title: Should CT play a greater role in preventing the resection of granulomas in the era of PET?
abstract: OBJECTIVE
  PET cannot distinguish between bronchogenic carcinoma and granuloma, but positive scans may prompt surgery. We systematically evaluated the CT appearance of resected carcinomas and granulomas to identify features that could be used to reduce granuloma resections.
  
  
  METHODS
  We retrospectively identified 93 consecutive patients between January 2005 and November 2008 who had resection of a pulmonary nodule pathologically diagnosed as bronchogenic carcinoma or granuloma and preoperative imaging with CT and PET. Each nodule was evaluated on CT for size, doubling time, location, borders, shape, internal characteristics, calcification, clustering, air bronchograms, and cavitation. A diagnostic impression was rendered. Bivariate and logistic regression analyses were performed. Pre-PET data regarding the proportion of resected granulomas and carcinomas between January 1995 and December 1996 were reviewed.
  
  
  RESULTS
  Sixty-eight percent (65/96) of nodules were carcinomas and 32% (31/96) were granulomas. The CT impression was benign in 65% (20/31) of granulomas and 5% (3/65) of carcinomas (p < 0.0001; negative predictive value [NPV], 87% [20/23]). Specific CT features significantly associated with granuloma were clustering, cavitation, irregular shape, lack of pleural tags, and solid attenuation. The combination of nonspiculated borders, irregular shape, and solid attenuation had an NPV of 86% (12/14). Granulomas represented 18% (9/50) of resected nodules in 1995 and 1996 (p = 0.066).
  
  
  CONCLUSIONS
  CT findings reduce but cannot eliminate the possibility that a nodule is malignant. Outcomes-based clinical trials are needed to determine whether CT features of benignity can guide less-invasive initial management and reverse a concerning trend in granuloma resection.
authors.affiliation: Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210 St, Bronx, NY 10467, USA.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: May
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Levsky
authors.forename: Alla
authors.initials: A
authors.lastname: Godelman
authors.forename: Vineet R
authors.initials: VR
authors.lastname: Jain
authors.forename: Brent P
authors.initials: BP
authors.lastname: Little
authors.forename: Panna S
authors.initials: PS
authors.lastname: Mahadevia
authors.forename: William B
authors.initials: WB
authors.lastname: Burton
authors.forename: Linda B
authors.initials: LB
authors.lastname: Haramati
mesh_terms: D000368:Aged; D002283:Carcinoma, Bronchogenic / Q000000981:diagnostic imaging* / Q000601:surgery; D016009:Chi-Square Distribution; D003937:Diagnosis, Differential; D005260:Female; D019788:Fluorodeoxyglucose F18; D006099:Granuloma / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D014055:Tomography, Emission-Computed; D014057:Tomography, X-Ray Computed
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18