ACR

Appropriateness
Criteria

Radiologic Management of
Thoracic Nodules and Masses
Charles E. Ray Jr, MD
a
, Benjamin English, MD
a
, Brian S. Funaki, MD
b
,
Charles T. Burke, MD
c
, Nicholas Fielman, MD

, Mark E. !insburg,
MD
e,"
, Thomas B. #inney, MD
g
, Jon #. #os$elic, MD
h
, Brian E. #ouri,
MD
i
, Jona$han M. %oren&, MD
j
, 'ji$ (. Nair, MD
k
, 'lber$ '. Nemcek Jr,
MD
l
, Charles '. )*ens, MD
m
, 'n$hony !. Saleh, MD
n,o
, !eorge
(a$akencherry, MD
+
, Tan,%ucien -. Mohamme, MD
.
Pulmonary and mediastinal masses represent a wide range of pathologic processes with very different
treatment options. Although advances in imaging (such as PET and high-resolution CT) help in many
cases with the differential diagnosis of thoracic pathology, tissue samples are freuently needed to
determine the !est man-agement for patients presenting with thoracic masses. There are many options
for o!taining tissue samples, each of which has its own set of !enefits and draw!ac"s. The purposes of
this report are to present the most current evidence regarding !iopsies of thoracic nodules and masses
and to present the most appropriate options for select common clinical scenarios.
The AC# Appropriateness Criteria
$
are evidence-!ased guidelines for specific clinical conditions that
are reviewed every % years !y a multidisciplinary e&pert panel. The guideline development and review
include an e&tensive analysis of current medical literature from peer-reviewed 'ournals and the
application of a well-esta!lished consensus methodology (modified (elphi) to rate the appropriateness
of imaging and treatment procedures !y the panel. )n those instances in which evidence is lac"ing or not
definitive, e&pert opinion may !e used to recommend imaging or treatment.
Key Words: Appropriateness Criteria, thoracic mass, mediastinal mass, !iopsy, pulmonary nodule
J Am Coll Radiol 2012;9:13-19. Copyright 2012 American College of Radiology
SUMMAR !" #$T%RATUR% R%&$%W
*ung cancer causes more deaths than the ne&t + most
common cancers com!ined (colon, !reast, and prostate
cancer). An estimated
,-%,.-/ deaths from lung
cancer occur in the 0nited
1tates each year, and the
incidence of the disease is
rising 2,3 . The diagnosis of
lung cancer
carries a very poor prognosis4 the e&pected 5-year
survival rate for all patients in whom lung cancer is
diagnosed is ,5.56
(compared with -..76 for
colon cancer, 786 for
!reast cancer, and 88.86
for prostate cancer). Early
di-agnosis is vital and
significantly improves
survival rates. The 5-year
survival rate approaches
5/6 in patients in
a
0niversity of Colorado (enver and 9ealth
1ciences Center, Aurora, Colorado.
!
0niversity of Chicago, Chicago, )llinois.
c
0niversity of :orth Carolina 9ospital,
Chapel 9ill, :orth Carolina.
d
0niversity of California, 1an
;rancisco, 1an ;rancisco, California.
e
Colum!ia 0niversity, :ew <or", :ew
<or".
f
1ociety of Thoracic 1urgeons, Chicago,
)llinois.
g
0niversity of California 1an (iego =edical
Center, 1an (iego, California.
h
Central
>entuc"y #adiology, *e&ington, >entuc"y.
i
?a"e ;orest 0niversity @aptist =edical
Center, ?inston-1alem, :orth Carolina.
'
0niversity of Chicago 9ospital, Chicago,
)llinois.
"
0niversity of ?ashington =edical Center,
1eattle, ?ashington.
l
:orthw
estern
=emori
al
9ospita
l,
Chicago
,
)llinois.
m
0niver
sity of
)llinois
College
of
=edicin
e,
Chicago
,
)llinois.
n
:ew
<or"
=ethod
ist
9ospita
l,
@roo"ly
n, :ew
<or".
o
Ameri
can
College
of
Chest
Physici
ans,
:orth!r
oo",
)llinois.
p
>aiser
Permanente, *os
Angeles =edical
Center, *os
Angeles, California.

Cleveland Clinic
;oundation,
Cleveland, Ahio.
Corresponding
author and reprints4
Charles E. #ay, Br,
=(, American
College of #adiology,
,78, Preston ?hite
(rive, #eston, CA
%/,8,D e-mail4
charles.rayEucdenver
.edu.
The AC# see"s and
encourages
colla!oration with
other organiFations on
the development of
the AC#
Appropriateness
Criteria
$
through
society rep-
resentation on e&pert
panels. Participation
!y representatives
from colla!orat-ing
societies on the e&pert
panel does not
necessarily imply
individual or society
endorsement of the
final document.
