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Let's take a look at a lung cancer screening CT

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with a comparison examination

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and how we approach some of the findings,

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whether they're lung nodules

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or other incidental findings in the lung parenchyma

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or cardiovascular structures.

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So here I have just my basic layout when I'm opening up a

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lung cancer screening CT

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that has comparison exam on the bottom.

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So I've got the current exam in the top row

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and my comparison images in the bottom.

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On the bottom. I also have my nodule detection tool from the

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current exam, which is showing me

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that it looks like there's a pulmonary nodule

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and we'll get into the details of that.

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And I have my emphysema detection tool also on the bottom

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right that's calculated using a density threshold

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of minus 950 hounds field units and lower.

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When I'm scrolling through the exam,

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sometimes the images don't line up just

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perfectly one-to-one.

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So I might take a minute to pause

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and adjust to make sure

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that the images are actually anatomically lined up,

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which just makes it a little bit easier when you're looking

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for nodules and trying to compare them.

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So I basically start looking at the lung parenchyma on the

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lung windows, looking both for lung nodules as well

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as important lung findings

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we're already seeing in the top of the lung.

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Some mild central lobular emphysema,

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low density holes without walls.

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We're seeing a little bit of paraseptal emphysema up at the

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apices here as well.

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Little bleb like cystic structures along the

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paraseptal pleural space.

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As I'm scrolling through the lungs, I like

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to take a quadrant approach.

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It's hard to focus your eyes on the entire field of view

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and we wanna do a good job at looking for pulmonary nodules.

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Many people take a quadrant approach where they scroll up

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and down the lungs, looking at the anterior portion

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of the right lung, and then may scroll back up looking at

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the posterior half of the right lung.

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And similarly may look at the anterior portion

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of the left lung and then the

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posterior portion of the left lung.

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But paying attention and focusing on each quadrant

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of the lung helps you in tactically identifying pulmonary

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nodules rather than looking at the whole image

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in a gestalt pattern.

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We can of course, always switch to the MIPS

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as we're looking at the images if we find something.

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Or we can use the MIP images to help us find something,

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as I found just right here between these vessels.

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And then switch out

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of MIPS directly into the thicker section images

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that don't have the MIPS on them.

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So I interact between the MIPS

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and the thin sections regularly scrolling through the MIPS

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to help find nodules and then characterize the

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nodules on the thinner slices.

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And here we see, uh, nodule in the left upper lobe.

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It's relatively central,

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which can make it a little bit harder

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to see when it's juxta vascular.

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This nodule measured about eight by six millimeters,

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so this is going to be an abnormal screen.

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An eight by six millimeter nodule is seven

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millimeters in mean diameter.

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So that's gonna make this a Lung-RADS category

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three solid nodule.

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And we're gonna recommend a follow-up CT in, uh,

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six months is an interval check on this nodule.

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The first time we find it, if we have comparison exams,

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we're certainly gonna look at them

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and we pull up the comparison exam on this patient,

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which was from a, a year ago.

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It was their lung cancer screen from a year ago.

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And here's that same nodule,

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but it was smaller so it's getting a little bit bigger.

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It's still in the same category of lung RADS three.

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And we're gonna do a check on that nodule in six months

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to see if it's continuing to grow

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and reaches a side threshold at which

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we're going to intervene.

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So we found emphysema.

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We found a lung nodule so far looking at the small airways

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and they are abnormally thickened

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circumferential thickening of the airway.

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So this patient has a combination of mild emphysema

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and airway predominant COPD.

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We're increasingly recognizing that airway while thickening

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and even small mucus plugging, increases patient's morbidity

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and mortality from COPD.

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So it's becoming more and more important that we identify

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and report these findings.

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We're gonna look at the soft tissue windows looking

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for incidental findings.

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We have a little bit of atheros calcification in the aortic

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arch, not uncommon at the age

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and pack your history of somebody

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who's been smoking cigarettes.

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We're gonna look for coronary arterial calcification.

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We see moderate coronary calcification using a

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visual scoring system.

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We also identify lipomas hypertrophy of the atrial septum

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and increased epicardial fat.

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We see it in the atrial septum here.

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We see it more coddly around the coronary sinus

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and we see it along the surface of the heart.

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This is increasingly recognized as a risk factor

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for cardiovascular disease, including coronary disease

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and coronary events as well as atrial arrhythmias.

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Then we're gonna make sure we look at those sagal images,

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making sure that we look for any evidence

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of compression fractures

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or bone mineral density abnormalities,

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which increases a patient's risk when they have lung disease

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of having pneumonia and requiring hospital admission

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and is associated itself

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with increased morbidity and mortality.

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And here we're seeing that the bone mineral density is

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measured at the L one vertebral body

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is a hundred household units.

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So that would meet the threshold for osteoporosis.

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So in summary, and this patient has come

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for lung cancer screening, we found a lung nodule,

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which has slightly grown since the prior year,

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making it a lung RADS three nodule will bring the patient

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back for interval CT at low dose in three months.

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We have found cardiovascular disease in the form

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of coronary arterial calcification, moderately severe,

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and other findings which increase cardiovascular risk,

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the epicardial fat.

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And then we've also found osteoporosis

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with abnormal bone mineral density.

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The cardiovascular findings

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and the bone mineral density findings would be considered

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significant in central findings

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that if the first time they're detected should warrant

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investigation and potential treatment

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opportunities for our patients.

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And we would make those s modifier findings in our lung

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cancer screening report.

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If you've seen them before in a prior exam

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as we did in this case, they're no longer

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new incidental findings.

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They're findings that have been reported before.

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You may put them in the impression of your report,

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but they don't qualify as a new S finding.

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And so you wouldn't use the S modifier if you already know

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about these findings from the past.