Skip to content

Lung Masses

Chandler Montgomery


  • Definitions: lesion \< 3 cm = pulmonary nodule. Lesion > 3 cm = lung mass

    • Pulmonary nodules are common and often benign, but presence of lung mass (>3cm) should prompt workup as chance of malignancy is high (>50%)

    • For nodules, refer to the Fleischner Society guidelines (incidental nodules) or Lung-RADS (detected on lung cancer screening) for surveillance/management recommendations

    • Note that in TN, prior histoplasmosis is a very common cause of pulmonary nodules

  • Differential diagnosis:

    • Malignant:

      • Primary non-small cell lung cancer (NCSLC): adenocarcinoma, squamous cell (SCC), large cell carcinoma

      • Metastatic: commonly melanoma, sarcoma, colon, breast, renal, testicular

        • Often multiple nodules/masses (e.g., cannonball) 
      • Neuroendocrine: small cell lung cancer (SCLC), carcinoid, large cell neuroendocrine

    • Infectious:

      • Granulomatous: TB, non-TB mycobacterium, endemic fungal (histo, blasto, coccidio)

        • May have component of calcification
      • Abscess: Staph aureus, Klebsiella, anaerobes, polymicrobial (aspiration)

      • Septic emboli, hydatid cyst, aspergilloma

    • Other: hamartoma, AVM, pulmonary infarct, inflammatory nodule (GPA, RA), sarcoidosis


  • History: smoking, cough, hemoptysis, dyspnea, chest pain, weight loss, fevers, night sweats, hoarseness, bone pain, neuro deficits

    • Lung cancer should always be considered in a patient with smoking history & new cough or hemoptysis
  • Exam: cachexia, lymphadenopathy, bone pain, hepatomegaly, neuro deficits

  • Imaging:

    • CXR has poor sensitivity for lung nodules, may show large mass or malignant effusion

    • CT chest (with contrast if possible - better evaluation of mediastinum/LNs)

      • Review prior chest imaging to assess age and growth pattern of lesion(s)

      • Benign features: small (sub-centimeter), calcified, fat attenuation, stable over 2 years, multiple nodules

      • Concerning features: large, growth, spiculation, upper lobe location, thick-walled cavitation, mediastinal invasion

      • Location- adenocarcinoma often more peripheral, SCC often more central, SCLC associated with massive LAD, mediastinal invasion, large hilar masses

  • Look for paraneoplastic syndromes:

    • SCLC: SIADH, Lambert-Eaton, Cushing’s syndrome

    • SCC: hypercalcemia (PTHrP)

    • Dermatomyositis, polymyositis, hypertrophic osteoarthropathy


  • Imaging: CT chest (with contrast if possible)m CTAP w/contrast vs. PET/CT to assess for metastasis, consider MRI brain if clinical stage III or IV disease

  • Biopsy: careful planning is key

    • For metastatic disease, obtain tissue from least invasive site

      • FNA or excision of palpable lymph node (cytology department, US-guided procedure, or EGS)
    • If uncertain how to best obtain tissue, consult IR, interventional pulm, and/or oncology to discuss approach

      • Surgical Bx: Wedge resection/lobectomy often preferred if solitary nodule amenable to both diagnostic and therapeutic resection in good surgical candidate

      • Bronchoscopy with EBUS (endobronchial US) often used to obtain biopsy of mediastinal tissue or central/peri-bronchial lesion

      • Trans-thoracic needle aspiration (TTNA): peripheral lesions not amenable to bronchoscopy


  • Planning is complex, usually discussed at multidisciplinary tumor board


    • Stage I/II: surgical resection ± adjuvant chemotherapy

    • Stage III: more complex requiring multidisciplinary approach

    • Stage IV: chemo ± targeted therapy depending on PD-L1 expression, presence of driver mutations for EGFR, ALK, ROS-1, BRAF, MET, RET, others

  • SCLC: usually widely metastatic at time of diagnosis, treated with systemic chemo/radiation

Last update: 2022-06-26 16:26:45