Pulmonary nodules

What is a pulmonary nodule?

A pulmonary nodule is a small spot of lung tissue which is denser than the lung surrounding it. They are usually round or oval. Most of these nodules are less than 1cm in size, though they can be as big as 3cm.

How are pulmonary nodules found?

These are usually found unexpectedly in patients who are having chest X-rays or CT scans to investigate chest-related symptoms.

They do not usually cause symptoms or make you unwell.

Are they common?

Yes. Up to 1 in 4 people will have pulmonary nodules found on a CT scan. They are more common in smokers, where 1 in 2 smokers will have pulmonary nodules.

We are now finding them more frequently as the quality of the pictures that the most modern CT scanners produce is very good.

This allows nodules as small as 1 or 2 mm to be seen.

What causes the nodule?

The majority of these nodules are benign and nothing to worry about.

They can be caused by:

• Scar tissue: If you have had a lung infection or an injury to the lung at some point, these heal with scar tissue.

• Infections: Certain infections such as tuberculosis and chicken pox can infect the lung and usually heal with lots of little nodules. You may not even have been aware of the infection when you had it. If you have a CT scan when you have an active infection this can show up as a nodule or even multiple nodules.

• Lymph glands: The body’s immune or defence system is stored in glands called lymph glands. These glands are found throughout your body. They release white blood cells and other parts of your immune system when they detect infection nearby. In the lung these glands are small but can be picked on CT scans and are a common cause for very small pulmonary nodules.

• Breathing in irritants: Some jobs such as coal mining or stone grinding can cause you to breathe in irritant dusts, which can cause pulmonary nodules.

• Inflammation or problems relating to an over-active immune system: Conditions such as Rheumatoid Arthritis, Sarcoisosis and Granulomatosis with polyangitis (also known as Wegeners Granulomatosis) can cause nodules in the lungs.

• Benign (non-cancerous) growths: Hamartomas are lumps of tissue made up of fat, cartilage and connective tissue. These can grow slowly over time but are not cancerous and don’t usually cause any problems.

• Cancer: Occasionally a pulmonary nodule is a lung cancer in its very early stages. When cancer is mentioned it is normal to feel anxious or worried. It’s important to know that less than 1 in 20 of pulmonary nodules turn out to be lung cancer. Even in smokers most small nodules are not cancer.

What might make it more likely that a nodule is a cancer?

There are some things which make it more likely that a nodule is a cancer. These include:

• Bigger nodules.

• Having an irregular or ragged shape which is pulling the surrounding lung in toward it.

• Being older when you develop a nodule.

• Being a smoker or having smoked for a long time.

• Having worked with cancer causing dusts like asbestos.

• Having a history of lung cancer in your family.

What will happen next?

Most pulmonary nodules are small when they are found. It can be difficult from the CT scan alone to be sure what something is.

There are a few different possible strategies:

• Pulmonary nodules (< 5mm diameter)

In a small number of patients with small nodules with no worrying appearances no further tests or CTs may be needed.

• Pulmonary nodules (> 5 mm diameter)

Most patients with nodules which are bigger than 5 mm will need follow up or investigation.

The most common approach is to repeat your CT at certain intervals after your first CT. How soon and often we repeat your CT scan depends on a few different things including the shape of the nodule, what risk factors you have for cancer and whether you have other lung diseases. 

Most people will usually have scans for up to two years after their first scan.

A typical schedule is 3 months, 1 year and then 2 years. If the nodule doesn’t grow or change we can usually stop scanning at this point.

If the nodule shrinks or disappears during this time you won’t require any further follow up.

Some nodules which are less solid and well defined are sometimes followed up for longer, up to 4 years in some cases.

Larger nodules

If a nodule is larger (> 8 mm) or a smaller nodule grows on after you have had a further scan you will usually need further tests.

These will be a combination of different types of CT scans and possibly biopsies.

Different types of scan

An ordinary CT scan tells you what a nodule looks like. There may be things on your CT scan which helps the doctors decide whether something is more or less likely to be cancer. However these types of CT are limited in how much information they give you.