/ 0120 'merican College o" Raiology '(
1132, 02405205678.11
9
D):
21.21285j.jacr.0 122.13.127
') Journal o" $he 'merican College o" Raiology5 (ol. 3 No. 2 January 0120
whom the disease is
detected when still
localiFed 2%3 .
9owever, only a!out
, in . lung cancer
cases is diag-nosed
at an early stage
2%3.
=etastatic disease
to the lungs can occur
with virtually any
primary malignancy.
(iagnosis of such
metastases allows
appropriate treatment
and prognostication of
pa-tients with the
disease. Although
diffuse metastatic dis-
ease to the lungs
typically mandates
systemic treatment
such as intravenous
chemotherapy, some
primary tumors such
as sarcomas may
metastasiFe solely to
the lungs, and surgical
resection may !e
curative 2+3 .
Cases in which
lung cancer is
diagnosed at an early
stage are typically
asymptomatic,
further delaying di-
agnosis. 1olitary
pulmonary nodules
represent the most
typical radiographic
presentation of early
lung cancer, and
multiple pulmonary
nodules may !e the
first sign of
malignancy in a
patient without a
prior diagnosis.
@iopsy of pulmonary
nodules therefore al-
lows a tissue
diagnosis of
malignancy and, in
some cases, staging
of the primary tumor.
(iagnosis !y less
invasive means may
also preclude
more invasive
surgi-cal
procedures
performed for
diagnosisD this is
partic-ularly
important in this
high-ris" patient
population 2.3 .
;or e&ample,
findings from
PETGCT have
!een shown to
reduce the num!er
of futile
thoracotomies and
the total num!er
of thoracotomies
253.
@ecause of the
nature of this
document, its
discussion of
!iopsies centers on
percutaneous
approaches.
@ecause
percutaneous
!iopsy is now
typically
considered a first-
line procedure,
there is a severe
paucity of recent
lite-rature directly
comparing
percutaneous with
other approaches
(eg, surgical,
video-assisted
thoracoscopy,
!ronchoscopy with
or without
fluoroscopic
guidance).
&ariant *. ' ;;,
year,ol *oman
*ho +resen$e $o
$he emergency
e+ar$men$ *i$h
shor$ness o"
brea$h< CT
+ulmonary
angiogra+hy *as
nega$i=e "or
+ulmonary
embolism bu$
emons$ra$e an
incien$al 2.;,cm
noule in $he le"$
lo*er lobe< $he
lesion *as
smoo$h, an $here
*as no
associa$e
aeno+a$hy< she
ha a >1,+acks,a,
year smoking
his$ory an
e=ience o"
signi"ican$ chronic
obs$ruc$i=e
+ulmonary
isease on ches$
CT
Treatment+,rocedure Rating
Comment
s
?ercu$aneous lung bio+sy 4
FD!,?ET *hole boy 4
Surgical lung bio+sy5resec$ion ;
Follo*,u+ imaging only 0
Conser=a$i=e managemen$ 2
@o no$hingA
No$eB Ra$ing scaleB 2,
0, an 7 usually no$
a++ro+ria$e< C, ;, an
8 may be
a++ro+ria$e< >, 4, an
3 usually a++ro+ria$e.
FD! 0,D
24
FE"luoro,0,
eoFyglucose.
The reader should
"eep these other
approaches in mind
and on a case-!y-
case !asis !ased on
anatomy and
clinical
presentation should
determine whether
nonpercutane-ous
approaches should
!e seriously
considered.
,ulmonary
Nodules
=ost !iopsies in the
thora& will !e
performed for pulmo-
nary nodules 2Cariants
,-53. These nodules
may !e soli-tary or
multipleD in the latter
case, metastatic
disease or an
infectious etiology
is more li"ely than
a primary lung
cancer. )nitial
clinical evaluation,
including "nown
ris" factors for
lung cancer, is
necessary !efore
!iopsy is at-
tempted. There are
several pu!lished
guidelines for the
management of
small pulmonary
nodules detected
on CT scans, the
most widely cited
of which is
supported !y
&ariant '. '
81,year,ol
man *ho
uner*en$
screening
coronary
ar$ery CT
scan< an
incien$al
2.;,cm
noule *as
no$e in his
righ$ u++er
lobe< $he
lesion *as
smoo$h,
an $here
*as no
associa$e
aeno+a$hy
< he has no
kno*n risk
"ac$ors "or
lung cancer
Treatment+,roced
ure
?ercu$aneous lung
bio+sy
FD!,?ET *hole boy
Follo*,u+ imaging
only
Surgical lung bio+sy5
resec$ion
Conser=a$i=e
managemen$ @o
no$hingA
No$eB
Ra$ing
scaleB 2,
0, an 7
usually no$
a++ro+ria$
e< C, ;,
an 8 may
be
a++ro+ria$
e< >, 4,
an 3
usually
a++ro+ria$
e. FD! 0,
D
24
FE"luoro
,0,
eoFygluc
ose.
