A single focal formation of the lung is an independent radiological syndrome. In the picture, such darkening has small dimensions (up to 1 cm), different intensity and contours. To determine the nature, differential diagnosis of focal formations in the lungs is required, which we will discuss below.

It is not necessary to determine the nosological form when decoding the image. It is necessary to carefully describe the structure of the darkening and order additional examinations. The X-ray method is not characterized by a high degree of sensitivity, but is characterized by less radiation compared to computed tomography. It is used to identify pathological syndromes; for additional study of the darkening structure, other radiation and clinical-instrumental methods are used. At the final stage, a biopsy is used, and methods for dynamic monitoring of focal shadows measuring up to 5 and 10 mm have been developed.

Single focal formation of the lung

Most single focal formations of one or both lungs are not accompanied by pronounced clinical signs. An asymptomatic course does not allow the disease to be detected at an early stage.

A single focus is a local area of ​​compaction of the pulmonary parenchyma, which is reflected in the image as a shadow of a round or similar shape. According to international standards, a lesion up to 3 cm in diameter can be considered a lesion. By domestic standards - up to 1 cm.

If we approach the differential diagnosis of the disease based on phthisiatric indicators, we can establish the following characteristics of pathological shadows:

Tuberculoma;
Infiltrate;
Focal tuberculosis.

If we approach the decoding of a chest X-ray according to international standards, then a cancerous node up to 3 cm in diameter should be included in the differentiation. This shadow on the image is most often caused by non-small cell cancer in stage T1. For domestic radiologists and radiology doctors, visualization of shadows up to 10 mm in diameter presents significant difficulties.

The term “single” does not imply the presence of a single entity. There can be from one to six individual shadows. If there are more blackouts - multiple blackouts. Radiologists often call such lesions disseminated, since they are located in both lungs.

An important clinical characteristic of the “focal lung formation” syndrome is the presence of signs of malignancy. According to statistics, about 70% of nodes at autopsy show malignancy. X-ray examination allows you to identify signs of malignancy when the size of the node is more than 1 cm. With a dynamic study (performing several consecutive radiographs), the specialist has the ability to differentiate foci of benign and malignant etiology.

Focal formations in the lungs on CT (computed tomography) are determined quite clearly. The study makes it possible to differentiate benign and malignant growth. The specificity of symptoms is determined by the foci of decay, infiltration of lymphatic vessels, and enlargement of the lymph nodes located near the lesion.

To correctly verify the cause of solitary lung formation syndrome, additional research methods and alternative methods should always be used.

Signs of focal formations of lung tissue

When radiographs are taken in patients with suspected tumors, dynamic monitoring of the syndrome is recommended. Practice shows that one radiograph is not enough to reliably verify a tumor. If a series of images is available, it is possible to assess the progression of the lesion, despite active anti-inflammatory treatment.

Positron emission tomography with 18-fluorodeoxyglucose allows us to identify the functional and organic structure of a malignant or benign neoplasm.

X-ray and tomogram of a patient with single formations on the apexes due to tuberculosis

Morphological examination of material from patients in all clinical situations using a single algorithm allows for accurate verification. Under a microscope, atypical cells look quite specific. The use of this method makes it possible to determine the morphological substrate of cancer. A biopsy is an invasive procedure and is therefore performed only under strict indications. Before its use, differential diagnosis is carried out by radiation, laboratory, instrumental, and clinical examinations.

There is no single algorithm for analyzing the signs of focal lung formations. Each radiologist develops x-ray analysis schemes in practice.

Until recently, radiography and fluorography were considered the main method of primary tumor detection. Lesions are detected in 1% of patients who undergo chest x-ray examination.

General fluorograms and radiographs do not show signs of a single formation up to 1 cm in diameter. In practice, specialists miss larger lesions from overlapping anatomical structures: ribs, roots of the lungs, cardiac shadow. Anomalies in the development of blood vessels and the bronchial tract also interfere with the visualization of small shadows in the image.

Signs of focal formations are often found on radiographs that were taken 1-2 years ago. Each X-ray department stores patient images for at least 3 years.

Such approaches were rational in the absence of computed tomography and PET/CT, which have high sensitivity and reliability in detecting pathology of the pulmonary parenchyma.

X-ray examination is rational in order to exclude pneumonia, chronic lung diseases, emphysema, and obstructive disease. Computed tomography helps to identify lesions 2-4 times more than radiography. Due to the high radiation exposure to the patient, it cannot be used for mass examination of people. Methods for reducing human radiation exposure during CT scans are being developed and undergoing clinical testing, but have not yet been widely implemented.

CT can detect more lesions in the pulmonary parenchyma than X-ray examination. If the solitary focal formation in the lung is less than 1 cm, the rationality of performing computed tomography increases significantly. A radiologist or attending physician can determine the indications for its use.

Computed tomography is not an absolute method for detecting a tumor. When the size of the formation is less than 5 mm, the sensitivity of the method is about 72%. The effectiveness of such screening for early lung cancer is poor. The low density of lesions on CT scans is caused by a specific feature called “ground glass”. Low-density formations are detected with a sensitivity of up to 65%. Clinical studies have shown that small focal formations in the lungs are detected on CT with a probability of 50%. Only when the lesion size exceeds 1 cm does the sensitivity increase to 95%.

To improve accuracy, some researchers have developed their own algorithms that work based on three-dimensional modeling of maximum irregularities, volumetric rendering.

