What are lung apex nodules. How are lung nodules diagnosed. Are all lung nodules cancerous. What factors increase the risk of cancerous lung nodules. How are lung nodules treated. When should you be concerned about a lung nodule. What is the follow-up process for lung nodules.

What Are Lung Apex Nodules?

Lung apex nodules are small abnormal areas found in the upper part of the lung, typically discovered during chest CT scans. These scans may be performed for various reasons, including lung cancer screening or to investigate respiratory symptoms. It’s crucial to understand that the presence of a lung nodule doesn’t automatically indicate cancer.

How common are lung nodules? Studies suggest that up to 50% of adults who undergo chest CT scans have at least one lung nodule. The vast majority of these nodules are benign, often resulting from old infections, scar tissue, or other non-cancerous causes.

Types of Lung Nodules

• Solid nodules: Appear as uniformly dense areas on CT scans
• Ground-glass nodules: Have a hazy appearance on imaging
• Part-solid nodules: Contain both solid and ground-glass components

Diagnosis of Lung Nodules: A Step-by-Step Process

When a lung nodule is detected, healthcare providers follow a systematic approach to determine its nature. This process often involves multiple steps and may take several months to complete.

Initial Detection and Assessment

The first step in diagnosing a lung nodule is typically through imaging studies. What characteristics do doctors look for in lung nodules? Key factors include:

• Size: Larger nodules are more likely to be cancerous
• Shape: Irregular or spiculated edges may indicate malignancy
• Location: Certain areas of the lung are more prone to cancerous nodules
• Density: Solid nodules may be more concerning than ground-glass opacities
• Growth rate: Rapid growth is often associated with malignancy

Follow-up Imaging

After the initial detection, your doctor will likely recommend a follow-up CT scan. How long should you wait between scans? The timing can vary from a few months to a year, depending on the nodule’s characteristics and your risk factors. This follow-up helps assess any changes in the nodule’s size or appearance.

Advanced Imaging Techniques

In some cases, additional imaging studies may be necessary. For instance, a PET (Positron Emission Tomography) scan can help differentiate between benign and malignant nodules by measuring metabolic activity.

Are All Lung Nodules Cancerous?

No, the majority of lung nodules are not cancerous. In fact, studies show that over 95% of small lung nodules (less than 8mm) are benign. However, it’s essential to undergo proper evaluation to rule out malignancy.

Common Causes of Benign Lung Nodules

• Infections: Bacterial, fungal, or viral infections can leave scarring
• Inflammation: Conditions like sarcoidosis or rheumatoid arthritis
• Hamartomas: Benign tumors composed of various tissue types
• Granulomas: Small areas of inflammation, often due to past infections

Risk Factors for Cancerous Lung Nodules

While most lung nodules are benign, certain factors increase the likelihood of malignancy. Understanding these risk factors can help guide management decisions.

Patient-Related Risk Factors

• Age: Older individuals have a higher risk of cancerous nodules
• Smoking history: Current and former smokers are at increased risk
• Family history of lung cancer
• Personal history of other cancers
• Exposure to occupational carcinogens (e.g., asbestos, radon)

Nodule-Related Risk Factors

• Size: Larger nodules have a higher probability of being cancerous
• Growth rate: Rapid growth is concerning for malignancy
• Appearance: Irregular or spiculated edges may indicate cancer
• Location: Upper lobe nodules are more likely to be malignant

Treatment Options for Lung Nodules

The management of lung nodules depends on various factors, including the nodule’s characteristics, the patient’s risk profile, and overall health status.

Watchful Waiting

For small, low-risk nodules, active surveillance with periodic CT scans may be recommended. How often should these scans be performed? Typically, follow-up scans are done at 3, 6, or 12-month intervals, depending on the nodule’s features and growth rate.

Biopsy Procedures

When a nodule is suspicious for cancer or shows growth over time, a biopsy may be necessary. There are several approaches to obtaining a tissue sample:

• Bronchoscopy: A thin tube is passed through the airways to reach the nodule
• Transthoracic needle biopsy: A needle is inserted through the chest wall under CT guidance
• Surgical biopsy: In some cases, a minimally invasive surgical procedure may be required

Treatment of Malignant Nodules

If a nodule is confirmed to be cancerous, treatment options may include:

• Surgery: Removal of the affected lung tissue
• Radiation therapy: Targeted radiation to destroy cancer cells
• Systemic therapy: Chemotherapy, immunotherapy, or targeted drugs

When Should You Be Concerned About a Lung Nodule?

While the discovery of a lung nodule can be anxiety-inducing, it’s important to maintain perspective. What are the red flags that warrant immediate attention?

• Rapid growth of the nodule between scans
• Development of respiratory symptoms (e.g., persistent cough, chest pain)
• Changes in the nodule’s appearance or density
• Presence of multiple risk factors for lung cancer

If you experience any of these signs, it’s crucial to communicate with your healthcare provider promptly.

The Psychological Impact of Lung Nodule Diagnosis

The discovery of a lung nodule can have significant psychological effects on patients. How can you cope with the uncertainty and anxiety associated with this diagnosis?

