[03.17] CMD - Benign & Malignant Pulmonary Disease V2.pdf

Solitary pulmonary nodule

What term describes an x-ray density completely surrounded by normal aerated lung with circumscribed margins of any shape?

One to six centimeters

What is the typical size range in greatest diameter for a solitary pulmonary nodule?

Malignant and non-malignant

What are the two broad clinical categories into which solitary pulmonary nodules can be divided?

Solid primary, metastatic, and hematolymphoid

What are the three histopathologic categories of malignant pulmonary nodules?

Infection, infarct, histiocytosis, sarcoidosis, beryllium disease, vasculitis, and amyloidosis

What are seven histopathologic categories of non-malignant pulmonary nodules?

Granulomas, abscess, necrobiotic nodule, and miliary

What are four specific infectious entities that can present as non-malignant pulmonary nodules?

Solid and subsolid

What are the two major classification categories of solitary pulmonary nodules on imaging?

Solid SPNs

Which type of SPN is characterized by areas of opacification that are denser than those seen in subsolid SPNs?

Part solid or pure ground-glass opacity

What are the two types of subsolid solitary pulmonary nodules?

Differentiate between solid and subsolid SPNs

What is the first and most critical imaging task when assessing an SPN because it dictates the timing of monitoring and diagnostics?

Benign calcification patterns

When a new nodule is found on CT scanning, what radiographic patterns should the clinician first look for?

Stability in size or number

What should a clinician check for by retrieving a patient's previous CT scans or X-ray films when a new nodule is found?

Two years

What is the minimum duration over which an SPN must demonstrate stability in size and number on archival films to be considered benign?

No further testing is needed

What is the management recommendation if a solitary pulmonary nodule demonstrates benign calcification on CT or has been stable for two years?

Assess cancer probability and surgical risk

What two actions must a clinician perform if an SPN shows growth, an increase in number, or no signs of benignity over two years?

Lung function testing

What objective testing modality is used to assess a patient's surgical risk when considering nodule resection?

Predicted postoperative FEV1 less than zero point eight liters

What specific spirometric threshold of predicted postoperative lung function indicates high risk for thoracic surgery?

VO2 max less than ten to fifteen milliliters per kilogram per minute

What specific cardiopulmonary exercise testing threshold indicates high risk for thoracic surgery?

Age, sex, race, and family history

What are four demographic factors to consider when estimating the pre-test probability of nodule malignancy?

Tobacco and other inhaled carcinogens

What are the two major environmental exposures to consider when estimating malignancy probability?

Size and morphology

What two physical characteristics of the nodule itself must be evaluated to estimate malignancy probability?

Nodule location, multiplicity, and growth rate

What are three spatial and temporal characteristics of SPNs used to estimate malignancy probability?

One to four nodules

Within what specific range of nodule multiplicity does the risk of cancer increase as the number of nodules increases?

Surrounding emphysema and fibrosis

The presence of what two chronic parenchymal lung changes on imaging increases the probability of nodule malignancy?

Ten-fold or greater

By what factor or greater does cigarette smoking increase a patient's risk for developing lung cancer?

Asbestos, arsenic, bischloromethyl ether, hexavalent chromium, mustard gas, and nickel

What are six occupational chemical or material exposures that increase the risk of lung cancer?

Ionizing radiation and radon

What are two non-chemical environmental radiation exposures that increase the risk of lung cancer?

Chronic bronchitis, emphysema, and tuberculosis

What three prior lung diseases are established clinical risk factors for lung cancer?

Genetic polymorphisms

What genetic factors can predispose a patient to developing a malignant pulmonary nodule?

Lack of growth over a period of more than two years

What temporal radiological finding is the strongest sign that a pulmonary nodule is benign?

Stable nodule

What clinical term describes a pulmonary nodule that has shown no growth or change over a period of more than two years?

Dense central nidus, multiple punctate foci, granuloma, and hamartoma

What are the four characteristic patterns of benign calcification in pulmonary nodules?

Granuloma

Which benign calcification pattern is also known colloquially as a bull's eye?

Hamartoma

Which benign calcification pattern is also known colloquially as a popcorn ball?

No follow-up or diagnostic work-up is needed

What is the recommended management for a patient whose nodule is stable and demonstrates radiographic signs of benignity?

