0:00

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

0:03

This is again my typical layout.

0:05

So I have at my fingertips my axial mips,

0:08

which help us increase the detection for small nodules.

0:11

Have my lung windows, my bone, soft tissue windows,

0:15

and then I have my coronal and sagittals all my fingertips

0:17

and I can easily mag in

0:19

and out of any one of these as I'm finding abnormalities.

0:23

I can also use information to look at lung volume

0:25

and lung density analysis,

0:29

and I can confirm my radiation dose here is in the low

0:32

radiation dose range for an advertised patient.

0:35

So important things for me

0:36

to confirm when I'm looking at a case.

0:39

So as we're looking at this ct, starting at the lung apices,

0:42

we're already starting to see abnormality in the lungs.

0:46

We look at that a little bit closer.

0:47

We can see there's some diffuse ground glass

0:49

in the lung parenchyma.

0:51

It's in the upper lobes

0:52

and we can see some paraseptal emphysema here along the

0:56

fissure a little bit along the mediastinal pleural surfaces

0:59

going all the way up to the apex.

1:02

This paraseptal emphysema

1:03

or emphysema along the interlobular SEPTA

1:06

with this ground glass.

1:09

As we keep scrolling, we have a discrete thin walled cyst.

1:12

So this case is showing us a bevy of lung abnormalities,

1:14

a discrete thin walled incidental cyst, not a lesion

1:17

that's cystic and needs to be classified using lung rads.

1:21

And then we come into a part solid nodule here.

1:24

It's an atypical juxta pleural nodule.

1:27

We like to try and call intra pulmonary lymph nodes,

1:31

never possible to minimize the necessary workup.

1:34

The criteria of which is a solid nodule can't be parked

1:38

solid or ground glass that is along a pleural surface

1:41

with a broad base, whether it's the fial pleura,

1:44

the mediastinal pleura, the causal pleura along the ribs

1:48

or the diaphragmatic pleural surface.

1:50

And it has an angular shape or triangular morphology.

1:54

And if it's centered on a fissure, it might be by convex.

1:57

So this is technically a juxta pleural nodule.

2:00

The problem is it's not solid.

2:02

It has ground glass components and it has solid components.

2:05

That is not a criteria

2:07

for a juxta pleural benign int pulmonary lymph node.

2:10

We're also gonna measure it in both of its diameters to see

2:13

what it measures out.

2:15

Jux pleural nodules have

2:17

to be under 10 millimeters in diameter

2:19

to meet that criteria.

2:21

And with this one, if we average the mean

2:23

and max diameter that we're seeing here,

2:26

we're getting under 10 millimeters, mean diameter.

2:28

So it meets the size criteria for juxta pleural nodule.

2:32

It meets the pleural interface criteria,

2:35

but it's part solid

2:36

that is not a benign juxta pleural inter

2:39

pulmonary lymph node.

2:41

So again, we've got a part solid nodule masquerading

2:44

as a juxta pleural inter pulmonary lymph node.

2:46

So very important to apply all those criteria.

2:50

And as we keep scrolling throughout the lungs,

2:52

we see this irregular area here of some dilated bronchi.

2:55

There's bronchiectasis branching tubular structure

2:59

With some small areas of ATE impaction.

3:02

Patients who have a history of cigarette smoking can

3:04

certainly have different types

3:05

of lung disease including small airway disease

3:07

and bronchiectasis.

3:09

This can also be the results

3:10

of a prior pneumonia pulmonary infection.

3:14

And we see that ground gloss opacity we saw in the upper

3:18

lobe starting to peter out as we get to the lower lobes.

3:21

So we got a part solid nodule, which is a lung rads, three

3:24

by size criteria with a mean diameter

3:27

of about 8.5 millimeters.

3:29

And I measured the solid component at just

3:31

under six millimeters.

3:33

We have lung disease

3:35

and let's take a look a little bit closer at that.

3:38

The distribution of abnormalities is ground glass,

3:41

upper lobe predominant, which is classic

3:43

for respir respiratory bronchiolitis in an individual who is

3:47

actively smoking cigarettes as this individual was.

3:50

And we have paraseptal emphysema,

3:52

which we saw on the pleural surfaces, bronchiectasis

3:56

branching findings and we saw that benign cyst as well.

3:59

So a lot of findings.

4:01

The next step is we're going

4:02

to recommend appropriate follow-up for lung RADS three,

4:05

which is gonna be a follow-up CT in six months.

4:07

And depending on that, additional

4:09

recommendations will be made.

4:11

So here's a layout of serial CT exam on this patient,

4:14

beginning with a screening CT we just looked at on the

4:17

right, followed by a CT in October, 2021.

4:22

So, uh, we've moved on by six months between these exams,

4:27

the lung RADS three followup has not changed.

4:30

I'll try and match up those images.

4:32

Look across the nodule very carefully.

4:35

We then have a next CT in August of 2022.

4:39

This came a little bit earlier than going back

4:41

to annual screening at 12 months.

4:43

Sometimes patients used to come a little bit earlier

4:46

or a little bit later for their screening exams

4:48

and exactly on the 12 month calendar.

4:50

And the nodule is again unchanged.

4:53

And then on the far left, we have March 20, 24.

4:57

So we're almost three years from the initial CT

4:59

that we looked at on right, and the lesion is unchanged.

5:02

This is characteristic of a benign lesion,

5:05

benign biologic behavior.

5:07

We will of course continue to recommend annual screening

5:10

for CT for this patient and watch it closely,

5:13

but we can't just focus on the nodule that we know about

5:17

and watch that over time.

5:18

We have to look for other nodules too

5:20

and not just be drawn to that.

5:21

And if we look just very closely

5:24

in a short distance from the juxta pleural part,

5:26

solid nodule, this patient has now developed a

5:29

new solid nodule.

5:31

So don't get drawn into only looking at the nodules

5:34

that were there in the past, particularly the ones driving

5:36

your lung RADS three and four, A follow-up recommendations,

5:39

but still be very attentive to new nodules like this,

5:43

A new nodule that didn't exist

5:44

before of this size as a higher likelihood of malignancy.

5:47

And we're gonna now make sure we file this patient a little

5:50

bit more closely because we found that new nodule,

5:53

so they're now a new lung Rads three

5:55

because of the new finding.

5:56

And the recommendation would not be

5:57

to come back in six months.