Solitary Pulmonary Nodules: Part II. Evaluation of the Indeterminate Nodule

Various strategies may be used to evaluate indeterminate solitary pulmonary nodules. Growth rate assessment is an important and cost-effective step in the evaluation of these nodules. Clinical features (eg, patient age, history of prior malignancy, presenting symptoms, smoking history) can be useful in suggesting the diagnosis and aiding in management planning. Bayesian analysis allows more precise determination of the probability of malignancy (pCa). Decision analysis models suggest that the most cost-effective management strategy depends on the pCa for a given nodule. At contrast material–enhanced computed tomography, nodular enhancement of less than 15 HU is strongly predictive of a benign lesion, whereas enhancement of more than 20 HU typically indicates malignancy. At 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) positron emission tomography, lesions with low FDG uptake are typically benign, whereas those with increased FDG uptake are typically malignant. Results of transthoracic needle aspiration biopsy influence management in approximately 50% of cases and, in indeterminate lesions with a pCa between 0.05 and 0.6, is the best initial diagnostic procedure. It is optimally used in peripheral nodules and has been reported to establish a benign diagnosis in up to 91% of cases. Although there is no one correct management approach, the ability to distinguish benign from malignant solitary pulmonary lesions has improved with the use of these strategies.


  • 1 Gurney JW, Lyddon DM, McKay JA. Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis. Part II. Application. Radiology 1993; 186:415-422. Google Scholar
  • 2 Edwards WM, Cox RS, Jr, Garland LH. The solitary nodule (coin lesion) of the lung: an analysis of 52 consecutive cases treated by thoracotomy and a study of preoperative diagnostic accuracy. AJR Am J Roentgenol 1962; 88:1020-1042. Google Scholar
  • 3 Lillington GA, Caskey CI. Evaluation and management of solitary multiple pulmonary nodules. Clin Chest Med 1993; 14:111-119. Crossref, MedlineGoogle Scholar
  • 4 Dewan NA, Gupta NC, Redepenning LS, Phalen JJ, Frick MP. Diagnostic efficacy of PET-FDG imaging in solitary pulmonary nodules. Chest 1993; 104:997-1002. Crossref, MedlineGoogle Scholar
  • 5 Good CA, Wilson TW. The solitary circumscribed pulmonary nodule. JAMA 1958; 166:210-215. Crossref, MedlineGoogle Scholar
  • 6 Good CA. Management of patient with solitary mass in lung. Chic Med Soc Bull 1953; 55:893-896. Google Scholar
  • 7 Lillington GA. Disease-a-Month 37th ed. St Louis, Mo: Mosby–Year Book, 1991; 271-318. MedlineGoogle Scholar
  • 8 Yankelevitz DF, Henschke CI. Does 2-year stability imply that pulmonary nodules are benign? AJR Am J Roentgenol 1997; 168:325-328. Crossref, MedlineGoogle Scholar
  • 9 Hood RT, Jr, Good CA, Clagett OT, McDonald JR. Solitary circumscribed lesions of the lung: study of 156 cases in which resection was performed. JAMA 1953; 152:1185-1191. Crossref, MedlineGoogle Scholar
  • 10 Yankelevitz DF, Reeves AP, Kostis WJ, Zhao B, Henschke CI. Determination of malignancy in small pulmonary nodules based on volumetrically determined growth rates (abstr). Radiology 1998; 209(suppl):375. Google Scholar
  • 11 Gurney JW. Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis. Radiology 1993; 186:405-413. LinkGoogle Scholar
  • 12 Black WC, Armstrong P. Communicating the significance of radiologic test results: the likelihood ratio. AJR Am J Roentgenol 1986; 147:1313-1318. Crossref, MedlineGoogle Scholar
  • 13 Kunstaetter R, Wolkove N, Kreisman H, Cohen C, Frank H. The solitary pulmonary nodule. Med Decis Making 1985; 5:61-75. Crossref, MedlineGoogle Scholar
  • 14 Lillington GA, Cummings SR. Decision analysis approaches in solitary pulmonary nodules. Semin Respir Med 1989; 10:227-231. CrossrefGoogle Scholar
  • 15 Cummings SR, Lillington GA, Richard RJ. Managing solitary pulmonary nodules. Am Rev Respir Dis 1986; 134:453-460. MedlineGoogle Scholar
  • 16 Swensen SJ, Brown LR, Colby TV, Weaver AL, Midthun DE. Lung nodule enhancement at CT: prospective findings. Radiology 1996; 201:447-455. LinkGoogle Scholar
  • 17 Yamashita K, Matsunobe S, Tsuda T, et al. Solitary pulmonary nodule: preliminary study of evaluation with incremental dynamic CT. Radiology 1995; 194:399-405. LinkGoogle Scholar