Differential diagnosis of focal formations in the lungs

For differential diagnosis of formations, computed tomography or radiography is required. For correct verification, lesions should be analyzed based on the following indicators:

1. Dimensions;
2. Structure;
3. Contours;
4. Density;
5. Condition of surrounding tissues.

Individually, each described symptom has a probabilistic meaning, but together they reflect the nosological form. Despite this, even with the most careful analysis of the signs of a solitary formation, it is rarely possible to diagnose the nosological form. For example, adipose tissue has low intensity, clear contours (lipoma), but is also found in hamartoma, tuberculoma, and arteriovenous malformations. It creates low-intensity shadows in the image, which should be distinguished from “frosted glass”. With large lipomas, diagnosis is not difficult, but problems arise with small accumulations of lipocytes.

The location of the lesion in the pulmonary parenchyma is not of fundamental importance. According to researchers, coincidences or exceptions to standard radiographic rules occur in 70% of cases. A similar number of cancers are located in the upper lobes. In the right lung, localization is observed more often than in the left.

Tuberculosis infiltrates are characterized by a similar arrangement. Lung cancer in idiopathic pulmonary fibrosis is located in the lower lobe.

Tuberculous infiltrates are located more often at the apexes.

Structural characteristics of single lesions:

1. Uneven or even contours;
2. Clear, fuzzy edges;
3. Perifocal screenings, corolla radiata;
4. Different shape;
5. Excellent foci density.

In differential diagnosis, specialists pay attention to fuzzy, uneven contours of tumors and inflammatory infiltrates.

Some practical examinations have shown that tumor formations up to 1 cm have low-density contours, and radiance is not always visible on a computed tomogram.

Focal formations of the lungs on tomography in 97% of cases have a rim with uneven contours. Wavy borders with a lesion larger than 1 cm are a serious sign of cancer. Such tumors require morphological verification and careful additional examination using computed tomography, PET/CT.

Clear contours can be seen in the following diseases:

Squamous cell, small cell carcinoma;
Carcinoid.

One practical study in the literature indicates wavy contours of the lesion in malignant cancer in only 40% of cases. If these results are available, additional criteria should be introduced to allow differential diagnosis of single lesions in the lungs on a tomogram:

1. Solid structure (uniform);
2. Mixed knots;
3. Formation of the “frosted glass” type.

The formations that give rise to haze syndrome on a tomogram have a low density. The contours are represented by unchanged pulmonary interstitium. The formations characterize non-destructive inflammatory processes, atypical adenomatous hyperplasia. The morphological basis of the phenomenon is the thickening of the walls of the interalveolar septa in local areas with air alveoli.

The picture reflects inflammatory infiltration, fibrous cords. A similar picture with carcinoid is due to bronchoalveolar spread of the tumor. The “frosted glass” phenomenon is not visible on radiographs. It is also not visible on linear tomograms.

A solid, mixed node can be characterized by the presence of a dense area in the central part with a peripheral decrease in density in the form of dullness. The picture is formed around old foci, post-tuberculosis cavities. About 34% of non-solid lesions are formed by malignant tumors that are larger than 1.5 cm on radiographs.

The solitary formation is characterized by a typical structure:

Round shape;
Low density;
Excellent contours.

The syndrome occurs in any pathological process.

The structure of a single formation is clearly visible on the tomogram:

Homogeneous low density structure;
Necrosis with air inclusions;
Fatty, high-density, fluid nodes.

The described characteristics are not characteristics of a specific pathological process. Only hamartomas are characterized by the inclusion of adipose tissue. Even calcification in foci occurs in different nosological forms.

The inclusion of air cavities and the identification of honeycomb cells are detected on CT 2 times more often than on a conventional x-ray.

Types of calcifications of a single focus:

"Popcorn";
Layered;
Diffuse - occupying the entire formation.

If calcification (calcium deposition) is detected, we can speak with a high degree of certainty about the benign structure of the disease, but there are exceptions. Metastases of ovarian cancer, intestinal cancer, and bone sarcomas may become calcified after chemotherapy.

Computed tomogram – single lesions in the sixth segment with vasculitis

In malignant formations there are pinpoint, amorphous inclusions of calcium salts that do not have clear contours.

There is practical evidence that in peripheral formations the frequency of calcification reaches 13%. For lesions smaller than 2 cm, the frequency is lower – about 2%.

The deposition of calcium salts is not a sensitive diagnostic sign. The pathognomy of the symptom is quite low.

Another interesting symptom in the differential diagnosis of a single lesion in the lungs is “air bronchography”. The porous or honeycomb structure is due to the inclusion of air, which can be traced in the malignant tumor. The probability of air in cancer is 30%, but in a benign node - 6%. Air accumulation may mimic tissue breakdown, which also suggests a malignant lesion.

Focal secondary lung formations - growth rate assessment

Secondary pulmonary lesions on imaging should be monitored dynamically. Only in this way will differential diagnosis allow us to identify the maximum number of signs that allow us to optimally differentiate the nature of the lesion. Changes should be tracked using the available archival complex - radiographs, linear or computed tomograms, fluorograms. If the node does not enlarge for more than 2 years, this is a sign of a benign nature.

A significant portion of secondary lung formations are missed by the initial X-ray analysis. Archive analysis is a mandatory stage of differential diagnosis. The effectiveness of radiation examination in pathology is determined by the rate of change in the characteristics of the formation during malignant growth. The doubling time ranges from 40 to 720 days. Any node that appears in the image must be monitored throughout the month. If no changes are detected, dynamic monitoring should be carried out for 20 years.