&ariant
(. ' ;4,
year,ol
man
*i$h a
ne*ly
iagnos
e colon
carcino
ma< 7
+ulmona
ry
noules,
ranging
u+ $o 0
cm in
iame$er
, *ere
no$e on
s$aging
CT o"
$he
ches$< 2
o" $he
lesions
emons$
ra$es a
lobula$e

a++eara
nce
Treatment+,rocedur
e
?ercu$aneous lung
bio+sy
FD!,?ET *hole boy
Surgical lung
bio+sy5resec$ion
Follo*,u+ imaging only
Conser=a$i=e
managemen$ @o
no$hingA
No$eB
Ra$ing
scaleB 2,
0, an 7
usually no$
a++ro+ria$
e< C, ;,
an 8 may
be
a++ro+ria$
e< >, 4,
an 3
usually
a++ro+ria$
e. FD! 0,
D
24
FE"luoro
,0,
eoFygluc
ose.
&ariant ). ' 7;,year,ol man *i$h a 2.1,cm smoo$h,
*alle noncalci"ie noule in $he righ$ mile lobe
incien$ally seen on CT a"$er minor mo$or =ehicle
$rauma< he has no kno*n risk "ac$ors "or lung cancer
Treatment+,rocedure Rating
Comment
s
Follo*,u+ imaging only 4
?ercu$aneous lung bio+sy 7
FD!,?ET *hole boy 7
Surgical lung bio+sy5resec$ion 0
Conser=a$i=e managemen$ 2
@o no$hingA
No$eB Ra$ing scaleB 2, 0, an 7 usually no$ a++ro+ria$e< C, ;, an 8 may
be a++ro+ria$e< >, 4, an 3 usually a++ro+ria$e. FD! 0,D
24
FE"luoro,0,
eoFyglucose.
the ;leischner 1ociety 2-3 . =any nonradiologists use
Hpulmonary nodule calculatorsI to estimate the pretest
pro!a!ility of malignancy for any given solitary pulmo-
nary nodule. @y inputting several clinical and
radiologic ris" factors that increase the li"elihood of
malignancy (eg, age, smo"ing history, siFe and
morphology of the nod-ule), a calculation is performed
that gives the pro!a!ility of malignancy for a patient
presenting with a solitary pulmonary nodule. The
American College of Chest Phy-sicians recommends
the use of pulmonary nodule calcu-lators when
determining the diagnostic or treatment al-gorithms to
!e underta"en for patients presenting with solitary
pulmonary nodules. These calculators are widely
availa!le on the )nternet.
There is a distinct paucity of evidence in the
literature directly comparing !iopsy techniues across
multiple specialties. =ethods !y which !iopsies may !e
o!tained include percutaneous !iopsy with imaging
guidance, me-diastinoscopy with !iopsy, !ronchoscopy-
guided trans-!ronchial !iopsy, video-assisted
thoracoscopy, endo-scopic ultrasound transesophageal
!iopsy, and open surgical !iopsy. The location of a
nodule (eg, su!pleural, paramediastinal, su!carinal,
endo!ronchial) significantly affects the li"elihood of
success of one form of !iopsy compared with another.
Patients in whom !iopsies are performed are often
considered to !e at high ris" for complications from the
procedure. These ris"s (eg, pneumothora&, !leeding,
and !ronchopleural fistula) are due largely to the poor
under-lying pulmonary reserve and high incidence of
chronic o!structive pulmonary disease in this patient
population. Patients should !e counseled !efore the
procedure re-garding the significant ris"s associated
with their !iopsy procedures.
)n addition to pro!lems associated with a relatively
high-ris" patient population, percutaneous !iopsies of
pulmonary nodules may !e difficult to perform techni-
cally. Patients may often have difficulty suspending res-
pirations or may ta"e varia!le volume !reaths, resulting in
the target lesion moving in and out of the !iopsy plane.
*esions may also !e very small or central (deep) in loca-
Ray e$ al5Raiologic Managemen$ o" Thoracic Noules an Masses '-
tion, ma"ing needle placement challenging. ;or
these reasons and others, the failure rate of lung
!iopsies is relatively high. The 1ociety of
)nterventional #adiology guidelines for lung !iopsy
specify that an 756 success rate is accepta!le 2J3 .
Characteristics of pulmonary nodules affect the li"eli-
hood of malignancy. =orphologic characteristics, such
as smooth and well-defined margins and diffuse or cen-
tral nodular calcifications, favor !enignancy. Persistent
ground-glass and mi&ed ground-glass density nodules
have a high rate of malignancy 27-,/3 . The li"elihood of
cancer diagnosis increases with the siFe of the
pulmonary nodule, regardless of solid or ground-glass
density. :od-ules + cm in diameter are considered
pulmonary ma-lignancies until proven otherwise. Ather
characteristics, such as growth rate, dynamic changes on
contrast-en-hanced helical CT, and upta"e of %-
2
,7
;3fluoro-%-deo&y-glucose (;(K) during PET imaging
may help in distin-guishing !enign from malignant
lesions 2,,3 .