Positron Emission Tomography (PET) scans

You may be asked to have a PET scan. A PET scan is a type of CT scan which uses a different type of dye injection than the CT you will have had already. This contains a form of radioactive sugar. Sugar is the fuel supply for all of your body’s cells and tissues. Things which are more active or growing take up more sugar.

The PET scan measures how brightly the nodule lights up compared to the lung surrounding it. It also looks for spots or nodules elsewhere in the body.

After the PET scan your team will look at all of your scans and make a decision as to what the next step will be.

Biopsies

You may be asked to have a biopsy after you have had a PET scan. A biopsy is a test where a sample of the nodule is taken and looked at under a microscope. This can tell the team what the nodule is and whether it is cancer. There is a chance that the biopsy will not be able to tell the team what the nodule is.

How do you take a biopsy?

There are different ways of getting biopsies. 

CT guided biopsies

A CT guided biopsy uses the CT scanner to help a specialist X-ray doctor guide a very fine needle in between your ribs to where the nodule is in your lung. A biopsy is then taken through this needle. This is a common and straight forward procedure. It is an outpatient test and you will usually go home the same day.

Bronchoscopy with virtual bronchoscopic navigation

A bronchoscopy is a test where a camera is passed down your windpipe into your lungs. It is then guided to where the nodule is using the CT scans you have already had. This test is done as an outpatient using sedation and you usually go home the same day.

This test is only suitable if your nodule sits near one of the airways in your lungs

Will a biopsy definitely tell you what the nodule is?

No, not necessarily. It may not be possible to do these biopsies due to the size or position of the nodule.

During the biopsy it may not be possible to sample the nodule despite the best efforts of the team.

If a biopsy is taken, it may not have enough tissue or be able to definitively say what the nodule is.

It is important you understand this before you go through any biopsy.

What would happen if the biopsy wasn’t possible or successful?

In this situation your team may ask you to have an operation to take the whole nodule out. If they wanted you to have this, you would go to meet a chest surgeon to talk through what this involves.

If I have an operation and it does turn out to be cancerous, what happens next?

If the whole nodule has been taken out, usually no further treatment is required. You would normally continue to attend the chest clinic to be monitored for up to 5 years.

Why don’t you just biopsy or remove all nodules as soon as you find them?

You may remember that 9.5 out of 10 nodules are benign. Biopsies and operations come with a risk of side effects and complications. The risk from having CT scans to follow up the nodules is lower than the risk from biopsies and operations.

What if I wanted the nodule removed right away rather than going through with follow up scans or biopsies?

Some patients don’t feel that they can live with the uncertainty of having a nodule. In this case your team may refer you to speak to a chest surgeon about having the nodule removed. The chest surgeon would want you to have a PET scan and some other tests before they would consider an operation. 

What support will I have?

We understand that it can be very stressful going through this process. You would have the support of your Consultant and team who would see you regularly in clinic after each of your scans to go through the results. There are specialist nurses who also keep in touch with patients going through PET scans and biopsies to make sure they know what’s going on.

Can I do anything myself for these nodules?

You might remember that people who smoke have more of a tendency to developing pulmonary nodules. Stopping smoking may help to stop further nodules and allow some to shrink. If you want help to stop smoking then we will help you find the right support.

Contact numbers

University Hospital of North Tees

Lung health
Telephone: 01642 624270
Department of Respiratory Medicine
Monday to Friday 09:00am-05:00pm
Telephone: 01642 624936
Emergency Department
24 hours a day, 7 days a week
Telephone: 01642 382899

Where can I find out more information?

The British Thoracic society
The British Thoracic society has an in depth guideline on pulmonary nodules:
Website: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/pulmonary-nodules/

National Lung Cancer Nursing UK
You find more patient information can be found on the National Lung Cancer Nursing UK website:
Website: http://www.lcnuk.org

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Leaflet Reference: PIL1219
Date for Review: 28/08/2023