There are exceptions to the above rule - ground-glass lesions detected on computed tomography represent bronchioloalveolar cancer. With this nosology, dynamic observation is excluded.

When determining low-density contours along the periphery of the lesion, it is necessary to send the patient for computed tomography!

Another factor that limits follow-up of patients is the retrospective analysis of lesions smaller than 1 cm in diameter. Doubling the volume of a lesion measuring 5 mm with subsequent computed tomography leads to an increase in diameter to 6.5 mm. Such changes are not visualized on an x-ray.

Many researchers argue that such a picture is beyond the resolution of not only radiography, but also CT.

Significant importance is attached to the computer evaluation of the three-dimensional helical computed tomography model that is capable of modeling. Some technologically advanced diagnostic algorithms can identify small nodes, but require practical confirmation.

The malignant nature of a secondary focal formation can be established based on an analysis of clinical and radiological signs, although some specialists underestimate this approach.

What signs indicate a malignant process:

1. Wall thickness more than 16 mm;
2. Hemoptysis;
3. Fuzzy, uneven contours;
4. History of operations on tumors;
5. The size of the lesion is from 20 to 30 mm;
6. Doubling time less than 465 days;
7. Age over 70 years;
8. Low intensity shadow in the photo;
9. History of smoking.

The density of the secondary lesion may vary and therefore does not have significant diagnostic value. You just need to take into account the large intrinsic vascular network of the tumor, which is revealed by angiography and PET/CT.

If the formations are devoid of a vascular network, this is a benign growth. With such a picture, the nature of the focus should be taken into account. With tuberculosis, caseation is observed, which has a different density on the x-ray. Specific melting of lung tissue develops gradually. Only with weak immunity are mycobacteria activated. Dynamic observation allows us to determine the progression of the tuberculosis lesion. With cancer, the node grows much faster. Changes in the tumor are visualized when examining an x-ray after a month.

Filling with pus and exudate indicates a forming cyst or abscess. In this case, the dynamic tracking technique gives significant results. Tumors grow much faster than a tuberculous node.

Dynamic computed tomography allows one to clearly determine the nature of the lesion. When performing sections, contrasting is possible with the production of tomograms after 1,2,3,4 minutes.

Density measurement is carried out in ¾ of the slice volume. The amplification threshold allows one to differentiate between benign and malignant pathology. When detecting malignant tumors, a density of more than 15 HU indicates cancer with a confidence of more than 98%.

The technique has disadvantages:

Small lesions up to 1 cm have low specificity on CT;
Technical errors due to artifacts;
The contrast agent creates small lesions in the tissue.

The described disadvantages are compensated by the use of multilayer spiral CT. The procedure evaluates the density of the lesion. There are many studies indicating that an excess of formation density by 25 HU and a rapid decrease by 10-30 HU indicates cancer.

The overall accuracy of multilayer tomography in detecting malignant neoplasms does not exceed 93%.

Solitary focal formation in the lungs on PET/CT

All of the above information is based on a macroscopic analysis of solitary lung formations. The introduction of positron emission tomography with short-lived isotopes made it possible to obtain the functional characteristics of the formation under study.

Metabolic characteristics are assessed using 18-fluorodeoxyglucose. Metabolism in the tumor is more intense, so the isotope accumulates strongly. The sensitivity of PET/CT is up to 96%.

To obtain a more complete picture, the metabolic and macroscopic characteristics of the pathological focus are combined. False-positive errors in the study arise due to the accumulation of the radioisotope in active tuberculous cavities, primary tumors with ground-glass macroscopic appearance, which are not characterized by an intensive blood supply. Neoplasms smaller than 7 mm also do not result in intensive accumulation.

PET/CT data should be compared with clinical results and other radiological methods. The decisive method for identifying a tumor is a biopsy. The method involves taking a section of material from an identified node. Subsequently, the cellular composition is studied using a microscope. Identification of atypical cells requires surgery.

In conclusion, it should be noted that there is an interesting technique for managing patients with different results from radiation methods in patients with single pulmonary formations.

If a lesion more than 1 cm in diameter with radiant, uneven contours, “ground glass” is detected, verification by biopsy is required.

The remaining patients are classified as intermediate and undetermined. In this category of patients, lesions more than 10 mm in diameter are found, with wavy, smooth contours without inclusions. After obtaining signs of malignancy through biopsy, PET/CT, and other methods, a wait-and-see approach is used. Dynamic tracking is the most rational approach.

Patients with lesions less than 10 mm and no calcium inclusions do not require dynamic monitoring if the node is less than 5 mm. The recommendation is a routine preventive examination throughout the year.

Lesion sizes from 5 to 10 mm require monitoring after 3 and 6, 12 and 24 months. If there is no dynamics, observation is stopped. In case of changes in formation, a biopsy is rational.

Differential diagnosis of focal formations in the lungs is a complex process that requires the professional skill of a radiologist. Rational knowledge of different methods of radiation diagnostics, schemes for using different algorithms helps to detect cancer at an early stage.

The solitary lesion or "coin-shaped lesion" is a focal point< 3 см в диаметре, различимый на рентгенограмме легкого. Он обычно окружен легочной паренхимой.

2. How can a solitary lesion in the lung be represented?

Most often it is a neoplasm (cancer) or a manifestation of infection (granuloma), although it can represent a lung abscess, pulmonary infarction, arteriovenous anomaly, resolving pneumonia, pulmonary sequestration, hamartoma and other pathology. The general rule is that the likelihood of a malignant tumor corresponds to the age of the patient.