;(K is accumulated in malignant nodules. @enign
lesions such as hamartomas and inflammatory nodules
do not significantly accumulate ;(K. Thus, PET is a
valua!le tool in the evaluation of indeterminate lesions.
)n one meta-analysis of ,,.J. pulmonary nodules 2,%3 ,
PET was 8J6 sensitive and J76 specific. )t is important
to recogniFe the limitations of PET. )t is !est used in
patients with nodules , cm in diameter, and false-
negative results may occasionally occur with malignan-
cies such as well-differentiated adenocarcinomas, !ron-
chioloalveolar cell carcinomas, and carcinoid tumors.
;alse-positive lesions may result in patients with tu!er-
culosis, fungal infections, or sarcoidosis.
&ariant -. ' 80,year,ol man *i$h a +ersis$en$ 2.;,cm
groun,glass noule no$e on an ini$ial CT scan an a
"ollo*,u+ 7,mon$h CT scan< he has no smoking his$ory
an no recen$ res+ira$ory in"ec$ion
Treatment+,rocedure Rating Comments
?ercu$aneous lung bio+sy >
Surgical lung 8 Bio+sy e+ens on
bio+sy5resec$ion
local
+ercu$aneous
eF+er$ise.
Surgical
resec$ion may be
+er"orme
"ollo*ing
+ercu$aneous
bio+sy.
FD!,?ET *hole boy ; Bronchioloal=eolar
carcinoma is
o"$en
?ET nega$i=e.
Follo*,u+ imaging only ;
Conser=a$i=e 2
managemen$ @o
no$hingA
No$eB Ra$ing scaleB 2, 0, an 7 usually no$ a++ro+ria$e< C, ;, an 8 may
be a++ro+ria$e< >, 4, an 3 usually a++ro+ria$e. FD! 0,D
24
FE"luoro,0,
eoFyglucose.
'. Journal o" $he 'merican College o" Raiology5 (ol. 3 No. 2 January 0120
Transthoracic
needle aspiration and
!iopsy are the
mainstays for
o!taining tissue for
histopathologic diag-
nosis of pulmonary
nodules, and they
usually provide
adeuate tissue
uantity for
!iochemical analysis
2,+3. 1everal
technical measures
may increase the
yield or de-crease the
ris" of percutaneous
!iopsies4
,L preselecting
patients with
nodules having
high poten-tial for
malignancyD
%L providing
onsite analysis of
the specimen,
rather than placing
the specimen in
fi&ative for later
analysis, thus
allowing higher
diagnostic
accuracy 2,%,,.-
,-3D
+L performing
!oth fine-needle
aspiration (;:A)
and core !iopsies
of the same
lesion, which has
!een shown to
increase yield
over ;:A alone
2,J3, particularly
in the diagnosis of
!enign nodulesD
.L using a
steeper angle of
the !iopsy needle,
which may
decrease the ris"
for pneumothora&
2,73D and
5L using a ,8-
gauge or
smaller needle
2,83.
Percutaneous
!iopsy is limited
in its a!ility to
o!tain a specific
diagnosis of a
!enign pulmonary
process, and
yields of 5/6 are
e&pected 2%/,%,3 .
Performing !oth
core !iopsies and
;:A of !enign
lesions
significantly
increases the
diagnostic yield
2%%3. )n addition,
some investigators
have suggested
that multiple
larger !iopsy
samples ( +
samples , cm in
length) increases
the yield of
diagnosis for
!enign lesions
2%+3.
)n certain
instances,
nonradiologic
!iopsies of pulmo-
nary nodules may
provide higher
yields than image-
guided
procedures.
Cideo-assisted
thoracoscopic
!iopsy may have
very high success
rates in patients
with su!pleu-ral
nodules, and
!ronchoscopic
!iopsy of central
intralu-minal
lesions may also
provide !etter
success rates com-
pared with
percutaneous
!iopsy.
Percutaneous
lung !iopsy is
generally
associated with
higher
complication rates
compared with
solid organ !iopsy.
The 1ociety of
)nterventional
#adiology has pu!-
lished guidelines
stating that an
overall
complication rate
of ,/6 is
accepta!le for lung
!iopsies, compared
with
%6 for all other
organ systems 2J3 .
The most common
complication of
percutaneous lung
!iopsy is !leeding
(hemoptysis, chest
wall, parenchymal)D
however, the most
common
complication
reuiring intervention
is pneumothora&
(,/6-+/6). Chest
tu!e insertion is
needed in
appro&imately one-
third of patients with
pneumothoraces.
=ost post!iopsy
complications can !e
treated
conservatively, often
on an outpatient !asis
2%.- %-3 .
