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

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. Graphical Abstract