From the Guidelines
The patient's CT angiogram shows a moderate right-sided pulmonary infarction, a small subsegmental middle lobe infarct, and other incidental findings, and the most appropriate management is to initiate anticoagulation therapy and monitor the non-calcified 4mm middle lobe nodule with follow-up imaging in 12 months if the patient has risk factors for lung cancer. The CT angiogram (CTA) shows several findings that require attention, including a moderate pulmonary embolism (PE) on the right side with a small infarct in the middle lobe of the lung, though without signs of right heart strain which is reassuring 1.
- Anticoagulation therapy should be initiated promptly, typically with low molecular weight heparin followed by oral anticoagulants like apixaban, rivaroxaban, or warfarin for at least 3 months.
- The 4mm nodule in the middle lobe is likely benign, but follow-up imaging in 12 months is recommended if the patient has smoking history or other risk factors for lung cancer, as suggested by the Fleischner Society guidelines 1.
- If the patient is low-risk, no additional follow-up is needed for this nodule.
- The scan also shows evidence of healed granulomatous disease, which typically requires no treatment as it represents old, resolved infection.
- Additionally, gallstones (cholelithiasis) were noted, which should be monitored for symptoms like right upper quadrant pain, particularly after fatty meals.
- Finally, there is a small cyst or biliary hamartoma in the liver, which is generally a benign finding requiring no intervention unless it changes in size or appearance on future imaging, as supported by the most recent guidelines from the American College of Radiology 1.
From the Research
Impression of CTA Scan Findings
The CTA scan shows moderate right-sided pulmonary infarction (PI) with a small subsegmental middle lobe infarct, a non-calcified 4mm middle lobe nodule, healed pulmonary granulomatous disease, cholelithiasis (gallstones), and a small cyst or biliary hamartoma in the liver.
Key Findings
- Moderate right-sided pulmonary infarction (PI)
- Small subsegmental middle lobe infarct
- Non-calcified 4mm middle lobe nodule
- Healed pulmonary granulomatous disease
- Cholelithiasis (gallstones)
- Small cyst or biliary hamartoma in the liver
Clinical Implications
The presence of pulmonary infarction is often associated with pulmonary thromboembolism, but can also occur with other disorders such as vasculitis, angioinvasive infections, sickle-cell disease, tumor embolism, and pulmonary torsion 2. The findings of healed pulmonary granulomatous disease and cholelithiasis suggest a history of inflammatory or infectious processes.
Diagnostic Considerations
Pulmonary CTA is a reliable means of excluding or diagnosing PE, and continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality 3. The use of clinical prediction rules, such as the Wells score and revised Geneva score, can help identify patients with a high probability of PE and guide the appropriate use of pulmonary CTA 4.
Prognostic Implications
Survival after diagnosis of pulmonary infarction is comparable to uncomplicated pulmonary embolism, suggesting that outcome is not worse 5. However, the presence of underlying risk factors, such as history of malignancy and surgery within 30 days, can affect patient outcomes.
Radiologic Findings
The CTA scan findings are consistent with pulmonary infarction, which can present as solitary or multiple nodules/masses of undetermined etiology 2. The non-calcified 4mm middle lobe nodule may require further evaluation to determine its significance. The small cyst or biliary hamartoma in the liver is likely an incidental finding.