European Radiology

, Volume 29, Issue 4, pp 1684–1692 | Cite as

Rheumatoid pulmonary nodules: clinical and imaging features compared with malignancy

  • Matthew KoslowEmail author
  • Jason R. Young
  • Eunhee S. Yi
  • Misbah Baqir
  • Paul A. Decker
  • Geoffrey B. Johnson
  • Jay H. Ryu



The objective of this study was to identify clinical and imaging features that distinguish rheumatoid lung nodules from malignancy.


We conducted a retrospective review of 73 rheumatoid patients with histologically-proven rheumatoid and malignant lung nodules encountered at Mayo Clinic, Rochester, MN (2001–2016). Medical records and imaging were reviewed including a retrospective blinded review of CT and PET/CT studies.


The study cohort had a mean age of 67 ± 11 years (range 45–86) including 44 (60%) women, 82% with a smoking history, 38% with subcutaneous rheumatoid nodules, and 78% with rheumatoid factor seropositivity. Subjects with rheumatoid lung nodules compared to malignancy were younger (59 ± 12 vs 71 ± 9 years, p < 0.001), more likely to manifest subcutaneous rheumatoid nodules (73% vs 20%, p < 0.001) and rheumatoid factor seropositivity (93% vs 68%, p = 0.034) but a history of smoking was common in both groups (p = 0.36). CT features more commonly associated with rheumatoid lung nodules compared to malignancy included multiplicity, smooth border, cavitation, satellite nodules, pleural contact, and a subpleural rind of soft tissue. Optimal sensitivity (77%) and specificity (92%) (AUC 0.85, CI 0.75–0.94) for rheumatoid lung nodule were obtained with ≥ 3 CT findings (≥ 4 nodules, peripheral location, cavitation, satellite nodules, smooth border, and subpleural rind). Key 18FDG-PET/CT features included low-level metabolism (SUVmax 2.7 ± 2 vs 7.2 ± 4.8, p = 0.007) and lack of 18F-fluorodeoxyglucose (FDG)-avid draining lymph nodes.


Rheumatoid lung nodules have distinct CT and PET/CT features compared to malignancy. Patients with rheumatoid lung nodules are younger and more likely to manifest subcutaneous rheumatoid nodules and seropositivity.

Key Points

• Rheumatoid lung nodules have distinct clinical and imaging features compared to lung malignancy.

• CT features of rheumatoid lung nodules include multiplicity, cavitation, satellite nodules, smooth border, peripheral location, and subpleural rind.

• Key PET/CT features include low-level metabolism and lack of FDG-avid draining lymph nodes.


Multidetector computed tomography PET-CT scan Multiple pulmonary nodules Rheumatoid arthritis Rheumatoid nodule 



Cyclic citrullinated peptide


Diffusing capacity for carbon monoxide


Forced expiratory volume in 1 s




Forced vital capacity


Ground glass opacity


High-resolution computed tomography




Positron emission tomography


Pulmonary function test


Rheumatoid arthritis


Total lung capacity



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Jay H. Ryu.

Conflict of interest

Dr. Johnson has received research funding from Pfizer which is not relevant to this work. None of the additional co-authors have relevant disclosures.

Statistics and biometry

Mr. Paul A. Decker kindly provided statistical advice for this manuscript.

Informed consent

The study was approved by the Mayo Clinic Institutional Review Board (IRB16-006571). According to Mayo Clinic institutional policy, patient information may be used for research purposes only with prior patient consent.

Ethical approval

Institutional Review Board approval was obtained by the Mayo Clinic Institutional Review Board (IRB16-006571).

Study subjects or cohorts overlap

None of the study subjects or cohorts have been previously reported except for abstract presentation at the American Thoracic Society International Conference 2017.


• Retrospective

• Case-control study

• Performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterUSA
  2. 2.Division of Nuclear Medicine, Department of RadiologyMayo ClinicRochesterUSA
  3. 3.Division of Anatomic Pathology, Department of Laboratory Medicine and PathologyMayo ClinicRochesterUSA
  4. 4.Department of Health Sciences ResearchMayo ClinicRochesterUSA
  5. 5.Department of ImmunologyMayo ClinicRochesterUSA

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