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Solitary Pulmonary Nodules: Part I. Morphologic Evaluation for Differentiation of Benign and Malignant Lesions¹

¹ From the Departments of Radiology (J.J.E., H.P.M.) and Pathology (V.L.R.), Duke University Medical Center, Erwin Road, Durham, NC 27710; and the Department of Radiology, Rush Presbyterian Medical Center, Chicago, Ill (J.E.C.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 19, 1999; revision requested March 29 and received June 9; accepted June 10. Address reprint requests to J.J.E.

View larger version (136K): [in a new window]   Figure 1a.   Rib fracture in a 50-year-old woman with multiple myeloma. (a) Close-up posteroanterior radiograph of the right upper lung shows a poorly marginated nodular area of increased opacity overlying the anterior aspect of the right second rib (arrow). (b) CT scan shows a healed fracture of the right second rib (arrow). Note the lytic lesions in the vertebral body secondary to multiple myeloma.

View larger version (130K): [in a new window]   Figure 1b.   Rib fracture in a 50-year-old woman with multiple myeloma. (a) Close-up posteroanterior radiograph of the right upper lung shows a poorly marginated nodular area of increased opacity overlying the anterior aspect of the right second rib (arrow). (b) CT scan shows a healed fracture of the right second rib (arrow). Note the lytic lesions in the vertebral body secondary to multiple myeloma.

View larger version (139K): [in a new window]   Figure 2a.   Pseudonodule in a 50-year-old man. (a) Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung (arrow). Note the adjacent electrocardiographic lead attachment pad (arrowhead). On a follow-up radiograph obtained after removal of the attachment pad (not shown), no nodule was observed. (b) Front and back views of the electrocardiographic lead attachment pad show an eccentrically located silver nitrate pad, which explains the contiguous nodular area of increased opacity on the chest radiograph.

View larger version (85K): [in a new window]   Figure 2b.   Pseudonodule in a 50-year-old man. (a) Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung (arrow). Note the adjacent electrocardiographic lead attachment pad (arrowhead). On a follow-up radiograph obtained after removal of the attachment pad (not shown), no nodule was observed. (b) Front and back views of the electrocardiographic lead attachment pad show an eccentrically located silver nitrate pad, which explains the contiguous nodular area of increased opacity on the chest radiograph.

View larger version (132K): [in a new window]   Figure 3a.   Bone island in a 61-year-old man with melanoma. (a) Close-up posteroanterior radiograph of the upper chest shows a focal area of increased opacity overlying the right seventh rib posteriorly (arrow). (b) Fluoroscopic images show a well-marginated intraosseous lesion (arrow). This finding is consistent with a bone island and obviated further investigation.

View larger version (127K): [in a new window]   Figure 3b.   Bone island in a 61-year-old man with melanoma. (a) Close-up posteroanterior radiograph of the upper chest shows a focal area of increased opacity overlying the right seventh rib posteriorly (arrow). (b) Fluoroscopic images show a well-marginated intraosseous lesion (arrow). This finding is consistent with a bone island and obviated further investigation.

View larger version (135K): [in a new window]   Figure 4a.   Osteophyte of the left first rib in a 60-year-old woman. (a) Posteroanterior chest radiograph shows a poorly defined nodular area of increased opacity overlying the anterior aspect of the left first rib (arrow). (b) Posteroanterior chest radiograph obtained 2 years earlier shows that interval growth has occurred (cf a). This interval growth raised suspicion for malignancy. (c) Contiguous chest CT scans (image on right obtained at a lower level) reveal that the area of increased opacity is a large osteophyte of the first rib. Had fluoroscopy been performed, costly CT could have been avoided.

View larger version (137K): [in a new window]   Figure 4b.   Osteophyte of the left first rib in a 60-year-old woman. (a) Posteroanterior chest radiograph shows a poorly defined nodular area of increased opacity overlying the anterior aspect of the left first rib (arrow). (b) Posteroanterior chest radiograph obtained 2 years earlier shows that interval growth has occurred (cf a). This interval growth raised suspicion for malignancy. (c) Contiguous chest CT scans (image on right obtained at a lower level) reveal that the area of increased opacity is a large osteophyte of the first rib. Had fluoroscopy been performed, costly CT could have been avoided.

