image 3) [1]. Lesions that measure >30 mm are considered masses, rather than nodules, harbor a much higher likelihood of being malignant, and are discussed separately. (See "Overview of the initial evaluation, diagnosis, and staging of patients with suspected lung cancer".)

Multiple pulmonary nodules are, on occasion, also encountered incidentally. In this setting, the diagnostic evaluation refers to the predominant type or the most suspicious nodule (eg, largest, growing).

DIFFERENTIAL DIAGNOSIS

The causes of incidental pulmonary nodules can be categorized as benign or malignant (table 1). The estimated frequency of each etiology varies substantially among studies, reflecting differences in the population studied and the methodology used to establish a diagnosis [5-11]. Nonetheless, screening studies of smokers who are at high risk of malignancy suggest that the vast majority of nodules identified on computed tomography (CT) are benign. As an example, in the Pan-Canadian Early Detection of Lung Cancer and the British Columbia Cancer Agency studies, among the 12,029 nodules found, only 144 (1 percent) were malignant [12]. The incidence of malignant nodules is likely much lower in patient at average or low risk for lung cancer.

                                       
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Literature review current through: Nov 2017. | This topic last updated: Nov 21, 2017.
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