A biopsy of a lung nodule should be performed to determine whether it is malignant. The risks of biopsy and the procedural approach to tissue acquisition must of course take into account the patient's bleeding diathesis and comorbidities.
Biopsy of a solitary pulmonary nodule can be performed bronchoscopically or via CT-guided transthoracic needle aspiration (TTNA).
Because the yield from bronchoscopy is only 10-20% when the nodule is less than 2 cm in diameter, bronchoscopy with transbronchial needle aspiration (TBNA) may be helpful when the lesion is either endobronchial in location or near a large airway.
Prospective data from the NELSON lung cancer screening trial indicated that the sensitivity of bronchoscopy for suspicious nodules seen on CT scan is only 8.3%. However, if an endobronchial lesion is visualized, the sensitivity increases to 81.8%. [38] TBNA may also be helpful in sampling the mediastinal nodes. Fluoroscopy or endobronchial ultrasonography (EBUS) can be used to localize the lesions during TBNA to increase the diagnostic yield to 70% or more. [39, 40, 41]
TTNA reportedly has an accuracy of 90-95% when the lesion is 2 cm or larger in diameter, although the diagnosis is less accurate (60-80%) in lesions smaller than 2 cm. [42] Confirming a specific benign diagnosis is more difficult (approximately 70% accuracy). Therefore, most benign lesions are characterized as nondiagnostic following TTNA. The rate of pneumothorax following TTNA is approximately 20%, with 2-15% of patients requiring chest tube insertion. [43]
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Right upper lobe nodule shows peripheral calcification and high Hounsfield unit enhancement, suggesting that the lesion is a calcified, benign pulmonary nodule.
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A 1.5-cm coin lesion in the left upper lobe in a patient with prior colonic carcinoma. Transthoracic needle biopsy findings confirmed this to be a metastatic deposit.
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Mediastinal windows of the patient in the previous image
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Right lower lobe nodule demonstrating central calcification. The most likely diagnosis is histoplasmosis.
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Close-up view of a right lower lobe nodule demonstrating central calcification. The most likely diagnosis is histoplasmosis.
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Left upper lobe cavitating solitary nodule eventually identified as active pulmonary tuberculosis from percutaneous needle biopsy findings.
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A left upper lobe nodule with central lucency and poorly circumscribed margins was diagnosed as actinomycosis based on needle biopsy findings.
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Computed tomography (CT) scan of the patient in the previous image. After needle biopsy, the presence of classic sulfur granules confirmed a diagnosis of actinomycosis.
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A right lower lobe solitary pulmonary nodule that was later identified as a hamartoma.
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Wedge-shaped peripheral (pleural based) density observed secondary to pulmonary infarction (pulmonary embolism). This is termed the Hampton hump.
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Left upper lobe 1.5-cm nodule shows negative computed tomography (CT) scan numbers, suggesting fat in the lesion consistent with hamartoma.
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A left upper lobe solitary pulmonary nodule. The differential diagnosis in such cases is large, but computed tomography (CT) scan findings help to narrow the differentials and establish the diagnosis.
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Cavitating right lower lobe nodule later confirmed to be primary pulmonary lymphoma. Calcium deposits may also be present in the lesion.
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This left lower lobe carcinoid tumor was quite bloody after a percutaneous needle biopsy was performed.
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Lateral radiograph of the patient in the previous image.
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Computed tomography (CT) scan of a patient with a left lower lobe carcinoid tumor shows a well-circumscribed lesion.
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A popcorn calcification in the left lung nodule indicates a benign lesion or hamartoma. No further tests or observations were needed for this patient.
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A 1.5-cm right upper lobe nodule on a computed tomography (CT) scan was determined to be a benign, fibrous lesion on needle biopsy. A follow-up at 2 years showed no change in the size of this lesion.
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The parenchymal lesion in this computed tomography (CT) scan demonstrates low attenuation within the lesion, indicating the presence of fat. Fat density is observed only in hamartoma and lipoid pneumonia. The likely diagnosis is hamartoma
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This patient has a low risk for malignancy of the right upper lobe nodule. Therefore, continued observation with repeat chest radiographs to establish a growth pattern is the best treatment option.
