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A solitary pulmonary nodule, sometimes referred to as a “coin lesion,” is a less-than-3-cm isolated, rounded opacity on chest imaging outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy. Most are asymptomatic and represent an incidental finding on chest radiography or CT scanning. The finding is important because it carries a significant risk of malignancy. The frequency of malignancy in surgical series ranges from 10% to 68% depending on patient population. Benign neoplasms, such as hamartomas, account for less than 5% of solitary nodules (eFigure 9–15). Most benign nodules are infectious granulomas.

eFigure 9–15.

Hamartoma of the lung. Incidentally identified on a chest CT scan in a young, otherwise health 31-year-old male, the hamartoma appears as a round and well-demarcated left lower lobe mass with areas of dense calcification and much lower density fat.

The goals of evaluation are to identify and resect malignant tumors in patients who will benefit from resection while avoiding invasive procedures in benign disease. The task is to identify nodules with a sufficiently high probability of malignancy to warrant biopsy or resection or a sufficiently low probability of malignancy to justify observation.

Symptoms alone rarely establish the cause, but clinical and imaging data can be used to assess the probability of malignancy. Malignant nodules are rare in persons under age 30. Above age 30, the likelihood of malignancy increases with age. Smokers are at increased risk, and the likelihood of malignancy increases with the number of cigarettes smoked daily. Patients with a prior malignancy have a higher likelihood of having a malignant solitary nodule.

The first step in the imaging evaluation is to review old imaging studies. Comparison with prior studies allows estimation of doubling time, which is an important marker for malignancy. Rapid progression (doubling time less than 30 days) suggests infection, while long-term stability (doubling time greater than 465 days) suggests benignity. Certain radiographic features help in estimating the probability of malignancy. Size is correlated with malignancy. A study of solitary nodules identified by CT scan showed a 1% malignancy rate in those measuring 2–5 mm, 24% in 6–10 mm, 33% in 11–20 mm, and 80% in 21–45 mm nodules. The appearance of a smooth, well-defined edge is characteristic of a benign process. Ill-defined margins or a lobular appearance suggest malignancy. A high-resolution CT finding of spiculated margins and a peripheral halo are both highly associated with malignancy. Calcification and its pattern are also helpful clues. Benign lesions tend to have dense calcification in a central or laminated pattern. Malignant lesions are associated with sparser calcification that is typically stippled or eccentric. Cavitary lesions with thick (greater than 16 mm) walls are much more likely to be malignant. High-resolution CT offers better resolution of these characteristics than chest radiography and is more likely to detect lymphadenopathy or the presence of multiple lesions. Chest ...

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