Pulmonary Nodules and Lung Lesions

A solitary pulmonary nodule or “spot on the lung” is defined as a discrete, well-defined, rounded opacity less than or equal to 3 cm (1.5 inches) in diameter that is completely surrounded by lung tissue, does not touch the root of the lung or mediastinum, and is not associated with enlarged lymph nodes, collapsed lung, or pleural effusion.

A pulmonary nodule can be benign or cancerous. Lesions larger than 3 cm are considered masses and are treated as cancerous until proven otherwise.

Lung nodules are quite common and are found on one in 500 chest X-rays and one in 100 CT scans of the chest. Lung nodules are being recognized more frequently with the wider application of CT screening for lung cancer. Roughly half of people who smoke over the age of 50 will have nodules on a CT scan of their chest.

The thoracic surgeons and interventional pulmonologists at UT Southwestern Medical Center perform leading-edge procedures to evaluate and treat pulmonary nodules and various lung lesions – including bronchoscopic procedures, image-guided sampling, conventional surgical procedures, and more advanced minimally invasive and robotic techniques.

We feature the latest imaging techniques and treatments through our advanced imaging center, including endobronchial ultrasound (EBUS), electromagnetic navigational bronchoscopy (ENB), and many other techniques.

Our surgeons work closely with UT Southwestern’s interventional pulmonary team, oncologists, radiologists, and pathologists to deliver comprehensive care – all in one location, and usually on the same day. The pulmonary nodule clinic at UT Southwestern streamlines the evaluation and management of patients with pulmonary nodules and abnormal findings on imaging, including screening CT scan.

Causes of Lung Nodules

Lung nodules can be either benign (noncancerous) or malignant (cancer). The most common causes of benign nodules include granulomas (clumps of inflamed tissue) and hamartomas (benign lung tumors).

The most common cause of cancerous or malignant lung nodules includes lung cancer or cancer from other regions of the body that has spread to the lungs (metastatic cancer).

Lung nodules can be divided into a few major categories:

• Benign tumors, such as hamartomas
• Infections, including bacterial infections such as tuberculosis, and fungal infections such as histoplasmosis and coccidiomycosis
• Inflammation, such as rheumatoid arthritis, sarcoidosis, and Wegener's granulomatosis
• Malignant tumors, including lung cancer and cancer that has spread to the lungs from other parts of the body.

Overall, the likelihood that a lung nodule is a cancer is approximately 40 percent, but the risk of a lung nodule being cancerous varies considerably depending on several things, including:

• Age: Rare in people under 35 years of age. Half of lung nodules in people over age 50 are malignant
  
• Calcification: Lung nodules that are calcified are more likely to be benign
  
• Cavitation: Nodules described as “cavitary,” meaning that the interior part of the nodule appears to contain air on X-rays, are more likely to be benign
  
• Growth: Cancerous lung nodules tend to grow fairly rapidly with an average doubling time of about four months, while benign nodules tend to remain the same size over time
  
• Medical history: Having a history of cancer increases the chance that it could be malignant
• Occupation: Some occupational exposures raise the likelihood that a nodule is a cancer
• Smoking: Current and former smokers are more likely to have cancerous lung nodules than never smokers
• Size: Larger nodules are more likely to be cancerous than smaller ones
• Shape: Smooth, round nodules are more likely to be benign, while irregular or “spiculated” nodules are more likely to be cancerous

Diagnosis

If we suspect that you have a pulmonary nodule, we will conduct a physical examination and order tests to confirm the diagnosis. Studies to evaluate and diagnose pulmonary nodules might include:

• Bronchoscopy, including advanced guided techniques such as endobronchial ultrasound (EBUS), electromagnetic navigational bronchoscopy (ENB), and other procedures
• Chest X-rays (radiographs)
• Computed tomography (CT), including screening CT scan
• Fluoroscopy: Real-time X-ray imaging
• Image-guided sampling techniques that include CT-guided and ultrasound-guided biopsies (fine needle aspiration biopsy or FNA)
• Magnetic resonance imaging (MRI)
• Minimally invasive lung biopsy (thoracoscopic or robotic)
• Positron emission tomography (PET)
• Pulmonary function studies (PFT)

Based on the characteristics and size of the lung nodule on the CT scan, we may recommend:

• Observation and repeat X-ray studies if the nodule is likely benign
• Further imaging, such as a repeat CT scan of your chest or a PET scan
• Biopsy of the nodule via bronchoscopy (if the nodule is near one of your airways), a needle biopsy (if the nodule is located near the outside of your lungs), or lung surgery (video-assisted thoracoscopic surgery) if we think it may be malignant
• Treatments

When surgery is the most appropriate therapy, our thoracic surgeons treat pulmonary nodules and lung lesions with procedures that include:

• Lobectomy: Removal of an entire lobe by minimally invasive VATS or by robotic techniques
• Segmentectomy: Removal of a segment of a lobe by minimally invasive video-assisted thoracoscopic surgery (VATS) or by robotic techniques
• Wedge resection: Removal of the lung nodule along with a small amount of lung tissue

Minimally Invasive Surgery

Compared to surgery performed through an open chest incision, minimally invasive surgery provides several important benefits for patients, including:

• Faster recovery and return to normal activities
• Shorter hospital stay
• Less pain
• Little scarring
• Minimal blood loss
• No cutting of the ribs or sternum

When surgery is not possible in a patient with a cancerous or malignant nodule, our multidisciplinary team of surgeons and medical and radiation oncologists will provide recommendations about the best management options. These options may include advanced radiation techniques, systemic therapy with conventional chemotherapy, and/or targeted or personalized therapies.

Clinical Trials

UT Southwestern conducts clinical trials aimed at improving the treatment of pulmonary nodules. Talk with your doctor to see if a clinical trial may be right for you.