Interpret the non‑contrast chest computed tomography findings—including thyroid gland, hilar region, mediastinum, thoracic aorta, pulmonary arteries, heart and pericardium, coronary artery calcifications, breasts, axillary nodes, thoracic esophagus, and limited upper abdominal view—and advise the appropriate next imaging or management steps.

Interpretation of Non-Contrast Chest CT Findings and Next Steps

This non-contrast chest CT is severely limited for evaluating critical structures—particularly the hilum, mediastinum, and vascular anatomy—and a contrast-enhanced CT chest is mandatory to exclude life-threatening pathology such as malignancy, vascular complications, or mediastinal masses.

Critical Limitations of Non-Contrast CT

The report explicitly states multiple areas that "cannot be adequately assessed" without intravenous contrast, creating dangerous diagnostic blind spots:

• Hilar masses and lymphadenopathy are not evaluable, potentially missing lung cancer or metastatic disease 1
• Mediastinal lymphadenopathy and masses cannot be characterized, risking missed lymphoma, thymoma, or other mediastinal neoplasms 2
• Breast masses and chest wall masses are inadequately assessed, potentially delaying breast cancer or soft tissue tumor diagnosis 1
• Thoracic esophagus is decompressed and non-evaluable, precluding assessment of esophageal pathology 1

Findings That Require Action

Coronary Artery Calcifications

The presence of coronary artery calcifications on this non-contrast CT indicates underlying atherosclerotic disease and warrants cardiovascular risk stratification. 2

• Coronary artery calcification (CAC) should be reported using either visual assessment (none, mild, moderate, heavy/severe) or Agatston scoring if software is available 2
• CAC is present in 41-53% of patients over 40 years on chest CT and correlates with coronary heart disease risk 2
• Heavy or severe CAC should prompt further cardiovascular evaluation and aggressive risk factor modification 2
• The Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology recommend reporting CAC in all patients regardless of scan indication 2

Calcified Atherosclerotic Plaques in Thoracic Aorta

Thoracic aortic calcifications indicate systemic atherosclerosis but do not directly predict hemodynamically significant stenosis in the visualized segments. 3, 4

• Atherosclerotic thoracic aortic calcification (TAC) begins in the intima with patchy distribution and is common in patients with cardiovascular disease 3
• The aortic arch and proximal descending aorta are particularly vulnerable sites, concentrating approximately 60% of calcifications 5
• TAC provides limited incremental discriminative value as an incidental finding and does not currently support dedicated screening 3
• However, the presence of both CAC and TAC suggests diffuse atherosclerotic disease requiring comprehensive cardiovascular risk management 6, 4

Normal Findings

• Thyroid gland unremarkable: No action needed 1
• Thoracic aorta normal in caliber: Rules out aneurysm (ascending aorta >5.0 cm, descending >4.0 cm would be aneurysmal) 2, 7
• Pulmonary arteries grossly normal: No evidence of pulmonary artery dilation 2
• Heart not enlarged, no pericardial effusion: No acute cardiac pathology 2
• No suspicious axillary lymph nodes by size criteria: Limited reassurance given lack of contrast 1
• No acute findings in upper abdomen: Within the severe limitations of partial imaging 1

Mandatory Next Steps

Immediate: Contrast-Enhanced CT Chest

Order a contrast-enhanced CT chest (with IV contrast) to definitively evaluate all the inadequately assessed structures. 1, 7, 8

Specific indications for contrast CT include:

• Evaluation of hilar and mediastinal lymphadenopathy: Contrast enhancement is essential to differentiate normal vascular structures from pathologic lymph nodes and masses 1
• Assessment of mediastinal masses: Contrast allows characterization of thymic lesions, lymphoma, germ cell tumors, and other mediastinal pathology 2
• Breast and chest wall evaluation: If clinical concern exists, dedicated breast imaging (mammography/ultrasound) is more appropriate than CT 1
• Vascular assessment: Contrast CT provides near 100% sensitivity and 98% specificity for thoracic aortic pathology and allows complete evaluation of pulmonary arteries 7, 8

Clinical Correlation Required

The ordering clinician must provide clinical context to determine urgency:

• Respiratory symptoms, unexplained weight loss, or constitutional symptoms: Urgent contrast CT within 24-48 hours to exclude malignancy 1
• Chest pain or dyspnea: Consider cardiac evaluation given coronary calcifications; may warrant stress testing or coronary CT angiography 2
• Routine screening or asymptomatic: Contrast CT can be scheduled electively but should not be deferred indefinitely 1

Cardiovascular Risk Management

Given the documented coronary and aortic calcifications, initiate or optimize:

• Aggressive risk factor modification (hypertension, hyperlipidemia, diabetes control) 2
• Preventive pharmacotherapy (statin therapy, antiplatelet agents as appropriate) 2
• Consider referral to cardiology if heavy/severe CAC or if patient has cardiac symptoms 2

Common Pitfalls to Avoid

• Do not assume "unremarkable" structures are truly normal when the report explicitly states limitations due to lack of contrast 1
• Do not rely on size criteria alone for lymph nodes without contrast enhancement, as metabolically active normal-sized nodes can harbor malignancy 1
• Do not dismiss coronary calcifications as incidental—they represent atherosclerotic burden and predict cardiovascular events 2, 3
• Do not order another non-contrast CT—it will have the same limitations; contrast is required for definitive evaluation 1, 7, 8
• Do not delay contrast CT in symptomatic patients—a normal chest X-ray or limited non-contrast CT does not exclude serious pathology 1