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Pulmonary Nodules: Detection, Assessment, and CAD

Francis Girvin1 and Jane P. Ko

1 Both authors: Department of Radiology, Thoracic Imaging, New York University Medical Center, 560 1st Ave., New York, NY 10016.


Figure 1
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  		Fig. 1A —Missed lesion on radiograph in 56-year-old man with large cell neuroendocrine carcinoma. On radiograph, sizable lesion was not detected overlapping left first costochondral cartilage. Asymmetric density in this region is clue to nodule in this region.

 

Figure 2
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  		Fig. 1B —Missed lesion on radiograph in 56-year-old man with large cell neuroendocrine carcinoma. Lesion in left upper lobe was identified on CT scan obtained within 1 week of radiograph.

 

Figure 3
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  		Fig. 1C —Missed lesion on radiograph in 56-year-old man with large cell neuroendocrine carcinoma. Overlay on radiograph shows areas where nodules are commonly missed.

 

Figure 4
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  		Fig. 2A —73-year-old man with hamartoma. CT image shows popcorn pattern of calcification in left lower lobe nodule.

 

Figure 5
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  		Fig. 2B —73-year-old man with hamartoma. PET fusion image shows low metabolic activity, with imaging findings most consistent with hamartoma.

 

Figure 6
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  		Fig. 2C —73-year-old man with hamartoma. Histopathology slide from asymptomatic 62-year-old man with hamartoma shows chondroid tissue correlating with calcifications in this entity (H and E, x40) (Courtesy of Nonaka D, New York, NY)

 

Figure 7
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  		Fig. 3A —62-year-old woman who presented with growth of subsolid nodule representing adenocarcinoma with pleural invasion. CT image through nodules in right middle lobe shows two nodules that are subsolid, with one nearly entirely ground-glass (lateral) and the other part solid, part ground-glass in attenuation (medial).

 

Figure 8
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  		Fig. 3B —62-year-old woman who presented with growth of subsolid nodule representing adenocarcinoma with pleural invasion. In CT image obtained 3 years before A, lateral nodule is evident, yet smaller and more medial nodule is not evident.

 

Figure 9
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  		Fig. 4 —Chart shows spectrum of adenocarcinoma. Noguchi pathologic subtypes are on left with correlating appearance of subsolid nodules on CT on right. Subsolid nodules of pure ground-glass attenuation (top) correlate with more indolent constituents and predominantly solid attenuation with more aggressive forms of adenocarcinoma. BAC = bronchoalveolar carcinoma, VDT = volume doubling time.

 

Figure 10
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  		Fig. 5A —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Chest CT shows 2-cm irregularly marginated nodule in right upper lobe, partially occluding posterior subsegmental division of posterior segmental bronchus.

 

Figure 11
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  		Fig. 5B —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. CT-guided transbronchial biopsy displayed on bone window provides better visualization of bronchoscope and forceps tip just proximal to lesion.

 

Figure 12
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  		Fig. 5C —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Images of virtual bronchoscopy including endoluminal view of occluded subsegmental bronchus (F).

 

Figure 13
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  		Fig. 5D —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Images of virtual bronchoscopy including endoluminal view of occluded subsegmental bronchus (F).

 

Figure 14
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  		Fig. 5E —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Images of virtual bronchoscopy including endoluminal view of occluded subsegmental bronchus (F).

 

Figure 15
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  		Fig. 5F —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Images of virtual bronchoscopy including endoluminal view of occluded subsegmental bronchus (F).

 

Figure 16
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  		Fig. 5G —81-year-old man with history of bronchiectasis and atypical mycobacterial infection with right upper lobe nodule representing poorly differentiated non-small-cell lung cancer. Bronchoscopic correlation image shows infiltrative endobronchial lesion.

 

Figure 17
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  		Fig. 6A —76-year-old man with renal cell carcinoma metastasis assessed with nodule enhancement study. Patient presented with incidental nodule on chest radiograph that prompted CT evaluation. CT image displayed on lung windows shows solitary 7-mm nonspecific lung nodule.

