Pulmonary Exam PDF

Pulmonary Nodules and Lung Cancer Pulmonary Nodules - A small ( 3 cm = “mass” - Carries a MUCH higher risk of malignancy Benign Malignant Infectious Granuloma (80%) Primary Lung Cancer - Fungal: histoplasm...

Pulmonary Nodules and Lung Cancer Pulmonary Nodules - A small ( 3 cm = “mass” - Carries a MUCH higher risk of malignancy Benign Malignant Infectious Granuloma (80%) Primary Lung Cancer - Fungal: histoplasmosis - Adenocarcinoma (50%) - Mycobacteria: TB, NTB - MOST COMMON lung CA Hamartoma (10%) - Squamous Cell Carcinoma - Present middle aged, grow slowly - Second most common - “Popcorn calcification” - Focal areas of fat - Calcification alternating w/ fat Patient Hx: - Age - Risk increases w/ age - RARE < 35 y/o - History or current cigarette use/smoking - Hx of malignancy → metastasis? - Hx of pulmonary disease → COPD, others? - Family hx → lung cancer, rheumatologic dz, etc. - Occupational & Environmental Exposure - ASBESTOS → can develop into mesothelioma Initial Eval - Physical exam: ASYMPTOMATIC - Radiographic evaluation - Review presenting imaging modality (CXR vs. CT) - Compare to any previous chest imaging studies - Rapid progression (doubling in < 30 days) → INFECTION - Gradual progression → MALIGNANCY - Diagnostic test of choice = Chest CT w/o contrast - After PET Scan for metastases  Radiograph Interpretation Pulmonary Attenuation/ Calcification Pattern Nodule Border Enhancement Location Nodule Size Density Increased size = Solid nodule Benign Benign: Benign: Upper lobe increased risk of - More - Diffuse/ - Smooth Stable Nodule = more malignancy common complete - Well-defined x 2 years malignant calcification < 5 mm: 1% - Benign - Seen w/ prior Malignant: Malignant 5-9 mm: 2-6% infx → histo- - Spiculated Growth 19-20 mm: 18% Subsolid Nodule plasmosis or - Lobular > 20 mm: 50% - Pure ground TB glass or part - Central and solid laminated - Malignant calcification - Popcorn calcification → Hamartoma - Fat and calcified pattern Malignant - Stippled - Eccentric If nodule has fat or calcification → No further follow-up Likelihood of Malignancy - Utilize calculator to assess probability of malignancy - Low: < 5% - Watchful waiting or no further workup - Moderate: 5-65% - Serial imaging w/ chest CT - High: >65% - Resection Size of Nodule - < 6 mm solid nodule - DO NOT require routine follow up if pt. does not have risk factors for lung CA - If risk factors → 12-month CT - 6-8 mm solid nodule - Requires follow up Chest CT in 6-12 months - If nodule unchanged: - Low risk may stop serial CT - High or intermediate risk = repeat another chest CT in 18-24 months  - >8 mm solid nodule - Low risk patients → Chest CT in 3 months - High or intermediate risk pt → PET scan and/or biopsy, referral Management - Many pt. can be followed with serial chest CT’s - Surgical excisional biopsy - Gold standard for diagnosis of pulmonary nodule - AND can be curative for some malignancies - Diagnostic wedge resection via video-assisted thoracic surgery (VATS) - Used for patients at high risk (>65%) - Nonsurgical biopsy - Utilized bronchoscopic technique or transthoracic needle - Preferred in pt. who are intermediate risk (5-65%) w/ CT changes Utilize calculator to assess probability of malignancy - Low: 2cm) Smooth borders Irregular borders Small (