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Right apical nodule: Lung Nodules – Diagnosis & Treatment | Conditions, Treatments & Specialty

Lung Nodules – Diagnosis & Treatment | Conditions, Treatments & Specialty

Comprehensive care for lung nodules

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Hearing that there’s a “spot on your lung” after a chest X-ray or CT scan can be concerning. The good news is that these “spots” are typically small, benign (non-cancerous) lung nodules. We’re here to diagnose, monitor and guide you through treatment.

What is a lung nodule?

A lung nodule (or pulmonary nodule) is a small, round or oval-shaped growth in the lungs that is up to 3 centimeters in diameter. A lung nodule larger than 3 centimeters is called a lung mass.

Lung nodules are common, mostly in those who smoke, and are typically benign (non-cancerous) but can also be malignant (cancerous). You may have a single lung nodule or several.

Symptoms of lung nodules

Most lung nodules don’t cause any symptoms and are often found on a chest X-ray or CT scan performed for another reason.

If symptoms are present, they may include:

  • Coughing
  • Coughing up blood
  • Wheezing
  • Shortness of breath
  • Respiratory infection

What causes a lung nodule?

The most common causes of lung nodules are inflamed tissue due to an infection or inflammation (called granulomas) or benign lung tumors (such as hamartomas).

Less common, malignant lung nodules are typically caused by lung cancer or other cancers that have spread to the lungs (metastatic cancer).

Other causes may include:

  • Infections: When your immune system acts against an infection, it will form a granuloma. Infections can be bacterial, fungal or parasitic.
  • Inflammation: Inflammation from conditions like sarcoidosis and rheumatoid arthritis can also cause granulomas to form.

Is it cancer?

In most cases, a lung nodule does not mean cancer. However, certain risk factors can increase the likelihood that a lung nodule is malignant. These can include:

  • Being over the age of 50
  • A nodule larger than 3 centimeters
  • Smoking
  • Having a family history of lung cancer
  • Having symptoms of lung cancer
  • Growth or irregular borders
  • Having multiple nodules

Diagnosing lung nodules

Once a lung nodule is identified, you’ll likely see a pulmonologist who can assess it to determine whether it’s a cause for concern.

To start, your doctor will discuss your medical history with you, perform a physical exam and a chest X-ray or CT scan. These scans can help your doctor see the size, shape and location of the lung nodule, as well as other characteristics, like calcium deposits. From there, they may recommend additional tests to rule out cancer or to determine another underlying cause. These can include:

  • Positron emission tomography (PET) scan – A PET scan can help your doctor determine if a lung nodule is non-cancerous or cancerous, because it allows them to get a more detailed look.
  • Biopsy – During a biopsy, your doctor removes a small amount of tissue from the nodule to examine closely under a microscope. The biopsy can be collected through a minimally invasive procedure called a bronchoscopy, which involves placing a thin, flexible tube through your mouth or nose to the nodule.
  • Other tests – Your doctor may suggest blood testing or other tests to rule out other conditions, such as tuberculosis.

Treatment for lung nodules

Once the cause of your lung nodule is determined, your doctor and care team will discuss your next steps with you.

In most cases, if your lung nodule is small and your cancer risk is low, your doctor will suggest monitoring it through a series of X-rays over time to track its growth and any changes. Non-cancerous nodules grow slowly, if at all, while cancerous nodules grow quickly. If the nodule hasn’t grown or changed over a period of a few years, it can be left alone.

If your lung nodule is large, determined to be cancerous or causing you to have symptoms, your doctor may recommend having it removed it surgically. If surgery is recommended, your doctor will discuss all options with you.

Lung nodule care at Geisinger

Our pulmonology team is here to diagnose, monitor and provide treatment for lung nodules that’s right for you. We offer:

  • Knowledge and experience – Your pulmonology team’s combined years of experience and research give them the expertise necessary to diagnose, treat and help you manage lung nodules. Learn more about our pulmonologists.
  • Personalized care – When you need treatment for lung nodules, our pulmonology team will work one on one with you to create a treatment plan that’s tailored to your specific needs. With proper treatment and management of lung nodules, we can make sure that you stay healthy.
  • Convenient locations and appointments – With pulmonologists available in Geisinger clinics and hospitals throughout Pennsylvania, you don’t have to travel far to get the care you need. We also offer extended clinic hours and minimal wait times to be seen, so you get care that’s convenient for you.

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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.

Japanese classification of regional lymph nodes of the colon and rectum (JSCCR), numbering principles. — 24Radiology.ru

Japanese surgeons approached the problem of standardization of surgical technique in colon cancer in the most detailed and methodological way. Traditionally for the Japanese presentation, practical recommendations are formulated in the form of 2 parts: recommendations for classification and actual practical recommendations for treatment. A separate section is presented by the Japanese classification of lymph nodes.

In accordance with the “Japanese” classification, all lymph nodes are numbered with three digits.

  • The first digit – belonging to the large intestine – is indicated as “2”.
  • The second digit most often denotes the anatomical region corresponding to the vascular pedicle (iliac colic artery – 0, right colic artery – 1, middle colic artery – 2, left colic artery – 3, sigmoid – 4, rectal arteries – 5).
  • The third number is the degree of distance from the intestine: 1 – epicolic and paracolic lymph nodes, 2 – mesocolic (intermedial) lymph nodes, 3 – apical, or main, lymph nodes.