Strategies for Managing Anxiety

• Education: Learn about lung nodules from reputable sources
• Communication: Maintain open dialogue with your healthcare team
• Support: Seek emotional support from family, friends, or support groups
• Mindfulness: Practice stress-reduction techniques like meditation or yoga
• Healthy lifestyle: Focus on overall well-being through diet and exercise

Remember, it’s normal to feel anxious, but most lung nodules are benign. Focusing on the facts and following your doctor’s recommendations can help alleviate stress.

Future Directions in Lung Nodule Management

The field of lung nodule diagnosis and management is rapidly evolving. What advancements can we expect in the coming years?

Emerging Technologies

• Artificial Intelligence: AI algorithms to improve nodule detection and characterization
• Liquid biopsies: Blood tests to detect cancer-related DNA or proteins
• Advanced imaging techniques: New modalities to better differentiate benign from malignant nodules
• Personalized risk assessment: Integrating genetic and molecular markers for more accurate prognosis

These innovations hold promise for more accurate and less invasive diagnostic approaches, potentially reducing the need for invasive procedures and improving patient outcomes.

In conclusion, while the discovery of a lung nodule can be concerning, it’s essential to remember that most are benign. A systematic approach to evaluation, along with open communication with your healthcare team, can help navigate this challenging diagnosis. As research progresses, we can look forward to more refined and personalized approaches to lung nodule management, ultimately improving patient care and outcomes.

Lung Nodules | Is a Lung Nodule Cancer?

• If you have a lung nodule
• After the biopsy

A lung nodule (or mass) is a small abnormal area that is sometimes found during a CT scan of the chest. These scans are done for many reasons, such as part of lung cancer screening, or to check the lungs if you have symptoms.

Most lung nodules seen on CT scans are not cancer. They are more often the result of old infections, scar tissue, or other causes. But tests are often needed to be sure a nodule is not cancer.

If you have a lung nodule

Most often the next step is to get a repeat CT scan to see if the nodule is growing over time. The time between scans might range anywhere from a few months to a year, depending on how likely your doctor thinks that the nodule could be cancer. This is based on the size, shape, and location of the nodule, as well as whether it appears to be solid or filled with fluid. If a repeat scan shows that the nodule has grown, your doctor might also want to get another type of imaging test called a positron emission tomography (PET) scan, which can often help tell if it is cancer.

If later scans show that the nodule has grown, or if the nodule has other concerning features, your doctor will want to get a sample of it to check it for cancer cells. This is called a biopsy. This can be done in different ways:

• The doctor might pass a long, thin tube (called a bronchoscope) down your throat and into the airways of your lung to reach the nodule. A small tweezer on the end of the bronchoscope can be used to get a sample of the nodule.
• If the nodule is in the outer part of the lung, the doctor might pass a thin, hollow needle through the skin of the chest wall (with the guidance of a CT scan) and into the nodule to get a sample.
• If there is a higher chance that the nodule is cancer (or if the nodule can’t be reached with a needle or bronchoscope), surgery might be done to remove the nodule and some surrounding lung tissue. Sometimes larger parts of the lung might be removed as well.

These types of tests, biopsies, and surgeries are described in more detail in Tests for Lung Cancer.

After the biopsy

After a biopsy is done, the tissue sample will be looked at closely in the lab by a doctor called a pathologist. The pathologist will check the biopsy for cancer, infection, scar tissue, and other lung problems. If cancer is found, then special tests will be done to find out what kind of cancer it is. If something other than cancer is found, the next step will depend on the diagnosis. Some nodules will be followed with a repeat CT scan in 6-12 months for a few years to make sure it does not change. If the lung nodule biopsy shows an infection, you might be sent to a specialist called an infectious disease doctor, for further testing. Your doctor will decide on the next step, depending on the results of the biopsy.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Araujo LH, Horn L, Merritt RE, Shilo K, Xu-Welliver M, Carbone DP. Ch. 69 – Cancer of the Lung: Non-small cell lung cancer and small cell lung cancer. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa: Elsevier; 2020. 

Chiang A, Detterbeck FC, Stewart T, Decker RH, Tanoue L. Chapter 48: Non-small cell lung cancer. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.

Weinberger SE and McDermott S. UpToDate. Diagnostic evaluation of the incidental pulmonary nodule. This topic last updated: Jun 21, 2019. Accessed at https://www.uptodate.com/contents/diagnostic-evaluation-of-the-incidental-pulmonary-nodule on December 2, 2019. 

American Cancer Society medical information is copyrighted material. For reprint requests, please see our Content Usage Policy.

When to Worry About Lung Nodules or a Spot on the Lungs

If you’ve recently undergone a scan that revealed a nodule on your lungs, you’re probably worried, and you probably have questions. Is a nodule a lung tumor? Does it mean you may have lung cancer?

This news can create a lot of anxiety. Even if your physician tells you the pulmonary nodule is probably noncancerous, most likely he or she has told you the nodule needs to be rechecked every few months with follow-up scans, or that you may need to undergo more tests.

