A 60 yo female presents with shortness of breath.  She is a poor historian, but reports weight loss, fatigue and progressive shortness of breath.  She was recently diagnosed with a "lung problem" at an outside hospital and began treatment but then was lost to follow-up.  She presents cachectic with tachycardia, tachypnea, hypoxia and she is afebrile. What's the diagnosis?  Scroll down for answer. 

Diagnosis: Large right upper lobe mass with atelectasis of the right upper lobe

Discussion:  The patient was subsequently found on CT to have a large right upper lobe mass compressing the right upper lobar bronchus as well as widely metastatic disease to bone, brain and liver.

While this image shows a large and obvious mass consistent with malignancy, this is a good opportunity to review incidental lung nodules found on chest xray.

Classification of solid lung nodules by size:

• miliary nodules: <2 mm
• pulmonary micronodule: 2-7 mm
• pulmonary nodule: 7-30 mm
• pulmonary mass: >30 mm

Follow up for incidental solitary pulmonary nodules is most commonly directed by the 2017 Fleischner Society Recommendations (guidelines do not apply to patients <35 years of age or with a history of cancer or immunosuppression).  “Risk” below refers to patient’s risk for malignancy:

Fleischner Society Recommendations 2017:

Solitary nodule size: <6 mm

• low-risk patients: no follow-up needed
• high-risk patients: optional CT at 12 months

Solitary nodule size: 6-8 mm

• low-risk patients: follow-up at 6-12 months, then consider further follow-up at 18-24 months
• high-risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change

Solitary nodule size: >8 mm

• either low or high-risk patients: consider follow-up CT at 3 months, and/or CT-PET, and/or biopsy

References:

MacMahon, H et al. “Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017.” Radiology.  2017Jul;284(1):228-243

Mortani Barbosa EJ, Jr., et al. "Modern  Approach to Thoracic Imaging Diagnosis." Fishman's Pulmonary Diseases and Disorders, Fifth Edition.  Michael A. Grippi, et al, eds. New York, NY: McGraw-Hill, 2015.