View larger version (115K): [in a new window]   Figure 4c.   Osteophyte of the left first rib in a 60-year-old woman. (a) Posteroanterior chest radiograph shows a poorly defined nodular area of increased opacity overlying the anterior aspect of the left first rib (arrow). (b) Posteroanterior chest radiograph obtained 2 years earlier shows that interval growth has occurred (cf a). This interval growth raised suspicion for malignancy. (c) Contiguous chest CT scans (image on right obtained at a lower level) reveal that the area of increased opacity is a large osteophyte of the first rib. Had fluoroscopy been performed, costly CT could have been avoided.

View larger version (158K): [in a new window]   Figure 5a.   Cutaneous nodules in a 51-year-old man with neurofibromatosis and prostatic adenocarcinoma. (a) Posteroanterior radiograph shows numerous well-marginated nodular areas of increased opacity projecting over the lower aspect of the thorax and a poorly marginated nodule overlying the upper aspect of the left hemithorax (arrow). Because the location of the upper nodule was uncertain, CT was performed. (b) CT scan helps confirm the intraparenchymal location of the nodule in the left upper lobe. (c) CT scan demonstrates multiple cutaneous nodules.

View larger version (113K): [in a new window]   Figure 5b.   Cutaneous nodules in a 51-year-old man with neurofibromatosis and prostatic adenocarcinoma. (a) Posteroanterior radiograph shows numerous well-marginated nodular areas of increased opacity projecting over the lower aspect of the thorax and a poorly marginated nodule overlying the upper aspect of the left hemithorax (arrow). Because the location of the upper nodule was uncertain, CT was performed. (b) CT scan helps confirm the intraparenchymal location of the nodule in the left upper lobe. (c) CT scan demonstrates multiple cutaneous nodules.

View larger version (117K): [in a new window]   Figure 5c.   Cutaneous nodules in a 51-year-old man with neurofibromatosis and prostatic adenocarcinoma. (a) Posteroanterior radiograph shows numerous well-marginated nodular areas of increased opacity projecting over the lower aspect of the thorax and a poorly marginated nodule overlying the upper aspect of the left hemithorax (arrow). Because the location of the upper nodule was uncertain, CT was performed. (b) CT scan helps confirm the intraparenchymal location of the nodule in the left upper lobe. (c) CT scan demonstrates multiple cutaneous nodules.

View larger version (145K): [in a new window]   Figure 6a.   Segmental bronchial atresia in a 17-year-old girl. (a) Close-up posteroanterior radiograph of the right lower lung shows a nodular area of increased opacity in the lower lobe (arrow). (b) Chest CT scans (image on left obtained at a lower level) show a branching tubular area of increased attenuation in the right lower lobe as well as pulmonary parenchyma with lower than expected attenuation. These findings are characteristic of segmental bronchial atresia and obviated further work-up.

View larger version (92K): [in a new window]   Figure 6b.   Segmental bronchial atresia in a 17-year-old girl. (a) Close-up posteroanterior radiograph of the right lower lung shows a nodular area of increased opacity in the lower lobe (arrow). (b) Chest CT scans (image on left obtained at a lower level) show a branching tubular area of increased attenuation in the right lower lobe as well as pulmonary parenchyma with lower than expected attenuation. These findings are characteristic of segmental bronchial atresia and obviated further work-up.

View larger version (133K): [in a new window]   Figure 7a.   Multiple arteriovenous malformations in a 23-year-old woman with hereditary hemorrhagic telangiectasia. Contiguous chest CT scans reveal multiple small nodular areas of increased attenuation bilaterally with enlarged feeding and draining vessels, findings that are diagnostic for arteriovenous malformations. A chest radiograph obtained earlier (not shown) demonstrated a possible small solitary pulmonary nodule in the right lower lobe.

View larger version (130K): [in a new window]   Figure 7b.   Multiple arteriovenous malformations in a 23-year-old woman with hereditary hemorrhagic telangiectasia. Contiguous chest CT scans reveal multiple small nodular areas of increased attenuation bilaterally with enlarged feeding and draining vessels, findings that are diagnostic for arteriovenous malformations. A chest radiograph obtained earlier (not shown) demonstrated a possible small solitary pulmonary nodule in the right lower lobe.