Lack of clarity regarding your future health can be stressful. You want answers, and it can be very frustrating not knowing how long it’s going to take to get them. And, in some health care settings, it may take months.

First, you may be comforted to know that, while lung nodules may be an indicator of lung cancer, benign nodules are common. Common lung nodule causes may include scar tissue, previous infections or other reasons. A CT (computed tomography) scan alone may not be enough to confirm or rule out lung cancer. Lung nodules vary in shape, size and type, and physicians follow specific guidelines in determining whether more testing, such as a PET/CT (positron emission tomography) scan or a lung biopsy, is warranted.

To help you get the information you need, this article answers common questions about lung nodules, including:

• What does a spot on your lung mean?
• Can a CT scan tell if a lung nodule is cancerous?
• What are the benefits of getting an early lung cancer diagnosis?
• What should you do if you have a pulmonary nodule?
• Our rapid lung-nodule diagnosis program

If you’ve recently been told you have a lung nodule and would like to talk with someone at City of Hope about getting a diagnosis, call us or chat online with a member of our team.

What does a spot on your lung mean?

Lung nodules, pulmonary nodules, white spots, lesions—these terms all describe the same phenomenon: an abnormality in the lungs.

What is a pulmonary nodule?

Pulmonary nodules are abnormal growths that form in the lung. They’re typically smaller than 3 centimeters in diameter.

Lung nodules are commonly found after a patient undergoes a chest CT scan for some reason, such as when a patient experiences symptoms of lung disease or during a lung cancer screening. Sometimes, a physician inadvertently spots a lung nodule while doing a CT screening of the patient’s abdomen due to unrelated stomach pain or after an accident.

In a CT scan, the lungs appear as two black sponges with thin white lines running through them. That’s because lungs are filled with air, and air looks black on a CT scan or a chest x-ray. Lung nodules, in turn, are white specks in that black space, meaning there’s something else in your lungs where there should only be air.

Once patients have been told they have a pulmonary nodule, the first question they usually ask is: Is it cancer?

Can a CT scan tell if a lung nodule is cancerous?

The short answer is no. A CT scan usually isn’t enough to tell whether a lung lesion is a benign tumor or a cancerous lump. A biopsy is the only way to confirm a lung cancer diagnosis. But the nodule’s characteristics as seen on a CT scan may offer clues.

To determine whether the likelihood of lung cancer is high or low, physicians usually look at three distinct characteristics of the nodule: the size of the spot, its shape and whether the nodule is calcified.

• If the CT scan shows small nodules (less than a centimeter wide, or about the size of a green pea), they have a low probability of being cancerous. Larger nodules are more worrisome.
• Rounded nodules are less likely to be cancerous than spiculated (having jagged edges) ones.
• Calcified lung nodules contain calcium deposits that sometimes form in response to infection. These nodules are most likely noncancerous.

The care team may also consider the lung nodule’s location when assessing possible risk. Studies suggest that nodules located in the upper lobe of the lung may be more indicative of cancer. Not all nodules in that location are cancerous, however, and not every lesion elsewhere in the lung is benign.

Another key sign physicians look for when trying to determine whether a lung nodule may be cancerous is the difference in the size of the nodule between one scan and another taken at a later time. Cancerous nodules are more likely to grow. If the white spot enlarges between scans, that may be an indication of lung cancer.

So, while a CT scan can’t confirm whether your lung nodule is cancerous, it may determine whether further imaging tests are warranted. If this is the case, your doctor may order a PET scan and/or a biopsy of the suspicious lung tissue.

If the characteristics of your lung nodules indicate the possibility of cancer, experts recommend you undergo testing as soon as possible to determine whether your lung nodules are malignant or benign. If they’re benign, you get the peace of mind of knowing that. If they’re malignant, there are many benefits that come with getting an early lung cancer diagnosis.

Lung mass vs. nodule

Pulmonary lesions larger than 3 cm  are typically considered lung masses and not nodules, but not every lung mass is cancerous. If the care team identifies a mass on your lung, they’ll talk to you about scheduling additional tests, which may include a biopsy and/or a PET/CT scan.

What are the benefits of getting an early lung cancer diagnosis?

There’s a significant difference in lung cancer survival rates for cancers diagnosed in the early stages and those diagnosed at stage 3 or stage 4—which is when the majority of lung cancers are diagnosed.

When lung cancer is found when it’s localized—meaning there’s no evidence it’s spread outside the lungs—it’s much easier to treat than when it’s spread to regional (near to the lungs) or distant areas of the body. 

Early symptoms of lung cancer may include:

• A cough that’s new, worsens or produces blood
• Shortness of breath
• Chest pain when coughing or laughing
• Unexplained weight loss
• Lung infections that won’t go away

Many patients with lung cancer, though, don’t have any symptoms until the cancer has advanced to later stages. This initial lack of symptoms is why most lung cancers are diagnosed after they’ve advanced.

Once patients do experience symptoms, however, researchers have found that the average amount of time between seeking medical attention for those symptoms and the start of treatment is about 138 days. Such a delay gives the cancer even more time to grow and metastasize and leads to higher anxiety levels for the patient.