Thus, lung cancer is rare (though it does occur) in 30-year-olds, while 50-year-old smokers may have a 50-60% chance of having a malignant tumor.

3. How is a solitary lesion in the lung detected?

Usually, a solitary lesion is detected accidentally during a routine X-ray examination of the lung. Several large studies have found that more than 75% of lesions were unexpected findings on plain radiographs of the lung. Symptoms indicating lung disease were observed in less than 25% of patients. Nowadays, solitary lesions are detected using other highly sensitive studies, such as CT.

4. How often is a solitary lesion in the lung a tumor metastasis?

In less than 10% of cases, solitary lesions represent tumor metastases, so there is no need for an extensive tumor search in organs other than the lungs.

5. Is it possible to obtain a tissue sample from the lesion using fluoroscopic or CT-guided needle biopsy?

Yes, but the result will not affect your treatment. If the biopsy reveals cancer cells, the lesion should be removed. If the biopsy is negative, the lesion still needs to be removed.

6. What is the importance of radiological findings?

They are not the most important. The resolution of modern CT machines allows for a better assessment of signs characteristic of cancer:
a) Fuzzy or unevenly jagged edges of the lesion.
b) The larger the lesion, the more likely it is to be malignant.
c) Calcification of the lesion usually indicates a benign formation. Specific central, diffuse or layered calcification is characteristic of granuloma, while denser calcifications in the form of irregularly shaped grains are observed in hamartoma. Eccentric or small speckled calcifications may be present in malignant lesions.
d) CT can examine changes in the relative density of lesions after contrast administration. This information increases the accuracy of diagnosis.

7. What social or clinical evidence suggests that the lesion is more likely to be malignant?

Unfortunately, there is no data that is sensitive or specific enough to influence diagnosis. Both older age and long-term smoking are factors that make lung cancer more likely. Winston Churchill was supposed to get lung cancer, but he didn't.

Therefore, information that the patient is the president of a speleological club (histoplasmosis), his sister raises pigeons (cryptococcosis), he grew up in the Ohio River Valley (histoplasmosis), works as a gravedigger in a dog cemetery (blistomycosis), or simply took a tourist trip to the San Valley - Joaquin (coccidioidomycosis), provide interesting accompanying information, but do not affect diagnostic measures for a solitary lesion in the lung.

8. What is the most important part of the medical history?

Old chest x-rays. If the lesion appears recently, it is more likely to be malignant, and if it has not changed in the last 2 years, then the likelihood of a malignant tumor is less likely. Unfortunately, even this rule is not absolute.

9. If a patient was previously treated for a malignant tumor, and now he has a solitary lesion in the lung, can it be said that this lesion is a metastasis?

No. The probability that a lesion in the lung is a metastasis is less than 50%, even if the patient previously had a malignant tumor. Thus, diagnostic measures for such a patient will be the same as for any other patient with a newly appeared solitary lesion in the lung.

10. How should one deal with a solitary lesion in the lung?

Complete information about travel and activities is interesting, but does not affect the progress of the diagnosis. Due to the peripheral location of most lesions, bronchoscopy has a success rate of less than 50%. Cytological examination of sputum is not very informative, even if it is performed by the best specialists. CT is recommended as it can identify other potentially metastatic lesions and assess the status of the mediastinal lymph nodes.

As stated above, percutaneous needle biopsy is approximately 80% informative, but its result rarely influences subsequent management.

It is important to determine whether the patient can undergo radical surgery. The function of the lungs, liver, kidneys and nervous system should be considered stable. If it is unlikely that the patient will live for several more years, then there is simply no point in removing an asymptomatic lesion in the lung.

The main way for a patient to undergo surgery is resection of the lesion for diagnostic purposes, performed using thoracoscopy, which has the least invasiveness, or a small thoracotomy.

11. What should be the scope of the operation if the lesion is a cancerous tumor?

Although some studies suggest that wedge resection is sufficient, removal of the anatomical lobe of the lung remains the procedure of choice. Cancer that is found as a solitary lesion is an early stage with a 65% 5-year survival rate (in the absence of visible metastases). Relapses are divided into local and distant.

Educational video of the anatomy of the roots and segments of the lungs

Description of the presentation Algorithm for detecting focal formations in the lungs using slides

Focal formations are a zone of compaction of lung tissue, often round in shape, up to 3 cm in size. Foci can be single, single, or multiple.

The edges may be smooth or jagged, distinct or blurred. The diameter of the lesion is measured in two projections. If there are multiple lesions, indicate the minimum and maximum size.

The surrounding lung parenchyma is assessed. It can be intact, with perifocal inflammation, fibrotic, etc.

The structure of the lesion is assessed - homogeneous, heterogeneous. Calcifications, small cavities, fat and other inclusions are possible inside the defect.

If most of the defect is occupied by a cavity, a recalcified cyst or tuberculous cavity should be assumed. These nosological units are not included in the concept of “focal lesion”.