  • 18 Swensen SJ, Brown LR, Colby TV, Weaver AL. Pulmonary nodules: CT evaluation of enhancement with iodinated contrast material. Radiology 1995; 194:393-398. LinkGoogle Scholar
  • 19 Erasmus JJ, McAdams HP, Patz EF, Jr, Goodman PC, Coleman RE. Thoracic FDG PET: state of the art. RadioGraphics 1998; 18:5-20. LinkGoogle Scholar
  • 20 Patz EF, Lowe VJ, Hoffman JM, et al. Focal pulmonary abnormalities: evaluation with F-18 fluorodeoxyglucose PET scanning. Radiology 1993; 188:487-490. LinkGoogle Scholar
  • 21 Gupta NC, Frank AR, Dewan NA, et al. Solitary pulmonary nodules: detection of malignancy with PET with 2-[F-18]-fluoro-2-deoxy-d-glucose. Radiology 1992; 184:441-444. LinkGoogle Scholar
  • 22 Scott WJ, Schwabe JL, Gupta NC, Dewan NA, Reeb SD, Sugimoto JT. Positron emission tomography of lung tumors and mediastinal lymph nodes using [18F] fluorodeoxyglucose. Ann Thorac Surg 1994; 58:698-703. Crossref, MedlineGoogle Scholar
  • 23 Conti PS, Lilien DL, Hawley K, Keppler J, Grafton ST, Bading JR. PET and [18F]-FDG in oncology: a clinical update. Nucl Med Biol 1996; 23:717-735. Crossref, MedlineGoogle Scholar
  • 24 Gupta NC, Maloof J, Gunel E. Probability of malignancy in solitary pulmonary nodules using fluorine-18-FDG and PET. J Nucl Med 1996; 37:943-948. MedlineGoogle Scholar
  • 25 Hübner KF, Buonocore E, Gould HR, et al. Differentiating benign from malignant lung lesions using “quantitative” parameters of FDG PET images. Clin Nucl Med 1996; 21:941-949. Crossref, MedlineGoogle Scholar
  • 26 Dewan NA, Shehan CJ, Reeb SD, Gobar LS, Scott WJ, Ryschon K. Likelihood of malignancy in a solitary pulmonary nodule. Chest 1997; 112:416-422. Crossref, MedlineGoogle Scholar
  • 27 Erasmus JJ, McAdams HP, Patz EF, Jr, Coleman RE, Ahuja V, Goodman PC. Evaluation of primary pulmonary carcinoid tumors using FDG PET. AJR Am J Roentgenol 1998; 170:1369-1373. Crossref, MedlineGoogle Scholar
  • 28 Higashi K, Ueda Y, Seki H, et al. Fluorine-18-FDG PET imaging is negative in bronchioloalveolar lung carcinoma. J Nucl Med 1998; 39:1016-1020. MedlineGoogle Scholar
  • 29 Lowe VJ, Fletcher JW, Gobar L, et al. Prospective investigation of PET in lung nodules (PIOPILN). J Clin Oncol 1998; 16:1075-1084. Crossref, MedlineGoogle Scholar
  • 30 Strauss LG, Conti PS. The applications of PET in clinical oncology. J Nucl Med 1991; 32:623-648. MedlineGoogle Scholar
  • 31 Kubota K, Matsuzawa T, Fujiwara T, et al. Differential diagnosis of lung tumor with positron emission tomography: a prospective study. J Nucl Med 1990; 31:1927-1933. MedlineGoogle Scholar
  • 32 Quint LE, Francis IR, Wahl RL, Gross BH, Glazer GM. Preoperative staging of non–small-cell carcinoma of the lung: imaging methods. AJR Am J Roentgenol 1995; 164:1349-1359. Crossref, MedlineGoogle Scholar
  • 33 Lee SI, Shepard JO, Boiselle PM, Trotman-Dickenson B, McLoud TC. Role of transthoracic needle biopsy in patient treatment decisions (abstr). Radiology 1996; 201(suppl):269. Google Scholar
  • 34 Yankelevitz DF, Henschke CI, Altorki NK. Cost analysis of competing strategies for evaluating and treating solitary pulmonary nodules (abstr). Radiology 1996; 201(suppl):269. Google Scholar
  • 35 Klein JS, Zarka MA. Thoracic needle biopsy: an overview. J Thorac Imaging 1997; 12:232-249. Crossref, MedlineGoogle Scholar
  • 36 Westcott JL, Rao N, Colly DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology 1997; 202:97-103. LinkGoogle Scholar
  • 37 Li H, Boiselle PM, Shepard JO, Trotman-Dickenson B, McLoud TC. Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules. AJR Am J Roentgenol 1996; 167:105-109. Crossref, MedlineGoogle Scholar
  • 38 Klein JS, Salomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients. Radiology 1996; 198:715-720. LinkGoogle Scholar
  • 39 Moore EH. Needle-aspiration lung biopsy: a comprehensive approach to complication reduction. J Thorac Imaging 1997; 12:259-271. Crossref, MedlineGoogle Scholar
  • 40 Miller JA, Pramanik BK, Lavenhar MA. Predicting the rates of success and complications of computed tomography–guided percutaneous core-needle biopsies of the thorax from the findings of the preprocedure chest computed tomography scan. J Thorac Imaging 1998; 13:7-13. Crossref, MedlineGoogle Scholar

Article History

Published in print: Jan 2000