This is why getting the appropriate tests to determine whether a nodule is cancerous is so important, even if you don’t have any other risk factors for lung cancer.

At City of Hope, we recommend you undergo yearly lung cancer screenings if you’re at high risk of lung cancer (e.g., a life-long smoker), even if your lung nodule turns out to be benign.

Why you should undergo yearly lung cancer screenings if you’re at high risk of lung cancer

Lung cancer screenings are like mammograms or colonoscopies: a test that checks to see whether high-risk individuals have developed suspicious signs of cancer, or if cancer does develop, helps catch it as early as possible.

While mammograms and colonoscopies have garnered significant awareness over the years, the percentage of people who undergo yearly lung cancer screenings is very low. In fact, among people eligible for yearly lung cancer screenings in the United States, only about 5.8 percent get screened.

The United States Preventive Services Task Force advises that you’re at high risk of lung cancer if both of these apply to you:

• You’re between the ages of 50 and 80.
• You’re either a current smoker or a former smoker who smoked a pack a day for 20 years and quit smoking less than 15 years ago.

What should you do if you have a pulmonary nodule?

If you’ve been told you have a lung nodule, you should consult a pulmonologist or someone with training and experience in detecting and treating lung nodules or lung cancer. These doctors may be better equipped to offer the proper guidance and order further testing (when appropriate) to determine whether you have lung cancer.

You might also want to consider getting a second opinion. Getting a second opinion from a cancer center with a multidisciplinary approach to cancer diagnosis and care may help alleviate the stress and anxiety that comes with finding out you have a lung nodule.

Many patients come to City of Hope for a second opinion because of our personalized approach to cancer care and comprehensive treatment options. Patients with lung nodules, specifically, come to us for a second opinion because of our unique rapid lung-nodule diagnosis program.

The City of Hope rapid lung-nodule diagnosis program: Why we started it and how we approach cancer care

We’ve seen many patients feeling stressed and anxious for weeks or months after finding out they have nodules in their lungs. They either didn’t have clear answers about their lung nodules or weren’t comfortable with the answers they received. There’s no need to live with that anxiety.

We also know how crucial time is when it comes to diagnosing and treating lung cancer. That’s why we created our rapid lung-nodule diagnosis program, with results delivered in as few as four days.

At the rapid lung-nodule diagnosis program, we respect our patients’ time and need for peace of mind by reducing the time between when patients first discover they may have nodules in their lungs and the moment they find out whether those nodules are cancerous.

Before you even get to your first scheduled appointment, our team of cancer experts has already researched and reviewed your CT scans. Our tumor board consists of interdisciplinary experts, including an interventional radiologist, an interventional pulmonologist, a thoracic surgeon, a medical oncologist and a radiation oncologist—all reviewing your CT scans and medical records together.

Working together, we can better identify whether your lung nodules are suspicious for cancer. If they are, we schedule the appropriate tests as quickly as possible. These diagnostic procedures may include a PET scan, genomic testing, a bronchoscopy, endobronchial ultrasound or needle biopsy, depending on what’s appropriate for your case.

By day four of the program, we’ll give you a clear answer about what needs to happen next. If you don’t have lung cancer, we all celebrate and you go on your way. If you do have malignant nodules and a lung cancer diagnosis, you can get started with treatment right away.

Worrying about a lung nodule and the possibility of cancer is both normal and valid. We understand that patients need answers, and they need them as soon as possible. Our patients’ peace of mind and well-being are our top priority.

If you’re interested in scheduling an appointment with our rapid lung-nodule diagnosis program, call us or chat online with a member of our team.

Solitary pulmonary nodule

Solitary (solitary) pulmonary nodule is a solitary, most often round or spherical mass < 30 mm in diameter; located in the lung parenchyma, determined on an x-ray or CT scan, not associated with the presence of pneumonia (consolidation), atelectasis, or lymphadenopathy (abnormal enlargement of the lymph nodes).

First, let’s clarify the terminology.

In the English medical literature a distinction is made;

• Nodule : nodule < 10 mm.
• Node : node, > 10 mm but < 30 mm.
• Mass : education, > 30 mm. (usually neoplasia).

Most solitary pulmonary nodules are formations of benign etiology: infectious granulomas, the outcome of a bacterial, fungal or tuberculosis infection. Nodes of non-infectious origin include: hamartoma, sarcoid, Wegener’s granulomatosis, rheumatoid arthritis, arteriovenous malformation, etc.

Only one third of solitary pulmonary nodules are malignancies: bronchogenic carcinoma, metastases (20%) or carcinoid.

Modern statistical studies conducted in the USA showed an interesting picture: a single pulmonary nodule is detected in 1 case out of 500 chest X-rays or in 1 study out of 100 chest CT scans. In areas endemic for fungal diseases (for example, Ohio), these numbers are 2 times higher.

The standard method for evaluating suspicious solitary pulmonary nodules (i.e., nodules without undeniable signs of benignness) is CT.

CT is an undoubted determining method that allows you to objectively evaluate the node, identify the presence of fat, calcifications, additional signs that play a decisive role in assessing the benign or malignant potential of the formation under study. CT scans can be routinely performed without IV contrast. However, a bolus of contrast may be required for dynamic CT imaging of high-risk nodes.