Central, laminated, and popcorn

What are the three classic types of calcification seen on imaging in a benign hamartoma?

Laminated calcification

What type of calcification, besides a central nidus, is seen on a CT scan of a hamartoma?

Periphery of the lesion

Where are calcifications usually located if they are present in a malignant pulmonary lesion?

Granuloma

What benign calcified lung lesion is extremely common in the Philippines, especially among individuals undergoing routine physical examinations for work clearance?

Highly dense, well-defined calcification stable for five years

What are the three key radiographic characteristics of a healed TB granuloma?

Relatively large size, lack of/asymmetric calcification, and chest symptoms

What are three clinical and basic radiological signs suggestive of malignancy in an SPN?

Associated atelectasis or obstructive pneumonitis

What two secondary airway changes on chest imaging are suggestive of an underlying malignant nodule?

Growth on serial imaging or a positive PET scan

What two objective findings during serial radiological and metabolic monitoring are highly suggestive of malignancy?

Tuberculosis lesions also light up on PET scan

What is the primary diagnostic limitation of a positive PET scan in a country where TB is endemic?

Twenty to four hundred days

What is the overall range of doubling time for a malignant pulmonary nodule?

Less than one hundred days

What is the doubling time for most solid malignant pulmonary nodules?

Greater than two hundred days

How is the doubling time of subsolid and ground-glass malignant nodules characterized compared to solid malignant nodules?

An infectious or inflammatory cause

What does a very rapid doubling time of less than twenty days suggest on chest imaging?

Upper lobe

In what lung lobe are malignant nodules more commonly located?

High prevalence of tuberculosis

Why is the diagnostic significance of an upper lobe location for identifying malignant nodules reduced in Asian populations?

Lobulated or spiculated

What two types of margins on a pulmonary nodule are most strongly associated with malignancy?

Notches

What specific structural indentation is commonly seen along the margins of adenocarcinomas with overt tissue invasion?

Irregular walls greater than fifteen millimeters thick

What wall thickness and contour characteristics of a cavitary lesion suggest a malignant etiology?

Wall of the cavitation

When a cavitary lesion is seen on CT, what specific structure must be measured to differentiate tuberculosis from malignancy?

Greater than two centimeters

Above what size threshold does the pre-test probability of malignancy significantly increase?

Punctate and eccentric

What two patterns of calcification represent evidence of necrosis within a nodule and can occur in malignancy?

Vascular convergence and dilated bronchus leading into the nodule

What are two secondary vascular and airway features on CT suggestive of malignancy?

Diameter less than one point five centimeters, age less than forty-five, and never smoker

What are three clinical criteria that define a low risk of cancer in a patient with an SPN?

Quit seven or more years ago, and smooth nodule margins

What are two smoking cessation and margin criteria that classify a patient as having a low risk of cancer?

Diameter of one point five to two point two centimeters, age of forty-five to sixty, and current smoker of less than twenty cigarettes per day

What are three clinical criteria that define an intermediate risk of cancer in a patient with an SPN?

Quit less than seven years ago, and scalloped margins

What are two smoking cessation and margin criteria that classify a patient as having an intermediate risk of cancer?

Diameter of two point three centimeters or greater, age greater than sixty, and current smoker of twenty or more cigarettes per day

What are three clinical criteria that define a high risk of cancer in a patient with an SPN?

Never quit smoking, and corona radiata or spiculated margins

What are two smoking cessation and margin criteria that classify a patient as having a high risk of cancer?

Clinician intuition

What subjective assessment tool is used alongside structured risk prediction models to estimate malignancy probability?

Tammemagi, PanCan/Brock, Mayo Clinic/Herder, and LungRADS

What are four validated tools or risk prediction models used to assess the pre-test probability of nodule malignancy?

British Thoracic Society and Cancer Research UK phone application

What mobile phone application or tool can be used to easily calculate nodule malignancy risk in clinical practice?

VATS and examination of a frozen section

What two diagnostic and surgical interventions are recommended for patients with a high probability of malignancy?

Lobectomy of the nodule

What surgical intervention is recommended if a frozen section obtained during VATS is positive for malignancy?

Malignancy has spread to other sites

Under what specific anatomical condition is immediate lobectomy not recommended for a high-probability nodule?

