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Solitary Pulmonary Nodules: Detection, Characterization, and Guidance for Further Diagnostic Workup and Treatment

Yeong Joo Jeong1,2, Chin A. Yi1 and Kyung Soo Lee1

1 Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Kangnam-gu, Seoul 135-710, South Korea.
2 Present address: Department of Diagnostic Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Pusan, Korea.


Figure 1
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  		Fig. 1 —Screen shot of computer-aided detection system in 44-year-old woman shows 7-mm nodule in right apex (arrow) adjacent to mediastinal great vessels that was not detected on computer-assisted detection system but was detected by radiologists.

 

Figure 2
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  		Fig. 2A —Volume measurement of pulmonary nodule in 47-year-old man with lung adenocarcinoma on computer-aided detection system. Application of region of interest to nodule automatically leads to volume measurement with outline delineation and nodule segmentation.

 

Figure 3
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  		Fig. 2B —Volume measurement of pulmonary nodule in 47-year-old man with lung adenocarcinoma on computer-aided detection system. Volume imaging of nodule and resultant volume of 99 mm3 are shown.

 

Figure 4
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  		Fig. 2C —Volume measurement of pulmonary nodule in 47-year-old man with lung adenocarcinoma on computer-aided detection system. Volume imaging shows 127 mm3 of nodule at follow-up after 93 days. Calculated volume doubling time is 145 days.

 

Figure 5
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  		Fig. 3A —Adenocarcinoma in 67-year-old man shows net enhancement of ≥ 25 H and washout of 5-31 H at dynamic helical CT and positive uptake at integrated PET/CT. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 16-mm nodule (arrow) in left upper lobe has lobulated and spiculated margin.

 

Figure 6
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  		Fig. 3B —Adenocarcinoma in 67-year-old man shows net enhancement of ≥ 25 H and washout of 5-31 H at dynamic helical CT and positive uptake at integrated PET/CT. Attenuation measurements on dynamic helical CT through nodule indicate malignant characteristics, showing peak enhancement of 107 H, net enhancement of 62 H, and absolute loss of enhancement (washout) of 29 H.

 

Figure 7
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  		Fig. 3C —Adenocarcinoma in 67-year-old man shows net enhancement of ≥ 25 H and washout of 5-31 H at dynamic helical CT and positive uptake at integrated PET/CT. PET image (left) shows nodule having positive 18F-FDG uptake, with maximum standardized uptake value (SUV) of 5.6. PET image was integrated with CT image (right). Arrow on right = nodule.

 

Figure 8
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  		Fig. 4A —Metastatic adenocarcinoma in 57-year-old man with rectal cancer shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT and positive uptake on integrated PET/CT. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 9-mm nodule (arrow) in left upper lobe.

 

Figure 9
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  		Fig. 4B —Metastatic adenocarcinoma in 57-year-old man with rectal cancer shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT and positive uptake on integrated PET/CT. Attenuation measurements on dynamic helical CT through nodule indicate malignant characteristics, showing peak enhancement of 111 H, net enhancement of 46 H, and absolute loss of enhancement (washout) of 23 H.

 

Figure 10
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  		Fig. 4C —Metastatic adenocarcinoma in 57-year-old man with rectal cancer shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT and positive uptake on integrated PET/CT. PET image (left) shows nodule having positive 18F-FDG uptake, with maximum standardized uptake value (SUV) of 3.6. PET image was integrated with CT image (right). Arrow on right = nodule.

 

Figure 11
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  		Fig. 5A —Adenocarcinoma with predominantly nonmucinous bronchioloalveolar carcinoma component in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but little 18F-FDG uptake on integrated PET/CT. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 25-mm semisolid nodule (arrow) of mixed solid and ground-glass attenuation in left upper lobe.

 

Figure 12
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  		Fig. 5B —Adenocarcinoma with predominantly nonmucinous bronchioloalveolar carcinoma component in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but little 18F-FDG uptake on integrated PET/CT. Attenuation measurements on dynamic helical CT through nodule indicate malignant characteristics, showing peak enhancement of 110 H, net enhancement of 64 H, and absolute loss of enhancement (washout) of 26 H.