Causes of focal formations in the lungs. Malignant 20 -40% Bronchogenic cancer (leading cause) Alveolar cell carcinoma Metastasis of another cancer lesion to the lung Bronchial adenoma Benign 60 -80% Infectious granuloma (leading cause) Benign tumors Non-infectious granuloma Pulmonary infarction Echinococcal cyst

General approaches to focal formations A significant proportion of lesions are malignant; lesions require rapid examination, since rapid resection of bronchopulmonary cancer tumors gives a 50% 5-year survival rate. All lung lesions should be considered potentially malignant until proven benign

Indirect signs of benignity of the OO Presence of calcifications (highly reliable indicator) The presence of calcification in the center of the shadow makes the diagnosis of benignity absolute. Calcification not detected on plain radiographs may be detected on CT. Stability of the lesion, that is, lack of growth for 2 or more years. Highly reliable sign. Observation of lesions is possible only in the following situations - High or extremely high risk of surgical intervention - IHD, COPD. – Patient refusal In all cases, the decision on observation is made only at a consultation. Observation tactics are dangerous for the patient in all other cases.

Anamnesis collection for OO in the lung Specifies – Previous respiratory tract infections – Influenza-like conditions – Pneumonia (special attention to hilar diseases) Specifies the presence of – Chronic cough – Sputum – Hemoptysis – Weight loss – Fever

Taking an anamnesis when a lesion is detected in the lung Questions from the social and professional anamnesis section – Smoking – Alcohol – Traveling to Central Asia, Southeast Asia (echinococcosis, mycoses) – Working with stone, ore, sand. Questions about previous diseases – Thrombophlebitis – Presence of constipation-diarrhea syndrome (rectal cancer and metastases) – Hematuria (kidney cancer) – Discharge from the nipple (breast cancer)

There are no special laboratory tests! Indirect signs of intoxication (ESR, leukocytosis, anemia) are important. In some cases, testing for special tumor markers is possible

Imaging methods Plain radiographs can help identify the syndrome. Tomography. Computed tomography is the preferred research method, as it allows one to calculate the density of the formation) Puncture biopsy of the lung under fluoroscopic control in 2 projections. Obtaining a biopsy makes the diagnosis absolute. Gallium-67 scintigraphy is not superior to CT PET CT

Fiberoptic bronchoscopy This method is always advisable, but it is most informative only for central lung cancers.

Thoracotomy Goals: – To obtain a biopsy that could not be obtained by another method – To carry out a radical resection of the primary lung tumor (in the absence of metastases) – To remove a single metastasis of another tumor The question of thoracotomy is raised by the therapist to the thoracic surgeon if it is impossible to obtain a biopsy by any other method. This is true in cases where a tumor is not detected. In this case, high-risk factors are taken into account: – Age over 65 years – Pulmonary hypertension – Decompensation of CHF or diabetes – Disorders in the blood coagulation system – Mental disorders – Severe ischemic heart disease

Algorithm of reasoning when detecting a lesion in the lung Calcified? Benign formation (possibly echinococcosis) Observation once every 6 months Yes No Is there information about size stability? Yes > 450 days Yes Benign Surveillance. No Consultation with a phthisiatrician, oncologist Tomogram, CT scan, bronchoscopy Transthoracic, transbronchial biopsy Refusal of biopsy, impossibility of performing

Transthoracic, transbronchial biopsy Refusal of biopsy, impossibility of performing Benign Observation by an oncologist Observation and therapy in accordance with the biopsy Oncosearch Detection of the primary tumor Another tumor was not detected Observation over time. Dynamics are fast Dynamics are slow or absent. Malignant

Differential diagnosis of pneumonia In real practice, differential diagnosis begins to be carried out for pneumonia that is difficult to treat. Differential range – – Tuberculosis – Perifocal pneumonia (bronchogenic or broncho-alveolar cancer, lymphoma) – Manifestation of vasculitis – Manifestation of alveolitis – Eosinophilic pneumonia – Pulmonary embolism

Differential diagnosis Disease Diagnostic measures 1. Lung cancer CT, chest tomography, examination of sputum, pleural fluid, exudate for atypia, bronchoscopy with biopsy, biopsy of peripheral lymph nodes, liver ultrasound, lung biopsy 2. Metastases to the lung CT, tomogram, pleural fluid for atypical cells, search for a primary tumor, biopsy of peripheral lymph nodes, liver ultrasound, biopsy from the darkened zone 3. Tuberculosis CT, tomography, sputum analysis for VK (including the flotation method), analysis of pleural exudate, bronchoscopy and biopsy, Mantoux test, rinsing waters 4. PE Isotope scanning of the lungs, wedge-shaped shadow on a radiograph, ECG, accumulation of labeled fibrinogen, angiopulmonography 5. Alveolitis Determination of pressure in the pulmonary artery, p. O 2, r. CO 2, CT

In case of an atypical course of pneumonia, especially with multiple foci or with several foci, the probability of - Bacterial endocarditis of the tricuspid valve - Thrombosis of the right atrial appendage (with atrial fibrillation - Ultrasound of the veins of the leg) is discussed. A special risk group for such pneumonia is drug addicts and long-term bedridden patients.

This is a large number of neoplasms, different in origin, histological structure, localization and characteristics of clinical manifestation. They can be asymptomatic or with clinical manifestations: cough, shortness of breath, hemoptysis. Diagnosed using X-ray methods, bronchoscopy, thoracoscopy. Treatment is almost always surgical. The extent of intervention depends on clinical and radiological data and ranges from tumor enucleation and economical resections to anatomical resections and pneumonectomy.

General information

Lung tumors constitute a large group of neoplasms characterized by excessive pathological growth of tissues of the lung, bronchi and pleura and consisting of qualitatively altered cells with impaired differentiation processes. Depending on the degree of cell differentiation, benign and malignant lung tumors. There are also metastatic lung tumors (screenings of tumors that primarily arise in other organs), which are always malignant in type.