Minimally invasive tissue sampling

What alternative approach should be considered if a patient or clinician deems upfront surgical resection too aggressive?

Serial high-resolution CT scans

What is the recommended management for a patient with a low probability of nodule malignancy?

Three, six, nine, twelve, and twenty-four months

What is the exact serial interval schedule for performing high-resolution CT scans in a patient with low-probability SPNs?

Nodule is one centimeter or greater in diameter

What is the size threshold required to perform a PET scan in a patient with a moderate probability of cancer?

Contrast-enhanced CT

What imaging modality can be performed for moderate-probability nodules depending on institutional expertise?

Transthoracic fine-needle aspiration biopsy

What diagnostic procedure is indicated for a moderate-probability nodule if the lesion is peripherally located?

Bronchoscopy

What diagnostic procedure is indicated for a moderate-probability nodule if an air-bronchus sign is present on CT?

Nodule size, solid vs subsolid, and single vs multiple

What three major factors does the Fleischner Society 2017 Guidelines take into consideration to guide nodule management?

Tissue sampling or serial CT scan surveillance

What two management paths are determined based on the Fleischner Society 2017 Guidelines?

Six millimeters

What is the clinical size threshold, or magic number, used in the Fleischner Society 2017 Guidelines for solid nodules?

No routine follow-up

What is the recommended management for a single solid nodule less than six millimeters in size in a low-risk patient?

Optional CT scan at twelve months

What is the recommended management for a single solid nodule less than six millimeters in size in a high-risk patient?

CT scan at six to twelve months, then consider CT scan at eighteen to twenty-four months

What is the follow-up schedule for a single solid nodule of six to eight millimeters in a low-risk patient?

CT scan at six to twelve months, then CT scan at eighteen to twenty-four months

What is the follow-up schedule for a single solid nodule of six to eight millimeters in a high-risk patient?

Consider CT scan at three months, PET/CT, or tissue sampling

What are the three management options for a single solid nodule greater than eight millimeters in size in both low and high-risk patients?

No routine follow-up

What is the recommended management for multiple solid nodules less than six millimeters in size in a low-risk patient?

Optional CT scan at twelve months

What is the recommended management for multiple solid nodules less than six millimeters in size in a high-risk patient?

CT scan at three to six months, then consider CT scan at eighteen to twenty-four months

What is the follow-up schedule for multiple solid nodules of six to eight millimeters in a low-risk patient?

CT scan at three to six months, then CT scan at eighteen to twenty-four months

What is the follow-up schedule for multiple solid nodules of six to eight millimeters in a high-risk patient?

CT scan at three to six months, then consider CT scan at eighteen to twenty-four months

What is the follow-up schedule for multiple solid nodules greater than eight millimeters in a low-risk patient?

CT scan at three to six months, then CT scan at eighteen to twenty-four months

What is the follow-up schedule for multiple solid nodules greater than eight millimeters in a high-risk patient?

Use the most suspicious nodule as a guide to management

What is the key clinical rule when managing multiple solid nodules of varying sizes or risk levels?

No routine follow-up

What is the recommended management for a single ground-glass subsolid nodule less than six millimeters in size?

CT scan at six to twelve months to confirm persistence, then CT scan every two years until five years

What is the complete follow-up schedule for a single ground-glass subsolid nodule six millimeters or greater in size?

No routine follow-up

What is the recommended management for a single part-solid subsolid nodule less than six millimeters in size?

CT scan at three to six months to confirm persistence

What is the initial follow-up recommendation for a single part-solid subsolid nodule six millimeters or greater in size?

Annual CT scan should be performed for five years

What is the subsequent management if a single part-solid nodule six millimeters or greater remains unchanged and the solid component is less than six millimeters?

Highly suspicious for malignancy

How should persistent part-solid nodules with solid components of six millimeters or greater be clinically regarded?

CT scan at three to six months

What is the initial follow-up recommendation for multiple subsolid nodules less than six millimeters in size?

Consider CT scan at two and four years

What is the subsequent follow-up recommendation if multiple subsolid nodules less than six millimeters are found to be stable?

CT scan at three to six months

What is the initial follow-up recommendation for multiple subsolid nodules six millimeters or greater in size?