 

Figure 13
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  		Fig. 5C —Adenocarcinoma with predominantly nonmucinous bronchioloalveolar carcinoma component in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but little 18F-FDG uptake on integrated PET/CT. PET image (left) shows relatively little 18F-FDG uptake in nodule, with maximum standardized uptake value of 1.4. PET image was integrated with CT image (right). Arrow on right = nodule.

 

Figure 14
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  		Fig. 6A —Small adenocarcinoma in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but negligible 18F-FDG uptake on integrated PET/CT. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 9-mm nodule (arrow) in right upper lobe.

 

Figure 15
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  		Fig. 6B —Small adenocarcinoma in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but negligible 18F-FDG uptake on integrated PET/CT. Attenuation measurements on dynamic helical CT through nodule indicate malignant characteristics, showing peak enhancement of 121 H, net enhancement of 52 H, and absolute loss of enhancement (washout) of 8 H.

 

Figure 16
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  		Fig. 6C —Small adenocarcinoma in 49-year-old woman shows net enhancement of ≥ 25 H and washout of 5-31 H on dynamic helical CT but negligible 18F-FDG uptake on integrated PET/CT. PET image (left) shows negligible 18F-FDG uptake in nodule. PET image was integrated with CT image (right). Arrow on right = 18F-FDG uptake in nodule.

 

Figure 17
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  		Fig. 7A —55-year-old woman with lung adenocarcinoma. Positive correlation between extent of enhancement and microvascular density in immunostaining. Lung window of transverse thin-section (2.5-mm collimation) CT scan shows 23-mm nodule in left upper lobe (arrow).

 

Figure 18
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  		Fig. 7B —55-year-old woman with lung adenocarcinoma. Positive correlation between extent of enhancement and microvascular density in immunostaining. Attenuation measurements on dynamic helical CT through nodule show high enhancement: peak enhancement of 112 H, net enhancement of 48 H, and absolute loss of enhancement (washout) of 28 H.

 

Figure 19
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  		Fig. 7C —55-year-old woman with lung adenocarcinoma. Positive correlation between extent of enhancement and microvascular density in immunostaining. Microvessel density with immunostaining for CD31 shows dark brownish stain in vessel wall (arrows), indicating high vessel density. (x100)

 

Figure 20
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  		Fig. 8A —Adenocarcinoma in right upper lobe in 63-year-old woman with metastases in right lower paratracheal and right hilar nodes, which were detected on dynamic helical CT but not on integrated PET/CT. On transverse (5.0-mm section thickness) enhanced CT scan, lymph nodes having a short-axis diameter of < 10 mm are noticed in right lower paratracheal (arrow) area, representing benignity according to CT size criteria for malignant nodes.

 

Figure 21
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  		Fig. 8B —Adenocarcinoma in right upper lobe in 63-year-old woman with metastases in right lower paratracheal and right hilar nodes, which were detected on dynamic helical CT but not on integrated PET/CT. Attenuation measurements on dynamic helical CT through nodule indicate probable mediastinal nodal metastasis, with peak enhancement of 123 H and net enhancement of 71 H.

 

Figure 22
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  		Fig. 8C —Adenocarcinoma in right upper lobe in 63-year-old woman with metastases in right lower paratracheal and right hilar nodes, which were detected on dynamic helical CT but not on integrated PET/CT. PET (left) and integrated PET/CT (right) images show maximum standardized uptake value (SUV) of 8.8 in primary nodule (arrow) in right upper lobe. PET image obtained on similar level to A (not shown) did not show any identifiable 18F-FDG uptake in mediastinal nodes.

 

Figure 23
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  		Fig. 9 —Suggested algorithmic approach for solitary pulmonary nodules. SPN = solitary pulmonary nodule, CXR = chest radiography, Ben. = benign, Ca++ = calcification, WI = wash-in, Mal. = malignant, WO = washout.

 

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