Solitary Pulmonary Nodule

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A solitary pulmonary nodule is defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated with adenopathy, atelectasis, or pleural effusion.
Differential Diagnosis
Malignant bronchogenic, carcinoid, meta static cancer
Benign healed infectious granuloma, benign tumors (hamartoma), AVM, rheumatoid nodule, Wegener’s granulomatosis, hydatid cyst, round atelec tasis, intra pulmonary lymph nodes, pseudotumor
Clinical Features
History dyspnea, cough, hemoptysis, wheezing, chest pain, weight loss, fever, night sweats, rheumatologic screen, past travel history, occupational expo sures, medical history (smoking, lung cancer or other malignancies, TB, infections, rheumatoid arthritis), medications
Physical vitals, weight loss, clubbing, cyanosis, Horner’s syndrome, SVC syndrome, lymphadenopathy, respiratory examination, abdominal examination (hepatomegaly), bony tenderness
Investigations
Basic
Labs CBCD, electrolytes, urea, Cr, LDH, AST, ALT, ALP, bilirubin, INR, PTT
Imaging CXR, CT chest
Special
ABG
Screening for Inflammatory Disorders ESR, CRP, ANA, ANCA
Biopsy bronchoscopy or CT guided
PET/CT SCAN if moderate to high suspicion of lung cancer


Diagnostic Issues
Findings suggestive of Malignancy
Age >50
Border irregular, nodular cavity with thick wall, or speculation
Calcification eccentric or uncalcified
Diameter > 3 cm {> 1.2 in.]. If < 3 cm, 20 50% malignant. If > 3 cm, 50% malignant
Timings if malignant, usually able to detect an increase in size of SPN between 30 days and 2 years. Unlikely to be malignant if significant change in
Calcification Clues
Malignancy eccentric/uncalcified calcification
Tuberculosis or Histoplasmosis central/com platelets  calcification
Benign Hamartoma popcorn calcification
Management
Treatment if low probability, observation with serial CT scans. If medium prob ability, bronchoscopy with biopsy/brush or trans thoracic (CT/US guided) biopsy. If high probability, thoracotomy with resection or video assisted thora coscopy (for patients who cannot tolerate thoracotomy medically and physiologically)
Specific Entities
Pancoast Tumor
Pathophysiology superior sulcus tumors (mostly squamous cell carcinoma) invading and compres sing the paravertebral sympathetic chain and brachial plexus
Clinical Features shoulder and arm pain (C8, T1, T2 distribution), Horner’s syndrome (upper lidptosis, lower lid inverse ptosis, miosis, anhydrosis, enophthalmos, absence of ciliary spinal reflex and heterochromia), and neurological symptoms in the arm (intrinsic muscles weakness and atrophy, pain and paresthesia of 4th and 5th digit). Other asso ciated findings include clubbing, lymphadenopa thy, phrenic or recurrent laryngeal nerve palsy, and superior vena cava syndrome
Diagnosis CXR, CT chest, percutaneous core biopsy
Treatments concurrent chemoradiotherapy
Thoracic Outlet Obstruction
Pathophysiology Obstruction of the neurovascular bundle supplying the arm at the superior aperture of the thorax. Common structures affected include the brachial plexus (C8/T1 > C5/C6/C7, 95%), subclavian vein (4%), and subclavian artery (1%)
CAUSES anatomic (cervical ribs, congenital bands, subclavicular artery aneurysm), repetitive hyperabduction/trauma (hyperextension injury, painters, musicians), neoplasm (supraclavicular lymphadenopathy)
Clinical Features triad of numbness, swelling and weakness of the affected upper limb, particularly when carrying heavy objects. Brittle finger nails, Raynaud’s, thenar wasting and weakness, sensory loss, decreased radial and brachial pulses, pallor of limb with elevation, upper limb atrophy, drooping shoulders, supraclavicular and infraclavi cular lymphadenopathy. Specific maneuvers include Roos test (repeatedly clench and unclench fists with arms abducted and externally rotated), modified Adson’s maneuver (Valsalva maneuver with the neck fully extended, affected arm elevated, and the chin turned away from the involved side), costoclavicular maneuver (shoulders thrust back ward and downward), hyperabduction maneuver (raise hands above head with elbows flexed and extending out laterally from the body), and Tinel’s maneuver (light percussion of brachial plexus in supraclavicular fossa reproduces symptoms)
Diagnosis cervical spine films, CXR, MRI

Treatments conservative (keep arms down at night, avoiding hyperabduction), surgery

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