Single pulmonary nodule evaluation criteria

Localization:

benign nodules can be located in any part of the lungs, without specific preferences. Malignant nodes tend to be located in the upper lobes, on the right > than in the left lung. Adenocarcinoma tends to be peripheral, while squamous cell carcinoma is more central/medial.

Size:

The size of the node is not a determining criterion for evaluating the benign or malignant formation. In general, the larger the formation, the more suspicious it is for malignancy. But, benign formations can also grow to a decent size. And vice versa, if we see a nodule 2-3 mm in size, this does not mean that it is not cancer.

Structure:

Knot edges are a very important feature. Education with clear, even and well-defined edges are typical for benign nodules. The presence of uneven, bumpy edges with spicules is highly suspicious of a malignant nature.

Separately, it is necessary to single out the nodes not of a solid structure, but of the GGO (ground glass opacities) type of frosted glass. “Pure” GGO nodes can be both inflammatory and malignant. Nodes of a mixed nature, especially if the center is represented by a solid soft tissue component, and the periphery in the form of an aura of the ground glass type, are characteristic of neoplasia (adenocarcinoma of the bronchoalveolar type).

Calcifications: is a very important and “favorite” evaluation criterion. If there are calcifications in the node, this does not mean that the formation is benign! It is necessary to assess the location of calcifications in the node. Diffuse, laminated, centrally located (target), peripheral ring type, concentric and popcorn calcifications are criteria for benignity. The last type (popcorn) is typical for hamartoma. Eccentrically located calcifications are suspicious for the presence of a malignant formation. In cancer, amorphous, punctate microcalcifications may also occur. We should not forget about metastases of mucin-producing carcinomas, in which there may be diffuse, “dotted” calcifications. Bone-forming metastases from tumors such as osteosarcoma and chondrosarcoma can also mimic calcifications.

I would like to say: it’s good that metastases are very rarely single

The presence of a central hypodense zone: a non-specific symptom, it can occur in cancer and in inflammatory processes due to necrosis. This judgment also applies to the sign of an air bronchogram and cavitations (air cavities). Bronchograms are found in 50% of cases of bronchoalveolar carcinomas.

If fat is found in node (it is necessary to carefully measure the density of areas suspicious for fat), more often this indicates a benign formation. Read more – a single pulmonary nodule with fat inclusions.

Height:

The growth of a mass or its absence is one of the most important criteria in evaluating a lung mass for malignancy. It is a well-known fact: nodes with a stable, unchanging size during 2 years of dynamic observation are benign formations. Modern authors advocate such a protocol: if a suspicious nodule/nodule is detected, it is considered appropriate to carry out CT control after 3, 6, 12 and 24 months. If the node is stable, observation can be terminated. Important aspects: modern work has revealed an interesting fact, the dynamics of the increase in the volume of nodules with sizes < 10 mm when calculating in 3>, using the help of computer programs (for example: CAD nodule detection; VIP nodule assessment), exceeds in absolute terms the accuracy of the usual measurements in 2 >. For example: 6 months ago the knot was 5 mm in diameter, now it is 6×7 mm. If you measure the 3D volume, it may turn out that the node has increased in volume > 2.5 times. Such a concept was introduced as: doubling rate i.e. the time it takes for a node to double in size. By the way, some ground glass density nodules suspected of bronchoalveolar carcinoma have a low doubling rate, so they need longer follow-up.

Dynamic contrast enhancement:

a good technique for assessing nodules without specific signs that are difficult to determine: good or evil. It is generally accepted that if the gain in the node is < 15 H.U., this is a sign of good quality (90%), the gain is > 15 H.U. associated with 50% of malignancies. There are methods of sequential dynamic scanning at certain intervals through the area of ​​interest (node) with subsequent calculation of the curve of contrast enhancement and washout of contrast from the studied node/formation.

PET CT (PET; PET CT):

very good method for evaluating a single pulmonary nodule; specificity is up to 83-97%, and sensitivity, according to various data, ranges from 70 to 100%. But it must be remembered; this method works with a node size of 8-10 mm and above. False-positive results are often associated with an active inflammatory process or infection. A false-negative result was recorded in the case of low metabolic activity of the node, which is sometimes observed in bronchoalveolar cancers, carcinoids, and less often, adenocarcinomas.

Tactics:

Having finished with the descriptive part, a natural question arises before the radiologist. What to do next? What recommendation should be written in the protocol? In the journal European Radiology, February 2007, there was an extensive article on this topic, where it was clearly described how to proceed in a particular case. You can see the full article in the attachments; at the end you will find a table with a protocol of actions.

Along with radiological data, it is necessary to take into account the anamnesis and clinical data, including smoking history, the presence of specific complaints, etc. There are special automated programs for risk calculation.

For more information on the management of solitary lung nodules detected as an incidental finding outside of lung cancer screening, see a separate publication.

