0:00

Let's take a look at this lung cancer screening ct.

0:04

As we're scrolling down the lungs, we're starting

0:07

to see a very kind of a ratty irregular interface

0:10

between the lung parenchyma

0:12

and the pleural surface, which normally is purely smooth.

0:15

So let's hold that thought as

0:16

we continue to look at the exam.

0:18

And now coming into the lungs at the level

0:22

of the Arctic arch, we're seeing in the superior segment,

0:25

uh, the left lower lobe just behind the major fissure.

0:27

We're seeing this area of ground glass opacity.

0:31

It's not really round or ovoid.

0:33

It looks almost geographic or angular in shape.

0:36

It has a large surface along the pleural surface

0:39

and almost looks like a little bit

0:40

of a wedge shape in some areas.

0:42

So like a subsegmental area of ground glass opacity.

0:47

And then as we continue to come down the lungs,

0:50

we can see more of this subpleural reticulation.

0:52

There's more of it than we saw up higher.

0:54

There's a little bit of traction bronchiectasis

0:57

and there may even be a couple little honeycomb cysts right

1:00

here in the anate upper lobe.

1:03

And as we continue to scroll down the lung, we see more

1:06

of the subpleural reticulation

1:09

and it's most severe in the lower lobes.

1:12

Here we see some patchy ground glass o passy as well.

1:15

We almost see a bit of a mosaic attenuation pattern

1:18

as if perhaps the patient didn't take in a full inspiration.

1:22

So we might have a little bit of air trapping.

1:25

So we've got some evidence of fibrotic,

1:27

interstitial lung disease, subfloor, reticulation,

1:29

couple little honeycomb cyst, little traction bronchiectasis

1:32

suggesting this patient has pulmonary fibrosis.

1:35

But what's concerning in the lung cancer assessment is this

1:38

geographic area somewhat wed shaped

1:41

of ground glass in the left lower lobe superior segment.

1:45

We can look at it in different views

1:48

to get a better idea of its shape.

1:50

And so let's look at the coronal images for example.

1:55

And we can see it right here.

1:56

Again, it's almost like a wedge-shaped

1:58

or geographic area of ground loss.

2:00

It's very focal and confined.

2:02

And then we can see this evidence of subpleural middle,

2:05

lower lung predominant reticulation, um,

2:08

and evidence of fibrotic interstitial lung disease.

2:12

So next up we're gonna look, you know,

2:14

are there any comparison exams that's really important

2:16

to understand the behavior And this person had had a CT

2:20

chest with contrast approximately three months earlier

2:24

and we can see the same area

2:26

of ground glass in the same area of the lung.

2:30

You try then compare them side by side.

2:34

They look about the same.

2:36

Don't see any new solid nodular component given the size

2:41

of this geographic area

2:42

of ground glass opacity on the current screening exam.

2:46

This is over the 30 millimeter size threshold

2:49

that differentiates category two

2:51

and category three and lung rads.

2:52

So this would be a long RADS three interpretation

2:56

and categorization of this patient's exam

2:59

Along RAD three would be recommended

3:01

to have a follow-up CT in six months using a low dose nodule

3:05

protocol to look for, uh, growth versus a decrease in size

3:10

or the detection of any new solid component.

3:13

The lack of change in the short term

3:16

from three months in the prior exam is not sufficient time

3:19

for us to make that assessment as

3:22

to whether there has been any interval growth or not.

3:24

Given the fact that there is evidence

3:26

of fibrotic interstitial lung disease,

3:28

we know these patients are at increased risk

3:31

for developing lung cancer.

3:32

So that's gonna increase the likelihood of this patient has

3:36

lung cancer compared to a patient

3:38

who doesn't have fibrotic interstitial lung disease.

3:40

So we're gonna definitely wanna make sure

3:42

that this patient understands the risk of this being

3:45

a cancer and make sure they come back for

3:47

that interim six month low dose ct.

3:51

The other thing that can be done, given

3:53

that it looks somewhat subsegmental

3:55

and geographic, is to consider a short course of antibiotics

4:00

before that next CT is done

4:02

because of this is an area of infection

4:04

that could be treated even if it's clinically asymptomatic,

4:07

uh, that can help resolve it and

4:09

therefore resolve the issue of this being, uh,

4:12

potential adenocarcinoma of the lung.

4:15

So evidence of fibrotic interstitial lung disease increases

4:18

the likelihood of a patient having lung cancer

4:21

and of course patients should be evaluated

4:23

with pulmonary function tests

4:24

and consideration of a antifibrotic therapy.

4:27

Ground glass lesion, relatively geographic in shape,

4:31

somewhat atypical, not round or ovoid,

4:33

but meets that 30 millimeter size threshold

4:36

for being a lung rads.

4:37

Three patient should come back

4:38

for a follow-up low dose CT in six months

4:42

and consider a short course of antibiotics

4:44

before that occurs to make sure if there's inlet infection

4:47

that could be potentially treated

4:49

and resolve the issue as well.