Urgent considerations
See Differentials for more details
A solitary pulmonary nodule is rarely, if ever, an emergency. However, prompt evaluation is important to: facilitate timely treatment of malignancy when present; or, allay patient concerns if the nodule is benign.
On initial presentation, the clinician should obtain prior chest x-rays for comparison. If the chest x-rays do not provide a sufficient level of certainty in the diagnosis, then a chest computed tomography (CT) scan is indicated. This will help to determine the size/volume, density, location, edge characteristics, and pattern of calcification of the nodule. Other abnormalities within the chest or the abdomen and pelvis (e.g., associated mediastinal or hilar lymphadenopathy, pleural effusions, extra-thoracic primary cancers) can also be identified.
[Figure caption and citation for the preceding image starts]: A-D: calcification patterns of benign nodules; E, F: may be seen in malignant nodulesMazzone P.J., Stoller J.K. Semin Thorac Cardiovasc Surg. 2002;14:250-260; used with permission [Citation ends].
The likelihood of malignancy can be estimated or calculated from the patient history (e.g., age, history of tobacco use, history of prior malignancy, family history of lung cancer, occupational exposures) and review of the radiologic characteristics of the nodule. The diagnostic and therapeutic approach is guided by the likelihood of malignancy, in combination with factors such as the wishes of the patient and any preexisting comorbidity.
The clinician should be aware that, left untreated, patients with even early stages of lung cancer have a poor survival rate. Thus, patients with suspected malignancy should be managed expeditiously.[9] However, a holistic approach to the older frail patient with multiple comorbidities is important; patient preferences need to be considered and the burden of further investigation weighed against possible benefits to the individual.
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