Differential diagnosis

There are many causes of a solitary lung lesion, including: 11 lymphoma

X-ray syndrome of changes in the roots of the lungs

Transcript of a video lecture by Irina Alexandrov Sokolina ny about the radiological syndrome of changes in the roots of the lungs from the cycle of transmissions Radiation diagnostics for therapists.

Igor Evgenievich Tyurin, Doctor of Medical Sciences, Professor:

– Let me immediately move on to the next lecture and ask Irina Aleksandrovna to tell about the state of the roots of the lungs, about the pathology of the lymph nodes. Everything related to this problem. Please, Irina Alexandrovna.

Irina Alexandrovna Sokolina, Candidate of Medical Sciences, Head of the Department of Radiation Diagnostics of the Vasilenko Propaedeutics Clinic, PMSMU:

– Thank you very much, Igor.

Good afternoon, dear colleagues!

So, today we will talk about the X-ray anatomy of the roots of the lungs and the X-ray syndrome of changes in the roots of the lungs.

(Slide show) .

Anatomically, the roots of the lungs are a collection of structures that are located in a topographically defined way in the hilum of the lungs. They include a number of anatomical elements.

These are, first of all, the pulmonary artery, pulmonary veins, bronchi accompanying the pulmonary arteries, lymphatic vessels, nodes, cellular tissue and pleura.

I must say that for a long time these formations are located extrapulmonary and on radiographs they can be hidden by the shadow of the heart, therefore, anatomically and radiologically, the concept of the root of the lung is somewhat different.

(Slide show) .

From the point of view of radiology, the normal root of the lung on radiographs, which are performed with the correct position of the patient, is represented by a total shadow of large pulmonary vessels.

It must be said that when analyzing the root of the lung, it is necessary to pay attention to the patient’s attitude. This should be the correct setting of the patient, which is determined by the symmetrical distance between the spinous processes that we see and the sternoclavicular joints. Small turns can cause changes in the display of the lung root and simulate some pathological conditions.

02:03

(Slide show) .

The roots of the right and left lungs are normally located unequally. The right root is represented, as we see on the radiograph, by an arcuate curved shadow of medium density. This shadow is expanded in the upper section and narrows slightly downward. The root of the right lung is located at the level of the II rib and II intercostal space.

Basically, the root of the right lung is represented by the lower lobar pulmonary artery and the intermediate bronchus located next to it. It is clearly visible on x-ray examination in the form of enlightenment.

The root of the left lung is most often covered by the shadow of the heart and is visible in a small number of patients. In accordance with the anatomical features, the root of the left lung is located one rib above the root of the right lung. This must be remembered when analyzing the radiograph.

This is about the location of the roots of the lungs.

(Slide show) .

The structure of the shadow of the root of the lung is normally heterogeneous, because it is represented mainly by vessels that branch into smaller branches. Root heterogeneity is formed. Plus, the root of the lung is also crossed by the bronchi. This normally creates heterogeneity of its structure.

(Slide show) .

The outer borders of the lung root are represented, as I have already said, by diverging vascular shadows. The direction of the arteries, as we know, is more vertical. The veins are more horizontal. The clarity of the contour in some areas may not be so pronounced due to the layering of enlightenment from the bronchi.

As for the division of the root into sections: head, body and tail. It retains its relevance. The lower part of the root of the lung (tail) is formed mainly by small ramifications of the vessels of already segmental bronchi.

04:38

(Slide show) .

Regarding the width of the roots of the lungs. Basically, the width of the lung root is determined by the right root. Normally, it represents the width of the arterial trunk and the intermediate bronchus. Normally, if you take these two structures, it should not exceed 2.5 centimeters.

As a rule, if we measure directly only the vascular trunk (that is, the lower lobar pulmonary artery), then its width should not exceed 1.5, maximum 2 centimeters.

(Slide show) .

We talked about the criteria by which we evaluate the root of the lung in x-ray examination. Location, structure, borders, sharpness of contours and width of the root.

The CT image shows the roots of the lungs on several scans. We analyze them sequentially. The bronchi are well identified here, since they are air-containing, and the vascular structures adjacent to them.

It must be said that it is practically impossible to differentiate vascular structures from enlarged lymph nodes, especially if mediastinal tissue is poorly expressed (this is usually found in children, young people). Differential diagnosis between vascular pathology and enlarged lymph nodes or some pathological formations is usually carried out using intravenous contrast. It allows us to distinguish these structures.

(Slide show) .

As regards the change in the roots of the lungs. By this is meant any deviation from the normal x-ray picture of the roots. This may be due to various pathological conditions. Most often this is an increase in lymph nodes.

Pathological conditions of blood vessels in the form of aneurysmal expansion or agenesis of some vascular elements can lead to changes in the roots of the lungs. These are lesions of the bronchi – mostly tumor. Change in blood supply in the form of pulmonary edema (disorders of tissue fluid metabolism). Sclerotic fibrous processes.

All this can lead to a change in the location, size, shape, structure and density of the contours of the roots of the lungs.

07:28

(Slide show) .

I must say that in isolation the root of the lung changes and there are no changes around – this is rare. In this case, the displacement of the roots of the lungs is usually due to a change in the volume of the lung tissue itself.