Em!oliFation of the
tract after !iopsy
using a coa&ial
system has !een
descri!ed, with
em!oliFation agents
varying from
collagen foam plugs
to autologous clot to
fi!rin glue 2%J-%83 .
The ris" for chest
wall implantation
caused !y
percutaneous !iopsy
is rare, with reported
rates ranging from
/6 to +6 2+/,+,3 .
Patients who
undergo
percutaneous lung
!iopsies that yield
definitive
malignant
diagnoses may or
may not undergo
therapy. ;alse-
positive results are
very rare. Pa-
tients with
definitive !enign
diagnoses can !e
managed
conservatively,
although false-
negative results
may occur in a
minority of
patients. Patients
who do not have
either a definitive
malignant or
!enign diagnosis
need close follow-
up, surgical
referral, or repeat
!iopsy (either per-
cutaneous or !y
other means).
(eath from
percutaneous lung
!iopsy is
e&tremely rare !ut
may occur from
sys-temic air
em!olism.
Mediastinal
Nodes and
Masses
=ediastinal
masses may arise
without a
concurrent
intraparenchymal
pulmonary mass
and may
represent
metastatic disease
2Cariants -, J3.
(efinitive
diagnosis !y
!iopsy is vital in
that it may
significantly
change the
treatment options
or may preclude
the need for e&-
ploratory surgery.
The !est method
of !iopsy largely
depends on the
location of the
mass and the
pro&imity of
ad'acent
structures.
)mage-guided
!iopsies of
mediastinal masses
are al-most always
performed using
CT guidance. The
lac" of an acoustic
window prevents
the use of
ultrasound, un-less
the mass e&tends to
the pleural surface
or invades the chest
wall. #eal-time CT
guidance, however,
may !e
&aria
nt ..
' >0,
year,
ol
*om
an
*i$h
+osi$i
=e
??D
an
abno
rmal
ches$
ra
io
gr
a+
hic
"in
in
gs<
on
CT
sc
an
nin
g,
bul
ky
@u
+
$o
7
cm
A
me
ia
s$i
nal
a
en
o+
a$h
y
*a
s
no$
e $hroughou$
$he meias$inum
@+re$racheal,
subcarinal,
aor$o+ulmonary
*ino*A< $he noes o
no$ emons$ra$e
calci"ica$ions or
necrosis< $here are no
associa$e +ulmonary
noules
Treatment+,rocedure Rating Comments
Enosco+ic5bronchosco+ic bio+sy 4
?ercu$aneous meias$inal bio+sy ; Consier i" bronchosco+ic bio+sy "ails, an $he meias$inal bio+sy
can be sa"ely +er"orme +ercu$aneously.
Surgical meias$inal bio+sy5resec$ion C Migh$ be a++ro+ria$e e+ening on local
+ercu$aneous5bronchosco+ic bio+sy eF+er$ise an accessibili$y
Follo*,u+ imaging only
Conser=a$i=e managemen$ @o no$hingA
No$eB
Ra$ing
scaleB 2,
0, an 7
usually no$
a++ro+ria$
e< C, ;,
an 8 may be a++ro+ria$e< >,
4, an 3 usually a++ro+ria$e.
??D +uri"ie +ro$ein
eri=a$i=e.
Ray e$ al5Raiologic Managemen$ o" Thoracic Noules an Masses '/
&ariant /. ' 88,year,ol man *i$h a long smoking his$ory an abnormal ches$ raiogra+hic "inings ob$aine "or
conges$ion< "ollo*,u+ CT emons$ra$e a 7,cm +ulmonary noule in $he lingula an meias$inal aeno+a$hy @u+ $o 0
cmA in $he +re$racheal an subcarinal regions, as *ell as le"$ +erihilar @u+ $o 0 cmA aeno+a$hy
Treatment+,rocedure Rating Comments
Enosco+ic5bronchosco+ic meias$inal bio+sy 4 De+ens on local eF+er$ise.
FD!,?ET *hole boy 4
?ercu$aneous lung bio+sy >
?ercu$aneous meias$inal bio+sy 8 De+ens on local eF+er$ise an accessibili$y o" $he
noes by +ercu$aneous a++roach.
Surgical +ulmonary noule bio+sy5resec$ion 7
Follo*,u+ imaging only 0
Conser=a$i=e managemen$ @o no$hingA 2
No$eB Ra$ing scaleB 2, 0, an 7 usually no$ a++ro+ria$e< C, ;, an 8 may be a++ro+ria$e< >, 4, an 3 usually a++ro+ria$e. FD! 0,D
24
FE"luoro,0,
eoFyglucose.
more difficult than e&pected !ecause of its relative poor
visualiFation of vascular structures on unenhanced CT. )n
select instances, the use of iatrogenic saline windows (so-
called salinoma) may !e helpful in decreasing the
incidence of post!iopsy pneumothora& !y moving the
pleural surface away from the needle path 2+%3 . 1everal
approaches have !een descri!ed, including parasternal,
suprasternal, and even transsternal. Awareness of the in-
ternal mammary vessels is crucial in safely performing a
parasternal approach.
