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CT Chest Nodule

INDICATION: COPD with reactive airway disease and history consistent with with wood working hypersensitivity pneumonitis.

TECHNIQUE: Axial 0.625mm CT images were obtained through the thorax without intravenous contrast administration. 1.25mm lung and 5mm soft tissue axial reconstructions were generated. Additional images were reconstructed in the coronal and sagittal planes. Axial MIP reconstructions were also generated. With the patient in prone position 1.25 mm, skipped 9 mm axial CT images were obtained with patient in both inspiration and expiration.

Pulmonary artery and thoracic aorta: Other than vascular calcifications in the aorta the pulmonary artery and thoracic aorta are normal with respect to size and position. Calcifications are noted in the visualized portion of the great vessels.

Heart: Normal in size and and location with no pericardial effusion or abnormal pericardial thickening. Significant to severe coronary artery calcifications are demonstrated.

Mediastinum: There are shotty mediastinal lymph nodes with the largest measuring approximately the 18 mm in its longest dimension in the AP window. The left however have normal morphology. No masses.

Lungs: The lungs are significant for primarily the moderate centrilobular emphysematous changes. Some paraseptal emphysematous changes are also noted. There are a few scattered small lung nodules however most are smaller than 4 mm and some are calcified. A 6 mm subpleural solid nodule is
noted in the right lower lobe and is best seen on series 4 image 86. A 4 mm nodule is noted in the right mainstem bronchus and is of unknown significance. Parenchymal bands and subpleural bands are noted consistent with mild scarring. There is moderate air trapping demonstrated on the expiratory view. No pleural effusions. No pneumothorax or pneumomediastinum.

Axilla: No enlarged lymph nodes.

Chest wall: Unremarkable.

Osseous Structures: Mild degenerative changes are noted in the bony structures.

Upper Abdomen: Gallstones are noted with a possible right common bile duct stone. Calcifications are noted in the aorta. The visualized portion of the spleen, pancreas, liver and the bilateral kidneys are unremarkable. No evidence of adrenal masses. No abnormal lymphadenopathy. Visualized abdominal vascular structures are unremarkable.

Lower Neck: 11 mm nodule is noted in the inferior portion of the left lobe of the thyroid. There is no evidence of significant supraclavicular lymphadenopathy.

1. Moderate emphysematous changes.
2. 6 mm right lower lobe subpleural lung nodule and shotty mediastinal lymph nodes.
3. 4 mm nodule in right mainstem bronchus which may be retained secretions however cannot rule out small mass.
4. Moderate air trapping consistent with small airway disease. The differential diagnosis would include reactive airway disease.
5. Severe coronary artery disease. Mild to moderate atherosclerotic vascular disease.
6. Gallstones and possible common bile duct stone.
7. Thyroid nodule, recommend correlation with physical exam and laboratory findings.

Recommendations: Recommend CT followup in 6 to 12 months.

Fleischner Society Recommendations:
Nodule Size Low Risk High Risk
<=4mm No follow up needed CT chest 12 months: If unchanged no f/u
4-6mm CT chest 12 months CT @ 6-12 months
If unchanged no f/u then at 18-24 months
6-8mm CT @ 6-12 mths CT 3-6mths
then 18-24mths then 9-12mths and 24mths
>8mm CT @ 3,9,24mths or PET/CT or Biopsy