This may be an increase in volume (we see on the right picture) due to bullous emphysema. Change due to the bulla, which displaces the root of the right lung. Some fibrous changes can lead to a displacement of the roots in one direction or another.

As a rule, the changes in the lung tissue that we see indicate the cause of such a displacement of the roots of the lungs.

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But there are situations when we do not see any changes, as on the plain radiograph in this case: almost lung tissue. But, look – the root of the left lung is located on the same level as the root of the right lung. This allows us to guess whether there is some process that leads to a decrease in volume.

On the lateral radiograph, we see lingual segment atelectasis, which in this case is hidden behind the shadow of the heart. It is this process that causes the displacement of the root of the lung.

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A change in the structure of the lung root is usually manifested by the fact that various elements become poorly distinguishable due to edema or fibrosis. This is manifested by the appearance of uniformity of the root shadow. Normally, the root is heterogeneous. It is compacted, the vascular structures and individual elements of the root are poorly differentiated.

In addition, the intensity of the [shadow] of the root of the lung increases. The lumen of the intermediate bronchus, which is normally, as we have seen, clearly visible, loses its transparency. Becomes veiled or not visible at all.

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An increase in the density of the lung root, as a rule, is due to calcification of the thoracic lymph nodes, which can have a different prevalence. It can be shell-shaped, lumpy, uneven, in the form of a mulberry.

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Changes in the contours of the roots of the lungs can be of several types. Most often, we see polycyclic contours of the roots of the lungs, which are mainly due to enlarged lymphatic vessels.

Here is a patient with sarcoidosis of the intrathoracic lymph nodes. There is a bilateral increase, expansion of the roots of the lungs and polycyclic contours, which are formed just by enlarged bronchopulmonary lymph nodes.

Here the so-called “symptom of the wings” can occur, which is due to the superposition of the anterior and posterior groups of bronchopulmonary lymph nodes.

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Hilly contours of the roots of the lungs are found mainly in tumor processes. At the same time, a predominantly unilateral expansion of the lung root is also noted.

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Fuzzy contours of the roots of the lungs, as a rule, are due to edema of the peribronchovascular tissue, which can occur with various congestive changes in the lungs. May occur reactively with inflammatory changes – due to perivascular, peribronchial edema or inflammation.

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Tight contours are due to fibrotic changes due to the development of perigillar fibrosis. This may be due to various processes.

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Of great importance, if we are talking about the syndrome of root changes, is the expansion and deformation of the root of the lung. A combined process with various changes in its structure and boundaries. Here, unilateral or bilateral expansion of the roots of the lungs is of great importance.

Unilateral expansion and deformation of the roots of the lungs usually occurs in tuberculous bronchoadenitis. As a rule, in these cases, we see the expansion of the root, a change in its structure, and fuzzy boundaries. These changes are best detected by computed tomography.

It must be said that with any suspicion of lung root expansion and to establish the cause of lung root expansion, further clarification using linear tomography is required. Of course, currently it is computed tomography (best of all – with intravenous contrast).

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In computed tomography examination, tuberculosis of the intrathoracic lymph nodes is manifested by an increase in the bronchopulmonary lymph nodes of the root of one lung and overlying lymph nodes of the mediastinum.

Confirm the specific nature of the lesion of the lymph nodes using intravenous contrast (in this case, uneven accumulation of the contrast agent occurs), in the capsule of the lymph node, fragmented. This is due to the fact that in the center there are caseous masses that do not accumulate a contrast agent. Perinodular tissue infiltration.

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Tuberculous lesions of the lymph nodes can be accompanied by various disorders in the lung tissue: in the form of bronchial compression, the formation of atelectatic disorders, dissemination of dropout foci.

Of course, tuberculosis of the intrathoracic lymph nodes is primary tuberculosis. It is more common in children. But it must be remembered that in the elderly, under unfavorable conditions, reactivation of old tubercular foci can also occur.

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Here is an example of an elderly patient (81 years old). He was admitted to the clinic with such complaints of fever, shortness of breath during exercise.

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He has a fairly long history. It begins in 1947, when he suffered from pneumonia. Then he was examined in anti-tuberculosis dispensaries, where the diagnosis of tuberculosis was rejected. Conducted examination and treatment in the hospital for bronchitis over the past years.

All the same, weakness and cough were growing. In connection with the above complaints, he was admitted for examination.

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From the anamnesis of life it is worth noting, of course, that he underwent a subtotal resection of the stomach without the use of chemotherapy. Seeing an oncologist.

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We see his radiographs from 2010. The root of the right lung is expanded, compacted. We see (inaudible term, 15:29) changes in the anterior segment: compaction of the lung tissue.

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He was further examined by linear tomography. We see the patency of all bronchi. At this stage, no evidence of tuberculous involvement was observed.

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Exactly against the background of the deterioration of the condition, the rise in temperature, an X-ray examination was carried out. In this case, we see that the root of the lung has a fuzzy contour, an increase in inflammatory changes in the upper lobe of the right lung.

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Look at the dynamics of these two pictures for 2010 and 2011. Here, of course, the negative dynamics is clearly visible in the last picture.