:onradiologic mediastinal mass !iopsy may !e
safer and have higher yields than radiologic !iopsy.
@roncho-scopically guided trans!ronchial ;:A 2++3 ,
endoscopic transesophageal ultrasound with ;:A 2+.-
+J3, medias-tinoscopy 2+53 , endo!ronchial ultrasound
2+73, and tho-racoscopy 2+83 may all !e used to o!tain
tissue from mediastinal masses. The indications for
image-guided versus nonradiologic procedures will
vary from institu-tion to institution.
,leural 0iopsies
Pleural !iopsies can !e separated on the !asis of whether the
region of interest is a focal mass or a diffuse process.
@iopsies for diffuse processes, such as tu!erculosis, are
freuently done without imaging guidance. @iopsies for
focal pleural-!ased mass lesions can freuently !e per-
formed with ultrasound guidance, particularly in the
presence of a pleural effusion 2 Cariant 7 3. @ecause of the
paucity of evidence in the literature, complication
rates are impossi!le to
determineD however, it is
antic-ipated that the ris"
for pneumothora& will !e
some-what lower than
that demonstrated with
intraparen-chymal
!iopsies.
SUMMAR
$ntraparenchymal
,ulmonary Nodules
,L The choice of
modalities
(percutaneous with
imag-ing guidance,
!ronchoscopy, video-
assisted thora-coscopy,
mediastinoscopy, or
open surgical) de-pends
in large part on the
location and siFe of the
lesion, the underlying
pulmonary function,
ad'a-cent structures,
clinical e&pertise at the
particular practice, and
operator preference.
%L )n patients with
incidentally noted
pulmonary nodules that
do not have an
appearance typical of
malignancy (eg, nodule
has smooth !orders,
calcification, does not
invade surrounding
structures) and no
"nown ris" fac-tors,
conservative follow-up
with imaging is more
ap-propriate than !iopsy.
+L PET imaging is
very sensitive for nodules
, cm in diameterD
however, there is a
relatively high rate of
false-negative results.
PET may !e particularly
helpful during follow-up
of patients
postintervention and for
assessing patients for
distant metastatic disease.
.L )ncreased
diagnostic yield is
e&pected when core !i-
opsy is performed in
addition to ;:A.
&ariant 1. ' ;C,year,ol *oman
*ho +resen$e $o $he emergency
e+ar$men$ *i$h +leuri$ic ches$ +ain
has a 7,cm
lobular mass
in=ol=ing $he
le"$ +leura
associa$e
*i$h rib
erosion
Treatment+,rocedure
?ercu$aneous lung bio+sy
FD!,?ET *hole boy
Surgical +leural bio+sy5resec$ion
Follo*,u+ imaging only 2
Conser=a$i=e managemen$ @o no$hingA 2
No$eB Ra$ing scaleB 2, 0, an 7 usually no$
a++ro+ria$e< C, ;, an 8 may be a++ro+ria$e< >,
4, an 3 usually a++ro+ria$e. FD! 0,D
24
FE"luoro,
0,eoFyglucose.
'1 Journal o" $he 'merican College o" Raiology5 (ol. 3 No. 2 January 0120
,L 1lide
fi&ation at the time
of ;:A improves
diagnostic yield
compared with
placing the
specimen in a
fi&ative for later
cytopathologic
evaluation.
%L =ost
complications can
!e treated using
percutaneous
techniues, and
many can !e
treated on an
outpatient !asis.
+L (elayed
pneumothora& is
"nown to occur,
!ut is a rare
complication.
Mediastinal
Masses or
Adenopathy
,L )n select
patient
populations,
image-guided
percutane-ous
;:A and !iopsy
may provide the
highest diagnos-
tic yield in the
safest manner.
%L :onradiologi
c !iopsies (eg,
mediastinoscopy
with !i-opsy,
!ronchoscopic or
endoscopic
ultrasound-guided
trans!ronchial or
transesophageal
!iopsy) may
provide a safer
alternative to
percutaneous
!iopsy.
,leural 0iopsies
,L Pleural
!iopsies for diffuse
disease (eg,
tu!erculosis) can
typically !e
performed
without imaging
guidance.
%L @iopsies
of focal pleural
masses can !e
performed
safely with
either CT or
ultrasound
guidance.
=any of the
diagnostic,
surgical, and
interventional
procedures
descri!ed here
are highly
specialiFed. Their
availa!ility and
utility vary !y
institutional and
operator
e&perience.
;or additional
information on
AC#
Appropriateness
Criteria, refer to
http4GGwww.acr.org
Gac.
R%"%R%NC%S
,. American *ung
Association. *ung
disease data4 %//7.
Availa!le at4 http4GG
www.lungusa.org.