Moreover, 1, 2 and 3 groups of lymph nodes correspond to the levels of lymph node dissection D1, D2, D3. When describing presacral lymph nodes, “0” (270, 280) is used as the last digit, and “2” (292) is used for inguinal lymph nodes. The principles of numbering of some other lymph nodes differ from the rule described above. The numbering of the lymph nodes in the Classification of Colorectal Cancer overlaps with that in the Classification of Gastric Cancer (JCGC): there is a match in the last digits. The lymph nodes of the superior mesenteric artery in colorectal surgery are designated as 214. In the Japanese Gastric Cancer Classification (JCGC), superior mesenteric nodes are designated as 14a and 14v for the base of the superior mesenteric artery and vein, respectively. Similar parallels can be drawn for lymph nodes number 216 – para-aortic (group 16 according to JCGC), 206 – infrapyloric (group 6 according to JCGC), 204 – gastroepiploic (group 4 according to JCGC), 210 – lymph nodes of the hilum of the spleen (group 10 according to JCG).

In accordance with the level of removed lymph nodes, the following volumes of lymph node dissection are distinguished: – D1 – removal of epicolic and paracolic lymph nodes; – D2 – D1 and removal of mesocolic lymph nodes; – D3 – D2 and removal of apical lymph nodes.

Preoperative TNM staging allows for a differentiated approach to choosing the volume of lymph node dissection. The main argument in favor of expanding lymph node dissection from category D2 to D3 is the data of radiation methods on the defeat of regional lymph nodes (cN+). In clinically N-negative stages, the volume of lymph node dissection is determined by the depth of tumor invasion (category cT). In cT1, D2 lymph node dissection is recommended. When the tumor invades the muscle layer, D3 lymph node dissection is recommended, since, according to Japanese registries, at the cT2 stage, there is a significant probability of damage to the apical lymph nodes. Diagnosis of cT3 and cT4 requires D3 lymph node dissection. Obviously, such a differentiated approach requires a specialized preoperative assessment of pathological changes detected during radiological and endoscopic studies.

What does CT show in pulmonary fibrosis

Fibrosis is the proliferation of connective tissue with the appearance of scars due to a violation of the mechanisms of healing of the wound surface.

When healing does not proceed properly, scarring may occur, leading to the fact that the organ cannot function fully.

Accordingly, pulmonary fibrosis is a scarring of lung tissue. The number of cells capable of saturating the blood with oxygen decreases. Consequently, respiratory efficiency decreases – respiratory failure develops, leading to intoxication, first with exercise, with aggravation of the course of the disease – at rest, and then – even in sleep. Scar tissue in the lungs not only has reduced functional properties, but also serves as an excellent environment for the development of associated infections, such as bacterial (pneumococcal or staphylococcal) pneumonia.

Pulmonary fibrosis is the outcome of tissue inflammation during interstitial (that is, with damage to the intercellular connective tissue) lung disease. The reasons for the development of such a disease may include lung injuries, high environmental pollution, smoking, inhalation of narcotic substances, mold, organic, asbestos, quartz and coal dust, infectious, autoimmune, viral diseases and their complications – bronchitis, tuberculosis, pneumonia, COVID- 19 and more.

Until recently, interstitial diseases themselves were synonymous with pneumofibrosis, but, fortunately, it was found that not all variants of such lung diseases are fibrosing.

The most complex and almost untreatable, primary or idiopathic pulmonary fibrosis is a rapidly progressive fibrosing lung disease of unknown cause.

Symptoms of pulmonary fibrosis

Pulmonary fibrosis is characterized by symptoms of shortness of breath and dry cough (rarely productive – with sputum) during exercise, persistent pain in the chest, fatigue due to shortness of breath, weight loss without changing diet. Auscultation of the lungs (listening with a phonendoscope) reveals early (in the inspiratory phase) inspiratory, that is, respiratory rales, most often localized in the lower posterior zones of the lungs.

Fibrosis can develop in one lung or both at the same time. Focal and total forms of fibrosis are also possible. With a total form, surgery is often required, since most of the lungs are affected. With a focal form, the changes are local in nature.

CT diagnosis of pulmonary fibrosis

The gold standard for diagnosing pulmonary fibrosis is high-resolution computed tomography. CT diagnostics of pulmonary fibrosis allows to reliably identify the degree of lung damage, to determine the localization of scar tissue. This diagnostic method is recognized as one of the most sensitive non-invasive methods for detecting pulmonary fibrosis. Thus, comparative studies conducted already in 1990 showed that pulmonary fibrosis using high-resolution computed tomography (HRCT) was detected in 91% of cases and only 39% using chest x-ray.

In the presence of pulmonary fibrosis in a serious stage, a pattern (a term adopted for pathological signs in medicine) is visible on CT scans of the so-called “honeycomb” lung – this condition is visible on scans as the same type of air-containing cysts located in several rows in the affected parts one or both lungs. In the early stages of pulmonary fibrosis, such a picture is not observed, so it was necessary to look for signs on CT that would allow to identify the disease at its onset. One of these signs was the presence of a “ground glass” pattern in the images – foci of slight compaction of the lung tissue. Also, specific signs of fibrosis in a patient can be detected when performing a CT scan of the lungs with functional tests. So, one of the signs – subpleural enhancement of the peripheral pulmonary interstitium – was previously considered a sign of the absence of pathology. Such changes are almost impossible to track using other methods of hardware diagnostics.

At the moment, the accuracy of CT diagnostic methods is increasing due to the introduction of new research protocols and careful study of the results of numerous studies. At the same time, the leading role in the diagnostic process is assigned to the radiologist, who interprets visible changes as pulmonary fibrosis or its absence. The search for early radiation signs of fibrosing lung disease is a key moment for the timely administration of antifibrotic therapy.

Also, it is multislice CT with the diagnosis made that is used to assess the rate of progression of the disease, identify favorable and unfavorable types of fibrotic changes, the success of treatment and the correct selection of therapeutic drugs.