Incidental pulmonary nodules during cardiac exploration

Patient data

A male patient known to have persistent atrial fibrillation and multiple cardiovascular risk factors comes to the emergency department complaining of the following signs and symptoms: fatigue, dyspnea, palpitations, all of which started suddenly.

Case discussion

Following the automatic analysis of the routine radiograph by the Rayscape algorithm, a nodular tissue formation with spiculated edges, located in the region of the upper right lung lobe, is detected. Doctors are notified of the need for further exploration.

After the visualization by the radiologist of the X-ray, a round-oval, non-homogeneous opacity of approx. 20mm, located in the upper area of the right lung, is identified. Additional exploration with CT is recommended. The scan is automatically passed through the Rayscape algorithm, and it identifies the following:

27x20x17mm spiculated nodular formation located in the posterior segment of the right lung lobe, with minimal pleural signs (aspect suggestive of a malignant primary tumor)
multiple pulmonary nodules in both pulmonary fields, with variable sizes, the largest having the diameter of 7mm

The CT scan is further analyzed by the radiologist and he additionally identifies:

signs of bilateral apical centrolobular emphysema
thickening of the bronchial wall at the hilar and perihilar level
fibrous thickening at the level of the medial segment of the right middle lobe
moderate degenerative changes at the level of the examined bone segment
osteosclerosis lesion of approx. 14 mm at the level of the right VII rib

The patient is referred for a multidisciplinary surgical and oncological consultation. This is an example of a case where the pathology of a patient is signaled by the algorithm during a simple routine exploration, which could go unnoticed.

More info:

Finding out if a lung nodule is malignant or benign is the main goal of the diagnostic procedure. The nodule’s development rate can be used as a reliable indicator of the difference. Benign nodules rarely grow in size. In comparison, malignant nodules might grow by a factor of two every four months on average (some as quickly as 25 days, some as slowly as 15 months). A sequence of X-rays or CT (computed tomography) images taken over a period can be used to assess the growth rate.

The second most reliable approach to tell if it is malignant or benign is evaluating a nodule’s calcification. Nodules that are benign have a tendency to be more uniformly colored, smoother, and more consistently formed. Nodules that are cancerous are much more prone to have asymmetrical forms, rougher surfaces, and varying colors or spotted patterns like granular, punctate or reticular patterns of calcification.

An imaging finding of calcification in a lung nodule suggests that the lesion is likely benign. However, not all calcified pulmonary nodules are benign, and main central lung carcinoid, metastasis, and primary bronchogenic cancer are among the differential diagnoses. The ability to identify calcification in malignant tumors is now more sensitive because to the widespread use of computed tomography.

The primary radiographic characteristic is that lung nodules are often homogenous and well-defined, because of their sharp borders with normal aerated lung parenchyma surrounding them. Lung nodules may be solitary or multiple. To be considered solitary, a nodule must be completely surrounded by normal lung parenchyma, without associated atelectasis, enlargement of the hilum, or pleural effusion.

X-rays or CT scans often give enough details to make an accurate diagnosis. The nodule’s cells might be collected by medical professionals for a biopsy. Using a needle or by conducting local surgery, cells can be isolated and, in addition with a patient’s sputum analysis, it might offer more reliable information.

References:

3. Ost D, Fein AM, Feinsilver SH (June 2003). "Clinical practice. The solitary pulmonary nodule". The New England Journal of Medicine. 348 (25): 2535–2542. doi:10.1056/NEJMcp012290. PMID 12815140

4. https://xvision.app/blog/2022/07/27/evaluation-of-patients-with-pulmonary-nodules/