Benign lung tumors make up 7-10% of the total number of neoplasms in this location, developing with the same frequency in women and men. Benign neoplasms are usually registered in young patients under the age of 35 years.

Reasons

The reasons leading to the development of benign lung tumors are not fully understood. However, it is assumed that this process is facilitated by genetic predisposition, gene abnormalities (mutations), viruses, exposure to tobacco smoke and various chemical and radioactive substances that pollute soil, water, atmospheric air (formaldehyde, benzanthracene, vinyl chloride, radioactive isotopes, UV radiation and etc.). A risk factor for the development of benign lung tumors are bronchopulmonary processes that occur with a decrease in local and general immunity: COPD, bronchial asthma, chronic bronchitis, prolonged and frequent pneumonia, tuberculosis, etc.).

Pathanatomy

Benign lung tumors develop from highly differentiated cells, similar in structure and function to healthy cells. Benign lung tumors are characterized by relatively slow growth, do not infiltrate or destroy tissue, and do not metastasize. The tissues located around the tumor atrophy and form a connective tissue capsule (pseudocapsule) surrounding the tumor. A number of benign lung tumors have a tendency to malignancy.

Based on location, they distinguish between central, peripheral and mixed benign lung tumors. Tumors with central growth originate from large (segmental, lobar, main) bronchi. Their growth in relation to the bronchial lumen can be endobronchial (exophytic, inside the bronchus) and peribronchial (into the surrounding lung tissue). Peripheral lung tumors originate from the walls of small bronchi or surrounding tissues. Peripheral tumors can grow subpleurally (superficially) or intrapulmonarily (deeply).

Benign lung tumors of peripheral localization are more common than central ones. In the right and left lungs, peripheral tumors are observed with equal frequency. Central benign tumors are most often located in the right lung. Benign lung tumors often develop from the lobar and main bronchi, rather than from segmental bronchi, like lung cancer.

Classification

Benign lung tumors can develop from:

• epithelial tissue of the bronchi (polyps, adenomas, papillomas, carcinoid, cylindromas);
• neuroectodermal structures (neurinomas (schwannomas), neurofibromas);
• mesodermal tissues (chondromas, fibromas, hemangiomas, leiomyomas, lymphangiomas);
• from embryonic tissues ( teratoma , hamartoma- congenital lung tumors).

Among benign lung tumors, hamartomas and bronchial adenomas are more common (in 70% of cases).

1. Bronchial adenoma– glandular tumor developing from the epithelium of the bronchial mucosa. In 80-90% it has central exophytic growth, localized in large bronchi and disrupting bronchial patency. Typically, the size of the adenoma is up to 2-3 cm. The growth of the adenoma over time causes atrophy and sometimes ulceration of the bronchial mucosa. Adenomas have a tendency to malignancy. Histologically, the following types of bronchial adenomas are distinguished: carcinoid, carcinoma, cylindroma, adenoid. The most common type among bronchial adenomas is carcinoid (81-86%): highly differentiated, moderately differentiated and poorly differentiated. 5-10% of patients develop carcinoid malignancy. Adenomas of other types are less common.
2. Hamartoma- (chonroadenoma, chondroma, hamartochondroma, lipochondroadenoma) – a neoplasm of embryonic origin, consisting of elements of embryonic tissue (cartilage, layers of fat, connective tissue, glands, thin-walled vessels, smooth muscle fibers, accumulation of lymphoid tissue). Hamartomas are the most common peripheral benign lung tumors (60-65%) localized in the anterior segments. Hamartomas grow either intrapulmonarily (into the thickness of the lung tissue) or subpleurally, superficially. Typically, hamartomas are round in shape with a smooth surface, clearly demarcated from surrounding tissues, and do not have a capsule. Hamartomas are characterized by slow growth and asymptomatic course, extremely rarely degenerating into a malignant neoplasm - hamartoblastoma.
3. Papilloma(or fibroepithelioma) is a tumor consisting of connective tissue stroma with multiple papillary processes, externally covered with metaplastic or cuboidal epithelium. Papillomas develop predominantly in large bronchi, grow endobronchially, sometimes obstructing the entire bronchial lumen. Often, bronchial papillomas occur together with papillomas of the larynx and trachea and can undergo malignancy. The appearance of papilloma resembles cauliflower, cockscomb or raspberry. Macroscopically, papilloma is a formation on a broad base or stalk, with a lobulated surface, pink or dark red color, soft-elastic, less often hard-elastic consistency.
4. Pulmonary fibroma– tumor d – 2-3 cm, arising from the connective tissue. Represents from 1 to 7.5% of benign lung tumors. Pulmonary fibroids equally often affect both lungs and can reach a gigantic size of half the chest. Fibroids can be localized centrally (in large bronchi) and in peripheral areas of the lung. Macroscopically, the fibromatous node is dense, with a smooth whitish or reddish surface and a well-formed capsule. Lung fibroids are not prone to malignancy.
5. Lipoma- a neoplasm consisting of adipose tissue. In the lungs, lipomas are detected quite rarely and are random radiological findings. They are localized mainly in the main or lobar bronchi, less often in the periphery. Lipomas arising from the mediastinum (abdomino-mediastinal lipomas) are more common. Tumor growth is slow, malignancy is not typical. Macroscopically, the lipoma is round in shape, densely elastic in consistency, with a clearly defined capsule, yellowish in color. Microscopically, the tumor consists of fat cells separated by connective tissue septa.
6. Leiomyoma is a rare benign tumor of the lungs that develops from the smooth muscle fibers of blood vessels or the walls of the bronchi. More often observed in women. Leiomyomas are of central and peripheral localization in the form of polyps on the base or stalk, or multiple nodules. Leiomyoma grows slowly, sometimes reaching gigantic sizes, has a soft consistency and a well-defined capsule.
7. Vascular tumors of the lungs(hemangioendothelioma, hemangiopericytoma, capillary and cavernous pulmonary hemangiomas, lymphangioma) account for 2.5-3.5% of all benign formations of this localization. Vascular tumors of the lungs can have peripheral or central localization. All of them are macroscopically round in shape, dense or densely elastic in consistency, surrounded by a connective tissue capsule. The color of the tumor varies from pinkish to dark red, size - from a few millimeters to 20 centimeters or more. Localization of vascular tumors in large bronchi causes hemoptysis or pulmonary hemorrhage.
8. Hemangiopericytoma and hemangioendothelioma are considered conditionally benign lung tumors, because they have a tendency to rapid, infiltrative growth and malignancy. On the contrary, cavernous and capillary hemangiomas grow slowly and are separated from surrounding tissues and do not become malignant.
9. Dermoid cyst(teratoma, dermoid, embryoma, complex tumor) – a disembryonic tumor-like or cystic neoplasm consisting of different types of tissue (sebaceous masses, hair, teeth, bones, cartilage, sweat glands, etc.). Macroscopically it looks like a dense tumor or cyst with a clear capsule. It accounts for 1.5–2.5% of benign lung tumors, mainly occurring at a young age. The growth of teratomas is slow, suppuration of the cystic cavity or malignancy of the tumor (teratoblastoma) is possible. When the cyst contents break into the pleural cavity or bronchial lumen, a picture of an abscess or pleural empyema develops. The localization of teratomas is always peripheral, most often in the upper lobe of the left lung.
10. Neurogenic lung tumors(neurinomas (schwannomas), neurofibromas, chemodectomas) develop from nerve tissue and make up about 2% of benign lung blastomas. More often, lung tumors of neurogenic origin are located peripherally and can be found in both lungs at once. Macroscopically they look like rounded dense nodes with a clear capsule, grayish-yellow in color. The issue of malignancy of lung tumors of neurogenic origin is controversial.