View larger version (83K): [in a new window]   Figure 8a.   Lung nodule caused by Dirofilaria (canine heartworm) in an asymptomatic 70-year-old man. (a) Close-up CT scan of the right lung shows a peripheral, smoothly marginated, noncalcified lung nodule. (b) Photograph of a specimen obtained with wedge resection shows a well-circumscribed, 2-cm nodule with yellow areas of geographic necrosis. (c) High-power photomicrograph (original magnification, x175; hematoxylin-eosin stain) shows intravascular Dirofilaria. Most infections manifest as lung nodules from embolic infarction caused by intravascular worms.

View larger version (117K): [in a new window]   Figure 8b.   Lung nodule caused by Dirofilaria (canine heartworm) in an asymptomatic 70-year-old man. (a) Close-up CT scan of the right lung shows a peripheral, smoothly marginated, noncalcified lung nodule. (b) Photograph of a specimen obtained with wedge resection shows a well-circumscribed, 2-cm nodule with yellow areas of geographic necrosis. (c) High-power photomicrograph (original magnification, x175; hematoxylin-eosin stain) shows intravascular Dirofilaria. Most infections manifest as lung nodules from embolic infarction caused by intravascular worms.

View larger version (142K): [in a new window]   Figure 8c.   Lung nodule caused by Dirofilaria (canine heartworm) in an asymptomatic 70-year-old man. (a) Close-up CT scan of the right lung shows a peripheral, smoothly marginated, noncalcified lung nodule. (b) Photograph of a specimen obtained with wedge resection shows a well-circumscribed, 2-cm nodule with yellow areas of geographic necrosis. (c) High-power photomicrograph (original magnification, x175; hematoxylin-eosin stain) shows intravascular Dirofilaria. Most infections manifest as lung nodules from embolic infarction caused by intravascular worms.

View larger version (152K): [in a new window]   Figure 9.   Solitary metastasis from bladder cancer in a 45-year-old woman. Chest CT scan shows a smoothly marginated, 1-cm peripheral nodule. Metastatic disease was confirmed at resection. Solitary metastases account for 3%-5% of all resected solitary pulmonary nodules.

View larger version (147K): [in a new window]   Figure 10.   Non-small cell lung cancer in a 63-year-old woman. Close-up chest CT scan of the right lung shows a lobulated and spiculated nodule in the lower lobe.

View larger version (145K): [in a new window]   Figure 11a.   Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia. (a) Close-up posteroanterior radiograph of the right lung shows a lobulated, well-marginated nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged draining vein (arrowhead). (c) CT scan shows the nidus of the malformation. (Figure 11b and 11c reprinted, with permission, from reference 16.) (d) Pulmonary angiogram helps confirm arteriovenous malformation. Note the early draining vein (arrows).

View larger version (127K): [in a new window]   Figure 11b.   Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia. (a) Close-up posteroanterior radiograph of the right lung shows a lobulated, well-marginated nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged draining vein (arrowhead). (c) CT scan shows the nidus of the malformation. (Figure 11b and 11c reprinted, with permission, from reference 16.) (d) Pulmonary angiogram helps confirm arteriovenous malformation. Note the early draining vein (arrows).

View larger version (131K): [in a new window]   Figure 11c.   Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia. (a) Close-up posteroanterior radiograph of the right lung shows a lobulated, well-marginated nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged draining vein (arrowhead). (c) CT scan shows the nidus of the malformation. (Figure 11b and 11c reprinted, with permission, from reference 16.) (d) Pulmonary angiogram helps confirm arteriovenous malformation. Note the early draining vein (arrows).

View larger version (178K): [in a new window]   Figure 11d.   Arteriovenous malformation in a 34-year-old man with hereditary hemorrhagic telangiectasia. (a) Close-up posteroanterior radiograph of the right lung shows a lobulated, well-marginated nodule in the lower lobe (arrows). (b) Chest CT scan demonstrates a feeding artery (arrow) and an enlarged draining vein (arrowhead). (c) CT scan shows the nidus of the malformation. (Figure 11b and 11c reprinted, with permission, from reference 16.) (d) Pulmonary angiogram helps confirm arteriovenous malformation. Note the early draining vein (arrows).

View larger version (109K): [in a new window]   Figure 12.   Intralobar sequestration in a 14-year-old boy. Chest CT scan shows a lobulated, well-marginated nodule with homogeneous attenuation in the right lower lobe. Intrapulmonary sequestration was confirmed at resection.

