Solitary Pulmonary Nodule

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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, rheuma tologic 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, lytes, urea, Cr, LDH, AST, ALT, ALP, bilirubin, INR, PTT
IMAGING old films (2 years ago), 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 un calcified
Diameter >3 cm [>1.2 in.]. If <3 cm, 20 to 50% malignant. If > 3 cm, 50% malignant.                   
TIMING 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 < 30 days or no change in 2 years
CALCIFICATION CLUES
MALIGNANCY eccentric/uncalcified calcification
TUBERCULOSIS OR HISTOPLASMOSIS central/com plete calcification
BENIGN HAMARTOMA popcorn calcification
Management
TREAT UNDERLYING CAUSE 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 thoracoscopy (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 bra chial plexus.
CLINICAL FEATURES shoulder and arm pain (C8, T1, T2 distribution), Horner’s syndrome (upper lid ptosis, 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 aper ture 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, particu larly 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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