Accessed Banuary
%//7.
%. #ies *AK, Eisner
=P, >osary C*, et
al. 1EE# cancer
statistics review
,8J5-%//+,
:ational Cancer
)nstitute (!ased on
:ovem!er %//5
1EE# data
su!mission, posted
to the 1EE# ?e!
site %//-).
Availa!le at4 http4GG
seer.cancer.govGcsrG
,8J5M%//+G.
+. van Keel A:,
Pastorino 0, Bauch
>?, et al. 1urgical
treatment of lung
metastases4 The
European
ArganiFation for
#esearch and
Treatment of
Cancer-1oft Tissue
and @one 1arcoma
Kroup study of %55
patients. Cancer
,88-DJJ4-J5-7%.
.. >lein B1, Nar"a
=A. Transthoracic
needle !iopsy4 an
overview. B Thorac
)maging
,88JD,%4%+%-.8.
5. ;ischer @, *assen
0, =ortensen B, et
al. Preoperative
staging of lung
cancer with
com!ined PET-CT.
: Engl B =ed
%//8D+-,4+%-8.
-. =ac=ahon 9,
Austin B9, Kamsu
K, et al. Kuidelines
for management of
small pulmonary
nodules detected on
CT scans4 a
statement from the
;leischner 1ociety.
#adiology
%//5D%+J4+85-.//.
J. Cardella B;, @a"al
C?, @ertino #E, et
al. Ouality
improvement guide-
lines for image-
guided
percutaneous
!iopsy in adults. B
Casc )nterv #adiol
%//+D,.41%%J-+/.
7. Kodoy =C@,
:aidich (P.
1u!solid pulmonary
nodules and the
spectrum of
peripheral
adenocarcinomas of
the lung4
recommended
interim guidelines
for assessment and
management.
#adiology %//8D
%5+4-/--%%.
8. >im 9<, 1him <=,
*ee >1, et al. Persistent
pulmonary nodular
ground-glass opacity at
thin-section CT4
histopathologic
comparisons. #adiology
%//JD%.54%-J-J5.
,/. *ee 9B, Koo B=,
*ee C9, et al. :odular
ground-glass opacities
on thin-section CT4 siFe
change during follow-
up and pathological
results. >orean B #adiol
%//JD74%%-+,.
,,. Beong <B, <i CA,
*ee >1. 1olitary
pulmonary nodules4
detection, charac-
teriFation, and guidance
for further diagnostic
wor"up and treatment.
AB# Am B #oentgenol
%//JD,7745J--7.
,%. Chandan C1,
Nimmerman >, @a"er P,
et al. 0sefulness of core
roll preparations in
immediate assessment
of neoplastic lung
lesions4 compar-ison to
conventional CT scan-
guided lung fine-needle
aspiration cytol-ogy.
Chest %//.D,%-4J+8-.+.
,+. Chen C=,
Chang B?, Cheung <C,
et al. Computed
tomography-guided
core-needle !iopsy
specimens demonstrate
epidermal growth factor
re-ceptor mutations in
patients with non-small-
cell lung cancer. Acta
#adiol %//7D.8488,-..
,.. (iacon A9,
1chuurmans ==,
Theron B, et al.
Trans!ronchial needle
aspirates4 comparison
of two preparation
methods. Chest
%//5D,%J4 %/,5-7.
,5. >ucu" C0, <ilmaF
A, <ilmaF A, et al.
Computed tomography-
guided transthoracic fine-
needle aspiration in
diagnosis of lung cancer4 a
compar-ison of single-pass
needle and multiple-pass
coa&ial needle systems and
the value of immediate
cytological assessment.
#espirology %//.D84+8%--.
,-. =aFFa E,
=addau C, #icciardi A,
et al. An-site evaluation
of percutane-ous CT-
guided fine needle
aspiration of pulmonary
lesions. A study of
+%, cases. #adiol
=ed (Torino)
%//5D,,/4,.,-7.
,J. <amagami T,
)ida 1, >ato T, et al.
Com!ining fine-
needle aspiration
and core !iopsy
under CT
fluoroscopy
guidance4 a !etter
way to treat patients
with lung nodulesP
AB# Am B
#oentgenol
%//+D,7/47,,-5.
,7. >o BP,
1hepard BA,
(ruc"er EA, et al.
;actors influencing
pneumothora& rate
at lung !iopsy4 are
dwell time and
angle of pleural
puncture contri!-
uting factorsP
#adiology
%//,D%,74.8,--.
,8. Keraghty
P#, >ee 1T,
=c;arlane K, et al.
CT-guided
transthoracic needle
aspiration !iopsy of
pulmonary nodules4
needle siFe and
pneumo-thora& rate.
#adiology
%//+D%%84.J5-7,.
%/. ;raser #1.
Transthoracic
needle aspiration.
The !enign
diagnosis. Arch
Pathol *a! =ed
,88,D,,54J5,--,.