View larger version (119K): [in a new window]   Figure 13.   Bronchioloalveolar cell carcinoma in a 65-year-old man. Chest CT scan shows an irregular nodule abutting the major fissure. Note the indentation of the adjacent portion of the major fissure owing to desmoplastic reaction around the tumor.

View larger version (134K): [in a new window]   Figure 14.   Non-small cell lung cancer in a 61-year-old woman. Close-up chest CT scan of the right lung shows a spiculated nodule with eccentric cavitation in the upper lobe.

View larger version (126K): [in a new window]   Figure 15.   Bronchioloalveolar cell carcinoma in a 68-year-old woman. Close-up chest CT scan of the right lung shows a poorly marginated nodule in the midlung. Small focal areas of low attenuation in the nodule (pseudocavitation) are suggestive of bronchioloalveolar cell carcinoma.

View larger version (144K): [in a new window]   Figure 16.   Aspergillus infection in a 48-year-old man with leukemia. Close-up chest CT scan of the right lung shows a thin-walled cavitary nodule.

View larger version (155K): [in a new window]   Figure 17.   Squamous cell lung cancer in a 60-year-old woman. Close-up posteroanterior radiograph of the right lung shows a smoothly marginated nodule in the lower lobe. Note the eccentric cavitation and thick walls.

View larger version (156K): [in a new window]   Figure 18.   Bullet track from a gunshot wound in a 20-year-old man. Close-up posteroanterior radiograph of the right lung shows a smoothly marginated, thick-walled nodule with eccentric lucency in the midlung. Note the bullet fragments overlying the right lung. These findings are consistent with parenchymal hematoma and a bullet track.

View larger version (134K): [in a new window]   Figure 19a.   Hamartoma in an asymptomatic man. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat. These findings are typical features of hamartoma. (b) Photograph of a resected specimen demonstrates a yellowish, glistening, lobular cut surface, a finding that is consistent with fat. (c) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) helps confirm the presence of adipose tissue (arrow) and shows epithelial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma. (Fig 19 courtesy of M. Rosado de Christenson, Col, USAF, MC, Armed Forces Institute of Pathology, Washington, DC.)

View larger version (131K): [in a new window]   Figure 19b.   Hamartoma in an asymptomatic man. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat. These findings are typical features of hamartoma. (b) Photograph of a resected specimen demonstrates a yellowish, glistening, lobular cut surface, a finding that is consistent with fat. (c) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) helps confirm the presence of adipose tissue (arrow) and shows epithelial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma. (Fig 19 courtesy of M. Rosado de Christenson, Col, USAF, MC, Armed Forces Institute of Pathology, Washington, DC.)

View larger version (186K): [in a new window]   Figure 19c.   Hamartoma in an asymptomatic man. (a) Chest CT scan shows a heterogeneous, sharply marginated lesion with small focal areas of calcification and fat. These findings are typical features of hamartoma. (b) Photograph of a resected specimen demonstrates a yellowish, glistening, lobular cut surface, a finding that is consistent with fat. (c) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) helps confirm the presence of adipose tissue (arrow) and shows epithelial tissue containing an island of basophilic cartilage (arrowhead). This mixture of epithelial and mesenchymal tissue is diagnostic for hamartoma. (Fig 19 courtesy of M. Rosado de Christenson, Col, USAF, MC, Armed Forces Institute of Pathology, Washington, DC.)

View larger version (116K): [in a new window]   Figure 20a.   Pulmonary hamartoma in a 74-year-old woman. (a) Chest CT scan obtained with 10-mm collimation demonstrates a nodule (arrow), but its internal morphologic features are poorly visualized. (b) Thin-section CT scan obtained with 1-mm collimation better demonstrates a punctate area of fat within the nodule (arrow), a finding that is diagnostic for hamartoma.

View larger version (132K): [in a new window]   Figure 20b.   Pulmonary hamartoma in a 74-year-old woman. (a) Chest CT scan obtained with 10-mm collimation demonstrates a nodule (arrow), but its internal morphologic features are poorly visualized. (b) Thin-section CT scan obtained with 1-mm collimation better demonstrates a punctate area of fat within the nodule (arrow), a finding that is diagnostic for hamartoma.

View larger version (102K): [in a new window]   Figure 21.   Granuloma in an asymptomatic 64-year-old man. Close-up chest CT scan of the left lung shows a soft-tissue nodule with central calcification in the upper lobe. Note the eccentric cavitation within the nodule.