Rare benign lung tumors include fibrous histiocytoma (tumor of inflammatory origin), xanthomas (connective tissue or epithelial formations containing neutral fats, cholesterol esters, iron-containing pigments), plasmacytoma (plasmocytic granuloma, a tumor resulting from a disorder of protein metabolism). Among benign lung tumors there are also tuberculomas– formations that are a clinical form of pulmonary tuberculosis and are formed by caseous masses, elements of inflammation and areas of fibrosis.

Symptoms

Clinical manifestations of benign lung tumors depend on the location of the tumor, its size, direction of growth, hormonal activity, degree of bronchial obstruction, and complications caused. Benign (especially peripheral) lung tumors may not produce any symptoms for a long time. In the development of benign lung tumors, the following are distinguished:

• asymptomatic (or preclinical) stage
• stage of initial clinical symptoms
• stage of severe clinical symptoms caused by complications (bleeding, atelectasis, pneumosclerosis, abscess pneumonia, malignancy and metastasis).

Peripheral lung tumors

With peripheral localization in the asymptomatic stage, benign lung tumors do not manifest themselves in any way. In the stage of initial and severe clinical symptoms, the picture depends on the size of the tumor, the depth of its location in the lung tissue, and its relationship to the adjacent bronchi, vessels, nerves, and organs. Large lung tumors can reach the diaphragm or chest wall, causing pain in the chest or heart area, and shortness of breath. In case of vascular erosion by a tumor, hemoptysis and pulmonary hemorrhage are observed. Compression of the large bronchi by the tumor causes disruption of bronchial obstruction.

Central lung tumors

Clinical manifestations of benign lung tumors of central localization are determined by the severity of bronchial obstruction, which is classified as grade III. In accordance with each degree of bronchial obstruction, the clinical periods of the disease differ.

• I degree - partial bronchial stenosis

In the first clinical period, corresponding to partial bronchial stenosis, the bronchial lumen is narrowed slightly, so its course is often asymptomatic. Sometimes noted cough, with a small amount of sputum, less often with an admixture of blood. General health does not suffer. Radiologically, a lung tumor is not detected during this period, but can be detected by bronchography, bronchoscopy, linear or computed tomography.

• II degree - valvular or valve bronchial stenosis

In the 2nd clinical period, valvular or valve bronchial stenosis develops, associated with obstruction of most of the bronchial lumen by the tumor. With ventral stenosis, the lumen of the bronchus partially opens on inspiration and closes on exhalation. In the part of the lung ventilated by the narrowed bronchus, expiratory emphysema develops. Complete closure of the bronchus may occur due to swelling, accumulation of blood and sputum. An inflammatory reaction develops in the lung tissue located at the periphery of the tumor: the patient’s body temperature rises, cough with sputum, shortness of breath, sometimes hemoptysis, chest pain, fatigue and weakness. Clinical manifestations of central lung tumors in the 2nd period are intermittent. Anti-inflammatory therapy relieves swelling and inflammation, leads to the restoration of pulmonary ventilation and the disappearance of symptoms for a certain period.