%,. >othary :,
@artos BA, 9wang
K*, et al. Computed
tomography-guided
percutaneous needle
!iopsy of
indeterminate
pulmonary
pathology4 effi-cacy
of o!taining a
diagnostic sample in
immunocompetent
and immu-
nocompromised
patients. Clin *ung
Cancer %/,/D,,4%5,-
-.
%%. Kreif B,
=armor 1, 1chwarF
<, et al.
Percutaneous core
needle !iopsy vs.
fine needle
aspiration in
diagnosing !enign
lung lesions. Acta
Cytol ,888D .+4J5--
-/.
%+. (o&tader
EE, =u"hopadhyay
1, >atFenstein A*.
Core needle !iopsy
in !enign lung
lesions4 pathologic
findings in ,58
cases. 9um Pathol
%/,/D .,4,5+/-5.
%.. Covey A=,
Kandhi #, @rody
*A, et al. ;actors
associated with
pneumo-thora& and
pneumothora&
reuiring treatment
after percutaneous
lung !iopsy in ..+
consecutive patients.
B Casc )nterv #adiol
%//.D,54.J8-7+.
%5. (ennie CB,
=atFinger ;#,
=arriner B#, et al.
Transthoracic
needle !iopsy of the
lung4 results of
early discharge in
5/- outpatients.
#adiology %//,D
%,84%.J-5,.
%-. <amagami T,
:a"amura T, )ida 1,
et al. =anagement of
pneumothora& after
percutaneous CT-
guided lung !iopsy.
Chest
%//%D,%,4,,58--..
%J. Engeler CE,
9unter (?,
Castaneda-Nuniga
?, et al.
Pneumothora& after
lung !iopsy4
prevention with
transpleural
placement of
compressed
collagen foam
plugs. #adiology
,88%D,7.4J7J-8.
%7. *ang E>,
Khavami #,
1chreiner CC, et al.
Autologous !lood
clot seal to prevent
pneumothora& at
CT-guided lung
!iopsy. #adiology
%///D%,-4 8+--.
%8. Petsas T,
1iam!lis (,
Kianna"enas C, et al.
;i!rin glue for sealing
the needle trac" in
fine-needle
percutaneous lung
!iopsy using a coa&ial
system4 part ))Q
clinical study.
Cardiovasc )ntervent
#adiol ,885D,74+J7-
7%.
Ray e$ al5Raiologic Managemen$ o" Thoracic Noules an Masses '2
+/. =atsuguma 9, :a"ahara #, >ondo T,
et al. #is" of pleural recurrence after needle
!iopsy in patients with resected early stage
lung cancer. Ann Thorac 1urg %//5D7/4%/%--
+,.
+,. 1ano <, (ate 9, Toyoo"a 1, et al.
Percutaneous computed tomography-guided lung
!iopsy and pleural dissemination4 an assessment
!y intraop-erative pleural lavage cytology.
Cancer %//8D,,5455%--++.
+%. Nwischen!erger B@, 1avage C, Alpard
1>, et al. =ediastinal transthoracic needle
and core lymph node !iopsy4 should it replace
mediastinoscopyP Chest %//%D,%,4,,-5-J/.
++. 1hah P*, 1ingh 1, @ower =, et al. The
role of trans!ronchial fine needle aspiration in
an integrated care pathway for the assessment
of patients with suspected lung cancer. B
Thorac Ancol %//-D,4+%.-J.
+.. Annema BT, Cersteegh =), Ceselic =, et
al. Endoscopic ultrasound-guided fine-needle
aspiration in the diagnosis and staging of lung
cancer and its impact on surgical staging. B Clin
Ancol %//5D%+47+5J--,.
+5. Cerfolio #B, @ryant A1, Elou!eidi
=A. #outine mediastinoscopy and
esophageal ultrasound fine-needle
aspiration in patients with non-small cell
lung cancer who are clinically :% negative4
a prospective study. Chest %//-D,+/4,J8,-
5.
+-. 9erth ;B, Ernst A, E!erhardt #, et al.
Endo!ronchial ultrasound-guided
trans!ronchial needle aspiration of lymph
nodes in the radiologically normal
mediastinum. Eur #espir B %//-D%748,/-..
+J. 1ingh P, CamaFine @, Badhav <, et
al. Endoscopic ultrasound as a first test for
diagnosis and staging of lung cancer4 a
prospective study. Am B #espir Crit Care
=ed %//JD,J54+.5-5..
+7. 9erth ;B, @ec"er 9(, Ernst A.
0ltrasound-guided trans!ronchial needle
aspiration4 an e&perience in %.% patients.
Chest %//+D,%+4-/.-J.
+8. Chang AC, <ee B, Arringer =@, et
al. (iagnostic thoracoscopic lung !iopsy4
an outpatient e&perience. Ann Thorac 1urg
%//%DJ.4,8.%--.