View larger version (151K): [in a new window]   Figure 22a.   Histoplasmoma in an asymptomatic 50-year-old man. (a) Close-up tomogram of the left lung demonstrates a smooth, well-marginated nodule. (b) Photograph of a resected specimen helps confirm central calcification and laminated fibrous tissue. (Fig 22 courtesy of M. Rosado de Christenson, Col, USAF, MC, Armed Forces Institute of Pathology, Washington, DC.)

View larger version (128K): [in a new window]   Figure 22b.   Histoplasmoma in an asymptomatic 50-year-old man. (a) Close-up tomogram of the left lung demonstrates a smooth, well-marginated nodule. (b) Photograph of a resected specimen helps confirm central calcification and laminated fibrous tissue. (Fig 22 courtesy of M. Rosado de Christenson, Col, USAF, MC, Armed Forces Institute of Pathology, Washington, DC.)

View larger version (78K): [in a new window]   Figure 23.   Pulmonary chondrohamartoma in a 40-year-old man. Close-up chest CT scan of the right lung shows a lobulated nodule with central popcornlike calcification in the upper lobe. (Reprinted, with permission, from reference 24.)

View larger version (113K): [in a new window]   Figure 24.   Typical pulmonary carcinoid tumor in a 68-year-old woman. Chest CT scan shows a lobulated lesion with scattered punctate calcifications in the left lower lobe.

View larger version (139K): [in a new window]   Figure 25a.   Non-small cell lung cancer in a 45-year-old woman. (a) Close-up chest radiograph of the right lung shows a lobulated, sharply marginated nodule in the upper lobe. Note the presence of emphysema and upper lobe bullae. (b) Close-up chest CT scan of the right lung reveals amorphous calcification in the nodule, a pattern that is typical of malignancy. Adenocarcinoma was confirmed at resection.

View larger version (90K): [in a new window]   Figure 25b.   Non-small cell lung cancer in a 45-year-old woman. (a) Close-up chest radiograph of the right lung shows a lobulated, sharply marginated nodule in the upper lobe. Note the presence of emphysema and upper lobe bullae. (b) Close-up chest CT scan of the right lung reveals amorphous calcification in the nodule, a pattern that is typical of malignancy. Adenocarcinoma was confirmed at resection.

View larger version (118K): [in a new window]   Figure 26.   Lung cancer in a 72-year-old man. Close-up chest CT scan of the right lung shows a lobular lesion with peripheral punctate calcification in the upper lobe, a finding that is consistent with "engulfed" granuloma. Unlike that in calcified granulomas, calcification in engulfed granuloma is typically peripheral and constitutes only a small part of the nodule.

View larger version (134K): [in a new window]   Figure 27a.   Metastatic osteosarcoma in a 21-year-old man. (a) Close-up chest CT scan of the left lung shows a small, high-attenuation nodule in the lower lobe (arrow). This finding was suggestive of a benign cause. (b) Chest CT scan obtained 8 months later reveals interval growth of the nodule, which has high attenuation and a lobulated contour. Resection revealed metastatic osteosarcoma.

View larger version (123K): [in a new window]   Figure 27b.   Metastatic osteosarcoma in a 21-year-old man. (a) Close-up chest CT scan of the left lung shows a small, high-attenuation nodule in the lower lobe (arrow). This finding was suggestive of a benign cause. (b) Chest CT scan obtained 8 months later reveals interval growth of the nodule, which has high attenuation and a lobulated contour. Resection revealed metastatic osteosarcoma.

View larger version (113K): [in a new window]   Figure 28a.   Granulomatous disease in a 48-year-old woman. (a) Chest CT scan (10-mm collimation) shows a nodule with peripheral calcification and a calcified right hilar node. (b) Thin-section CT scan (3-mm collimation) better demonstrates the diffuse solid calcification in the nodule, a finding that is typical of a benign cause.

View larger version (122K): [in a new window]   Figure 28b.   Granulomatous disease in a 48-year-old woman. (a) Chest CT scan (10-mm collimation) shows a nodule with peripheral calcification and a calcified right hilar node. (b) Thin-section CT scan (3-mm collimation) better demonstrates the diffuse solid calcification in the nodule, a finding that is typical of a benign cause.