Differential Diagnosis

The patient's presentation with multiple pulmonary nodules, mediastinal adenopathy, and a history of abnormal chest radiograph suggests a complex diagnosis. The following differential diagnosis is organized into categories:

• Single most likely diagnosis
  • Metastatic disease: The presence of at least 60 nodular and irregular mass lesions in the lungs, ranging in size from a few millimeters to 7.4 cm, is highly suggestive of metastatic disease. The patient's history of coronary artery bypass surgery and the presence of a left paracentral retrosternal mass lesion also support this diagnosis.
• Other Likely diagnoses
  • Primary pulmonary neoplasia: The CT findings of multiple pulmonary nodules and masses, including a spiculated 3 cm right hilar mass lesion and a 4.8 cm left hilar mass lesion, are also compatible with primary pulmonary neoplasia.
  • Lymphoma: The presence of mediastinal adenopathy and multiple lymph nodes in the pretracheal and AP window regions could suggest lymphoma.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Infectious diseases (e.g., tuberculosis, fungal infections): Although less likely, infectious diseases could present with similar radiographic findings, and missing these diagnoses could have severe consequences.
  • Vasculitis (e.g., Wegener's granulomatosis): Vasculitis could also present with multiple pulmonary nodules and masses, and missing this diagnosis could lead to delayed treatment and poor outcomes.
• Rare diagnoses
  • Sarcoidosis: Although rare, sarcoidosis could present with multiple pulmonary nodules and masses, as well as mediastinal adenopathy.
  • Langerhans cell histiocytosis: This rare disease could also present with multiple pulmonary nodules and masses, although it is less likely in a 60-year-old patient.