• III degree - bronchial occlusion

The course of the 3rd clinical period is associated with the phenomena of complete occlusion of the bronchus by the tumor, suppuration of the atelectasis zone, irreversible changes in the area of ​​lung tissue and its death. The severity of symptoms is determined by the caliber of the bronchus obstructed by the tumor and the volume of the affected area of ​​the lung tissue. There is a persistent increase in temperature, severe chest pain, weakness, dyspnea(sometimes attacks of suffocation), poor health, cough with purulent sputum and blood, sometimes - pulmonary hemorrhage. X-ray picture of partial or complete atelectasis of a segment, lobe or the entire lung, inflammatory and destructive changes. Linear tomography reveals a characteristic pattern, the so-called “bronchial stump” - a break in the bronchial pattern below the obstruction zone.

The speed and severity of bronchial obstruction depends on the nature and intensity of lung tumor growth. With peribronchial growth of benign lung tumors, clinical manifestations are less pronounced, and complete bronchial occlusion rarely develops.

Complications

With a complicated course of benign lung tumors, pneumofibrosis, atelectasis, abscess pneumonia, bronchiectasis, pulmonary hemorrhage, organ and vascular compression syndrome, malignancy of neoplasm. With carcinoma, which is a hormonally active lung tumor, 2–4% of patients develop carcinoid syndrome, manifested by periodic attacks of fever, hot flashes in the upper half of the body, bronchospasm, dermatosis, diarrhea, mental disorders due to a sharp increase in the blood level of serotonin and its metabolites.

Diagnostics

At the stage of clinical symptoms, dullness of percussion sound over the area of ​​atelectasis (abscess, pneumonia), weakening or absence of vocal tremor and breathing, dry or moist rales are physically determined. In patients with obstruction of the main bronchus, the chest is asymmetrical, the intercostal spaces are smoothed, and the corresponding half of the chest lags behind during respiratory movements. Necessary instrumental studies:

1. Radiography. Often benign lung tumors are incidental radiological findings detected during fluorography. At X-ray of the lungs Benign lung tumors are defined as rounded shadows with clear contours of varying sizes. Their structure is often homogeneous, sometimes, however, with dense inclusions: blocky calcifications (hamartomas, tuberculomas), bone fragments (teratomas). Using angiopulmonography vascular lung tumors are diagnosed.
2. Computed tomography. Computed tomography allows a detailed assessment of the structure of benign lung tumors ( CT lungs), which determines not only dense inclusions, but also the presence of adipose tissue characteristic of lipomas, fluid - in tumors of vascular origin, dermoid cysts. The contrast bolus-enhanced computed tomography method makes it possible to differentiate benign lung tumors from tuberculomas, peripheral cancer, metastases, etc.
3. Bronchial endoscopy. Used in the diagnosis of lung tumors bronchoscopy, which allows not only to examine the neoplasm, but also to perform a biopsy (for central tumors) and obtain material for cytological examination. With a peripheral location of the lung tumor, bronchoscopy can reveal indirect signs of the blastomatous process: compression of the bronchus from the outside and narrowing of its lumen, displacement of the branches of the bronchial tree and changes in their angle.
4. Biopsy. For peripheral lung tumors, transthoracic aspiration or needle biopsy of the lung under X-ray or ultrasound control. If there is a lack of diagnostic data from special research methods, they resort to thoracoscopy or thoracotomy with biopsy.

Treatment

All benign lung tumors, regardless of the risk of their malignancy, are subject to surgical removal (in the absence of contraindications to surgical treatment). The operations are performed by thoracic surgeons. The earlier a lung tumor is diagnosed and removed, the less volume and trauma from surgery, the risk of complications and the development of irreversible processes in the lungs, including malignancy of the tumor and its metastasis. The following types of surgical interventions are used:

1. Bronchial resection. Central lung tumors are usually removed using a sparing method (without lung tissue) bronchial resection. Tumors with a narrow base are removed by fenestrated resection of the bronchial wall followed by suturing the defect or bronchotomy. Broad-based lung tumors are removed by circular resection of the bronchus and interbronchial anastomosis.
2. Lung resection. In case of already developed complications in the lung (bronchiectasis, abscesses, fibrosis), they resort to removing one or two lobes of the lung ( lobectomy or bilobectomies). If irreversible changes develop in the whole lung, it is removed - pneumonectomy. Peripheral lung tumors located in the lung tissue are removed using the enucleation(husking), segmental or marginal lung resection, when the tumor is large or complicated, they resort to lobectomy.

Surgical treatment of benign lung tumors is usually performed by thoracoscopy or thoracotomy. Benign central lung tumors growing on a thin stalk can be removed endoscopically. However, this method is associated with the risk of bleeding, insufficiently radical removal, and the need for repeated bronchological monitoring and a biopsy of the bronchial wall at the location of the tumor stalk.

If a malignant lung tumor is suspected, during the operation an urgent histological examination of the tumor tissue is performed. If the malignancy of the tumor is morphologically confirmed, the scope of surgical intervention is performed as for lung cancer.

Prognosis and prevention

With timely treatment and diagnostic measures, long-term results are favorable. Relapses following radical removal of benign lung tumors are rare. The prognosis for lung carcinoids is less favorable. Taking into account the morphological structure of the carcinoid, the five-year survival rate for the highly differentiated type of carcinoid is 100%, for the moderately differentiated type – 90%, for the poorly differentiated type – 37.9%. Specific prevention has not been developed. Timely treatment of infectious and inflammatory lung diseases, avoidance of smoking and contact with harmful pollutants can minimize the risk of neoplasms.