 

Figure 18
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  		Fig. 6B —76-year-old man with renal cell carcinoma metastasis assessed with nodule enhancement study. Patient presented with incidental nodule on chest radiograph that prompted CT evaluation. Unenhanced CT image shows nodule that measures 56 HU.

 

Figure 19
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  		Fig. 6C —76-year-old man with renal cell carcinoma metastasis assessed with nodule enhancement study. Patient presented with incidental nodule on chest radiograph that prompted CT evaluation. On CT image displayed on lung windows, at 2 minutes nodule measures 109 HU with peak enhancement of 53 HU. Subsequent workup revealed occult renal cell cancer and excision of lung nodule confirmed renal cell carcinoma metastasis to lung.

 

Figure 20
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  		Fig. 7A —81-year-old woman with adenocarcinoma of lung and false-negative nodule enhancement study. CT image displayed on lung windows shows 2.9-cm right lower lobe nodule.

 

Figure 21
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  		Fig. 7B —81-year-old woman with adenocarcinoma of lung and false-negative nodule enhancement study. Unenhanced CT image shows nodule that measures 26 HU.

 

Figure 22
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  		Fig. 7C —81-year-old woman with adenocarcinoma of lung and false-negative nodule enhancement study. On contrast-enhanced CT image, peak nodule attenuation is 39 HU at 2 minutes, representing peak enhancement of 13 HU. Lesion was not suitable for nodule enhancement study, given large size and obvious central necrosis.

 

Figure 23
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  		Fig. 8A —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. CT image 1.0-mm section through right upper lobe subsolid nodule shows small solid component within lesion.

 

Figure 24
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  		Fig. 8B —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. Images show that PET/CT failed to reveal metabolic activity.

 

Figure 25
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  		Fig. 8C —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. Images show that PET/CT failed to reveal metabolic activity.

 

Figure 26
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  		Fig. 8D —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. Images show that PET/CT failed to reveal metabolic activity.

 

Figure 27
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  		Fig. 8E —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. Images show that PET/CT failed to reveal metabolic activity.

 

Figure 28
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  		Fig. 8F —61-year-old woman with lung cancer with bronchoalveolar cell carcinoma components and negative PET/CT. Histopathology slide shows lepidic growth pattern typical of bronchoalveolar cell carcinoma (H and E, x200).

 

Figure 29
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  		Fig. 9A —54-year-old woman with lung cancer and lung metastases. CT image shows multiple lung nodules ranging in size from 2 to 16 mm.

 

Figure 30
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  		Fig. 9B —54-year-old woman with lung cancer and lung metastases. In axial HASTE image obtained at same level as A, many of nodules in small to intermediate range are not apparent.

 

Figure 31
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  		Fig. 9C —54-year-old woman with lung cancer and lung metastases. Three-dimensional maximum-intensity-projection, T1-weighted, volumetric interpolated breath-hold examination image provides better depiction of small-to-intermediate size lesions compared with HASTE image in this patient.

 

Figure 32
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  		Fig. 10A —Display images from a computer-aided diagnosis (CAD) device. Thin section CT image.

 

Figure 33
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  		Fig. 10B —Display images from a computer-aided diagnosis (CAD) device. Viewing CT image.

 

Figure 34
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  		Fig. 10C —Display images from a computer-aided diagnosis (CAD) device. Nodule marking multiplanar reformation CT image. Round CAD marks (red circles) can be displayed and either deleted or accepted after interpreter evaluates CT images and places own marks (green squares).

 

Figure 35
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  		Fig. 10D —Display images from a computer-aided diagnosis (CAD) device. Volume assessment CT image.

 

Figure 36
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  		Fig. 11A —51-year-old man with gastric cancer and lung metastasis. Staging CT image shows 2-mm nonspecific nodule.

 

Figure 37
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  		Fig. 11B —51-year-old man with gastric cancer and lung metastasis. CT image at 10-month follow-up shows 2-cm nodule, which shows importance of clinical context, even regarding very small lesions.

 

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