Each new nodule should be clarified with intensive measures until the histological assessment if a clear diagnosis in another way is impossible. These round lesions are usually discovered accidentally. In case of malignant nodules, generalized non-specific symptoms are often found: infectious and non-infectious granulomas may be accompanied by symptoms and underlying disease. At the medical history the doctor asks if the patient has had exposure to inorganic powders. If you have pulmonary symptoms: hemoftoe, cough, breathlessness, pain, if you have previously had TB, if you already had a known malignant underlying disease; depending on the diagnostic aspect, we can proceed with a more in-depth medical history.
Usually, it is devoid of relevant elements. Eventual rales are observed in cases
of bronchiectasis, allergic bronchopulmonary aspergillosis or silicosis,
arterial noises in case of AV fistulae, cyanosis. It is advisable to carry out a
very accurate internal examination including, above all, the palpation of all
the lymph nodes.
To the radiograph of the thorax (always p.a. and lateral, attention shadows of
breasts): if it is possible, use the previous radiographs for a comparison term!
- Diameter> 3.5 cm.
- Irregular contours with extensions (= spicules).
- Quick enlargement.
The presence of clear calcifications is expressed against malignancy
However, it should be noted that even with the most expensive imaging methods,
the nature of a pulmonary nodule can only be assumed to be unsubstantiated.
- CT scan of the thorax: it is indicated in each newly diagnosed pulmonary nodule.
The most suitable is the spiral technique since it allows to investigate all the
round nodules, and also the mediastinum and the ilo are represented in a
reliable way.
- Bronchoscopy: is suitable for the documentation / exclusion of a bronchial
carcinoma in a central position, for the diagnosis of oncogenic agents (bronchoalveolar
lavage, brush smears) and for the transbronchial biopsy of the pulmonary nodule
under radiological control. The results depend on the size of the outbreak from
which the biopsy sample was taken (4-6 biopsies usually offer an optimal outcome).
- Identification of a possible primary tumor or metastasis
- Laboratory tests: autoantibodies, specific antibodies in case of suspected
allergic bronchopulmonary aspergillosis, angiotensin conven enzyme (ACE) in case
of suspicion of sarcoidosis, tumor markers in case of suspected founded.
- Tuberculin test: Mendel-Mantoux test s.c. starting with 10 'in case of a
negative result, eventually repeat.
-Toracoscopy / thoracotomy videoassistita: if with the above methods you can not
get an obvious explanation, you should perform a surgical sampling of the
pulmonary nodule with a diagnostic purpose, possibly curative.
- Transthoracic puncture (possibly TC-guided): it is carried out in particular
in inoperable patients due to comorbidity or metastasis:
In other cases, a direct surgical procedure should be preferred
Isolated pulmonary nodules
History of smoking, generalized symptoms: weight loss, inappetence; symptoms often appears irregularly contoured / prolonged in the environment, possibly pleural reaction, possibly enlarged lymph nodes, dyspnoea, cough; enlarged lymph nodes of the hilum and / or mediastinum, atelectasis); sputum from absent to putrid (post-stenotic pneumonia) or hemorrhagic. Diagnostic Imaging: X-ray and CT scan of the chest (central or peripheral neoformatlvo process, bronchoscopy or thoracoscopy / video-assisted thoracotomy or CT, guided paracentesis, histology
Primitive tumor with different localization; very often, it is bronchial
carcinoma, squamous cell carcinoma of the upper respiratory tract, renal cell
carcinoma, colorectal, melanoma, sarcoma; Diagnostic imaging: contours from
rounded to irregular, features of the underlying disease
Acute dyspnea, phlebothrombosis; diagnostic imaging: typical triangular shape,
located in a subpleural site. Diagnostics: perfusion scintigraphy, chest CT scan
Due to TB, abscess, parasites [e.g. echinococcus, aspergilloma, mycenae but due
e.g. a Coccidi / histoplasmas. Signs of infection; imaging diagnostics (eg caves
with "fungus ball" In case of aspergilloma, pulmonary nodule with multiple cysts
in the case of echinococcus Identification of sputum germs, LBA, brushing smear,
operative preparation, blood culture, pleural effusion, serological tests
Other inflammatory granuloma. benign tumor (especially hamartoma, chondroma)
Possibly cough, possibly hemoptys; diagnostic imaging: tumor in the region of
the trachea or large bronchi, located in the intraluminal site
differential diagnosis with bronchial carcinoma
Thoracic trauma, iatrogenic phenomena, coagulation disorder, medical history is
essential for diagnosis
Usually, it is secondary in case of asbestos-induced pleural disease; diagnostic
imaging: signs of pleural asbestosis with thickening and plaques
Characteristic radiological repertoire