1. Solitary Pulmonary NoduleDr. Bhavin JankhariaRadiologist, Jankharia Imaging, Mumbai, India

2. Algorithm using a typical case 3. 52-years old lady went for a health check-up 4. Please identify the lesion 5. SPNLesion Detection Pickup - this is a variable factor depending on theradiologys experience Experience & Expertise The Ten-Thousand hours rule Overreading / underreading High kV - better rate of detection Digital radiograph - these allow manipulation on acomputer monitor and a higher rate of detection 6. She has a 2.2 cm sized nodule in the right mid-zone 7. Next Steps A Do nothing - old granuloma B Aggressive - suspected malignancy C Give antibiotics or AKT D Investigate further 8. Confirm intra pulmonary location 9. This lesion is intra-pulmonary seen on both frontal and lateral radiographs in the lung 10. This lesion is pleural in the minor fissure and ovoid and calcified and hence not significant 11. This lesion also pleural probably an old calcifiedhematoma and hence not an SPN 12. This patient had neurofibromatosis 1 and camefor a CT guided biopsy of a left upper lobe mass 13. Classic example of hyposkilia the patient hadnever been examined 14. This lady also came for a CT guided biopsy of aleft mid-zone lesion 15. Rib fracture callus 16. In our 52-years old lady, a CT scan show the lesion to be in the right upper lobe intra-pulmonary 17. Next Steps A Do nothing - old granuloma B Aggressive - suspected malignancy C Give antibiotics or AKT 18. Is this benign or malignant? 19. Criteria for benignity A - Calcification B - Absence of enhancement C - No growth in 2 years 20. Completely calcified - benign Engulfed calcific focus by a malignant lesion 21. April 06June 08AB C Completely calcified and no growth in 2 years - benign 22. plain post-contrastNo enhancement whatsoever - benign 23. JulyOur 52-years old lady 24. MayJulyShe shows a significant increase in sizeover 2 months 25. PlainPost-contrastContrast-enhanced study shows enhancement 26. Possible etiology A - Granuloma B - Malignancy C - Other 27. This does not show any criteria ofbenignity and hence is ofindeterminate etiology 28. Next steps A - Trial of therapy B - CT guided biopsy C - Bronchoscopy guided biopsy D - Lobectomy 29. CT guided biopsy 30. Tips during biopsy Biopsy not FNAC At least 5 cores Material for EGFR mutation studies 31. Gun-cannula technique stylet in cannula and gun 32. Gun-cannula technique stylet outside cannula and gun 33. Gun-cannula technique gun in cannula allowing multiplebiopsies to be obtained with a single puncture of the cannula 34. Foot pedal and in-room monitor allow accurate control along with CT fluoroscopy 35. DiagnosisAdenocarcinoma 36. Next steps A - Lobectomy B - PET/CT C - Chemotherapy D - Radiotherapy 37. PET/CT and Contrast-MRI of Brain forStaging 38. Lung CancerStaging Nodes Metastases Local staging 39. A 52-year old with bronchogenic carcinoma operable (T2N0M0) 40. A 68-year old with bronchogenic carcinoma operable (N1M0) 41. A 57-year old with bronchogenic carcinoma non-operable (N2M0) 42. A 52-year old doctor with bronchogenic carcinoma and solitary focus of uptake in the left humeral head 43. A 52-year old doctor with bronchogenic carcinoma nonoperable (N0M1) 44. The fundamental idea when dealing with a solitary pulmonary nodule >8mm is to not miss malignancy 45. If a lesion has definite criteria for benignity (no growth over 2 years, diffuse calcification and/or noenhancement whatsoever), then you can forget about it 46. Else, the lesion should be assumed to be malignant unless proved otherwise and should be biopsied 47. SPNPA radiographBENIGNINDETERMINATECalcificationOld X-raysLesion external or extra-pulmonaryBENIGNINDETERMINATENo change over 2 yearsCT scan / PET/CT BENIGN No enhancement or uptakeINDETERMINATE Calcification BIOPSY 48. Sometimes, some lesions are characteristic 49. Fungal BallCrescent sign in relation to the right upper lobeSPN due to a fungal ball in a cavity 50. AVMNodule showingcurvilinear vesseldensity on the lateralradiograph (red arrow).The CT shows thetypical appearance 51. Rounded AtelectasisMass of atelectasis due to previous pleural effusion (documented)showing air bronchograms within and peripheral curving anddisplacement of the bronchovascular bundles (red arrow) 52. Rounded AtelectasisMass of atelectasis due to previous pleural effusion (documented)showing air bronchograms within and peripheral curving anddisplacement of the bronchovascular bundles (red arrow) 53. Email: bhavin@jankharia.com Twitter: @bhavinjFB: www.facebook.com/bhavinjankharia