What is the diagnosis for a patient with a patent central airway, mild bilateral lower lobe atelectasis, multiple pulmonary nodules, vascular calcification, and coronary artery calcification?

From the Guidelines

The patient's CT scan shows stable pulmonary nodules with minimal changes, and continued surveillance imaging is recommended, typically with follow-up CT in 6-12 months depending on risk factors, as suggested by the guidelines for evaluating pulmonary nodules 1. The CT scan findings include multiple pulmonary nodules, with a 17.7 x 20.8 mm pleural-based nodule in the right lower lobe that previously measured about 19 x 16.6 mm, suggesting stability. A new 2 mm nodule is noted in the right upper lobe that wasn't clearly seen on the prior study. Other findings include mild bilateral lower lobe atelectasis, a 6.4 mm pulmonary cyst in the right upper lobe, vascular calcification in the aorta and major branches, coronary artery calcification, and a few calcified right hilar lymph nodes (largest 9 mm). The central airway is patent, and there is no pleural effusion.

• The size of the nodules is an important factor in determining the likelihood of malignancy, with larger nodules being more likely to be malignant, as stated in the American College of Chest Physicians evidence-based clinical practice guidelines 1.
• The location of the nodules within the lung is also worth noting, with a higher risk of malignancy for upper lobe than for lower lobe lesions, as mentioned in the guidelines 1.
• The new small 2 mm nodule is likely benign given its size, but it should be monitored on subsequent imaging to ensure stability, as recommended by the evaluation of individuals with pulmonary nodules guidelines 1.
• The patient's risk factors, such as smoking history and age, should be taken into account when determining the frequency of follow-up imaging, as suggested by the clinical practice consensus guidelines for Asia 1.

From the Research

Pulmonary Nodules

• The patient has multiple pulmonary nodules, including a 2 mm nodule in the apical segment of the right upper lobe, a 2 mm nodule in the right upper lobe laterally, a 6.7 mm nodule in the right middle lobe, a 5.5 mm nodule in the right lower lobe posteriorly, and a 17.7 x 20.8 mm pleural-based pulmonary nodule in the right lower lobe posteriorly 2.
• The probability of malignancy for nodules smaller than 6 mm is less than 1%, and for nodules 6 mm to 8 mm, it is 1% to 2% 2.
• Nodules that are 6 mm to 8 mm can be followed with a repeat chest CT in 6 to 12 months, depending on the presence of patient risk factors and imaging characteristics associated with lung malignancy, clinical judgment about the probability of malignancy, and patient preferences 2.

Management of Pulmonary Nodules

• The treatment of an individual with a pulmonary nodule should be guided by the probability that the nodule is malignant, safety of testing, the likelihood that additional testing will be informative, and patient preferences 2, 3.
• Management options include surveillance imaging, defined as monitoring for nodule growth with chest CT imaging, positron emission tomography-CT imaging, nonsurgical biopsy with bronchoscopy or transthoracic needle biopsy, and surgical resection 2, 4.
• Part-solid pulmonary nodules are managed according to the size of the solid component, with larger solid components associated with a higher risk of malignancy 2.

Diagnostic Strategies

• A multidisciplinary approach to the selection of pulmonary nodules for surgical resection can lead to reliable identification of primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease 5.
• The cost-effectiveness of initial diagnostic strategies for pulmonary nodules presenting to thoracic surgeons has been studied, with navigation bronchoscopy and computed tomography-guided fine-needle aspiration being more cost-effective than video-assisted thoracoscopic surgery or FDG-PET scan in certain scenarios 6.