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. 2023 Sep 12;14(1):146.
doi: 10.1186/s13244-023-01504-8.

Differentiation of pulmonary solid nodules attached to the pleura detected by thin-section CT

Jin Jiang #  1 , Fa-Jin Lv #  1 , Yang Tao  1 , Bin-Jie Fu  1 , Wang-Jia Li  1 , Rui-Yu Lin  1 , Zhi-Gang Chu  2
Affiliations

Differentiation of pulmonary solid nodules attached to the pleura detected by thin-section CT

Jin Jiang et al. Insights Imaging. .

Abstract

Background: Pulmonary solid pleura-attached nodules (SPANs) are not very commonly detected and thus not well studied and understood. This study aimed to identify the clinical and CT characteristics for differentiating benign and malignant SPANs.

Results: From January 2017 to March 2023, a total of 295 patients with 300 SPANs (128 benign and 172 malignant) were retrospectively enrolled. Between benign and malignant SPANs, there were significant differences in patients' age, smoking history, clinical symptoms, CT features, nodule-pleura interface, adjacent pleural change, peripheral concomitant lesions, and lymph node enlargement. Multivariate analysis revealed that smoking history (odds ratio [OR], 2.016; 95% confidence interval [CI], 1.037-3.919; p = 0.039), abutting the mediastinal pleura (OR, 3.325; 95% CI, 1.235-8.949; p = 0.017), nodule diameter (> 15.6 mm) (OR, 2.266; 95% CI, 1.161-4.423; p = 0.016), lobulation (OR, 8.922; 95% CI, 4.567-17.431; p < 0.001), narrow basement to pleura (OR, 6.035; 95% CI, 2.847-12.795; p < 0.001), and simultaneous hilar and mediastinal lymph nodule enlargement (OR, 4.971; 95% CI, 1.526-16.198; p = 0.008) were independent predictors of malignant SPANs, and the area under the curve (AUC) of this model was 0.890 (sensitivity, 82.0%, specificity, 77.3%) (p < 0.001).

Conclusion: In patients with a smoking history, SPANs abutting the mediastinal pleura, having larger size (> 15.6 mm in diameter), lobulation, narrow basement, or simultaneous hilar and mediastinal lymph nodule enlargement are more likely to be malignant.

Critical relevance statement: The benign and malignant SPANs have significant differences in clinical and CT features. Understanding the differences between benign and malignant SPANs is helpful for selecting the high-risk ones and avoiding unnecessary surgical resection.

Key points: • The solid pleura-attached nodules (SPANs) are closely related to the pleura. • Relationship between nodule and pleura and pleural changes are important for differentiating SPANs. • Benign SPANs frequently have broad pleural thickening or embed in thickened pleura. • Smoking history and lesions abutting the mediastinal pleura are indicators of malignant SPANs. • Malignant SPANs usually have larger diameters, lobulation signs, narrow basements, and lymphadenopathy.

Keywords: Diagnosis; Differential; Lung neoplasms; Tomography; X-ray computed.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of the study population. PACS, picture archiving and communication system; SNs, solid nodules; GGN, ground-glass nodule; SPANs, solid pleura-attached nodules
Fig. 2
Fig. 2
SPAN with narrow or broad basement and type I of nodule-pleura relationship. a A 59-year-old man with left lower lobe lobulated SPAN which is confirmed as invasive adenocarcinoma. On the axial CT image with a maximum section of the nodule, R-length is defined as the ratio of the length of the nodule-pleura interface (red dashed line) to nodule size (blue dashed line). Its R-length is 0.36, which indicates a narrow basement. The nodule-pleura relationship is type I (nodule clinging to the normal pleura without extrapleural fat infiltration). b, c A 49-year-old man with right lower lobe SPAN which is confirmed as a benign lesion during follow-up. On the axial CT image with a maximum section of the nodule, its R-length is 1, which indicates a broad basement, and the nodule-pleura relationship is also type I
Fig. 3
Fig. 3
SPAN with pleural thickening and type II of nodule-pleura relationship. A 53-year-old man with right lower lobe SPAN which is confirmed as an inflammatory lesion. On the axial enhanced CT image, it is found that there is a visible increase in pleural thickness (red dashed line) beyond the normal pleural appearance adjacent to the nodules (pleural thickening). R-thickening is defined as the ratio of the length of adjacent thickened pleura (red dashed line) to nodule diameter (yellow dashed line). Its R-thickening is 1.39. The nodule-pleura relationship is type II (nodule clinging to the thickened pleura without pleural infiltration)
Fig. 4
Fig. 4
SPAN with extrapleural fat thickening. A 76-year-old man with left upper lobe SPAN which is confirmed as invasive adenocarcinoma. On the axial CT image, significantly thickened extrapleural fat (asterisks) protrudes into the lung field
Fig. 5
Fig. 5
SPAN with type III of nodule-pleura relationship. A 48-year-old woman with left upper lobe SPAN which is confirmed as a benign lesion during follow-up. On the axial CT image, a part of the nodule with slightly high density embeds in the significantly thickened pleura (red arrows)
Fig. 6
Fig. 6
SPAN with type IV of nodule-pleura relationship. A 44-year-old man with left upper lobe SPAN which is confirmed as an invasive adenocarcinoma. On the axial CT image, the lobulated nodule crosses the potential pleural line (dashed line) and extends into extrapleural fat
See this image and copyright information in PMC

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