What could be causing this?

The first thing that comes to mind, considering the clinic of such a picture, these three processes. Perhaps the development of pneumonia, central cancer or metastases to the lymph nodes due to the fact that the patient had a history of a tumor.

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Computed tomography (we didn’t use contrast – rather elderly patient) shows clearly enlarged lymph nodes, unilateral enlargement of lymph nodes.

In the bifurcation group there is just an inhomogeneous structure of the lymph node.

In the paratracheal – a large lymph node: a cavity formation, which turned out to be a bronchomodular fistula. This was confirmed by bronchoscopic examination.

Atelectatic inflammatory changes in the upper lobe of the right lung and foci of seeding.

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Additional examination of the patient using computed tomography made it possible to establish the correct diagnosis in the patient.

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But there are difficult situations. A 32-year-old patient who was referred to us for computed tomography (he has been HIV-infected for several years) to clarify changes in the projection of the root of the left lung. We see a suspicion of a pathological formation in the root of the lung: the contours are deformed.

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In a native study, it is seen that there is a local expansion of the aorta in the region of the arch. But along with this, look, there are enlarged lymph nodes (they are shown here by yellow arrows) in the bifurcation group and the tracheobronchial group.

Their sizes are somewhere up to 1.5 centimeters. These are borderline sizes. There is a lot of discussion about what the size of the lymph nodes should be.

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After intravenous contrast, we clearly see an aneurysmal local expansion of the aortic arch.

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See how the lymph nodes (even slightly enlarged) accumulate the contrast agent: fragmented, by capsule. This made it possible to say that the patient, along with local expansion, also has tuberculosis of the intrathoracic lymph nodes.

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He was prescribed anti-tuberculosis therapy. In dynamics (we see here the study without contrasting) – a decrease in the size of the lymph nodes and partial calcification.

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Unilateral expansion and deformation of the root of the lung, in addition to tuberculous lesions, of course, most often occurs in tumor processes. In this case, not on the radiograph, we see the expansion of the root of the right lung, the compaction of the root of the right lung and the taut contours.

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Computed tomography at the root of the right lung revealed a large nodular formation: peribronchial nodular cancer. The presence of enlarged lymph nodes. The changes are due to the tumor process.

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The use of intravenous contrasting makes it possible to determine, first of all, the stage of a malignant tumor, the degree of invasion into large vessels, into the surrounding structures. This determines the tactics of treating the patient. In the dynamics of observation on the background of chemotherapy.

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Bilateral expansion and deformity of the lung roots is commonly seen in SHN sarcoidosis. At the same time, we see a bilateral rather symmetrical expansion of roots with polycyclic contours.

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On CT scan, the lymph nodes have very characteristic features. Systemic enlargement of lymph nodes is determined. They have a homogeneous structure, clear contours, no changes in the surrounding tissue.

As a rule, the lymph nodes are affected multiple – each in its own group. They very rarely lead to compression of the bronchi, to the occurrence of hypoventilatory atelectatic changes.

After contrast enhancement, in contrast to VLN tuberculosis, in sarcoidosis they evenly accumulate the contrast agent throughout the entire volume. Their density increases slightly.

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I must say that in the chronic course of sarcoidosis, the formation of calcification is observed. First, the induration of the lymph node in the center, and then the deposition of calcium. Previously, it was always believed that calcifications in the lymph nodes are the prerogative of tuberculosis only. No. According to our observations, all granulomatous processes can be accompanied by calcium deposition in the VLH.

At the same time, in sarcoidosis, we see that calcifications, as a rule, form and are most pronounced in the center of the lymph node, where this is mainly inflammation, and away from the bronchi.

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Here are VGLU calcifications. In silicosis, shell-like calcifications are characteristic, in sarcoidosis and in tuberculous lesions.

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Bilateral expansion and deformation of the roots of the lungs can be caused not only by an increase in lymph nodes, but also with pulmonary hypertension. In this case, in the patient, we see the expansion of the roots of the lungs and on the right, a characteristic symptom, which, by the way, is rare – a cigar-shaped contour.

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With intravenous contrast, we see a massive lesion of the right branch of the pulmonary artery, the expansion of the pulmonary artery. This is a chronic course of thromboembolism, as we see the recanalization of the thrombus. Severe bilateral hypertension leads to expansion of the roots of the lungs.

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Narrowing of the lung root is extremely rare. It is mainly due to agenesis of the pulmonary artery. At the same time, an increase in the transparency of one of the lung fields, the absence of a normal pulmonary pattern and the absence of a proper shadow of the lung root are noted radiographically. This is confirmed (earlier by angiopulmonography) by CT angiography.

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On scintigraphy this case. We see a complete lack of blood flow in the right lung.

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In conclusion, I would like to say that the [shadow] of the roots of the lungs radiologically form bronchi and lobar segmental branches of the pulmonary artery, lobar and segmental bronchi, large veins.

The morphological basis of changes in the roots of the lungs is an increase in lymph nodes, pathological conditions of blood vessels, bronchial lesions, disorders of tissue fluid metabolism, sclerotic fibrous processes.