Dr. Pepe’s Diploma Casebook: Case 42 – SOLVED!


Dear Friends,

To continue reviewing basic chest patterns, I present the case of a 52-year-old man with a solitary pulmonary nodule.


1. Probably malignant
2. Probably benign
3. Indeterminate
4. Need previous films

Check the images below, leave your thoughts and conclusion in the comments section and come back on Friday for the answer.

52-year-old man with a solitary pulmonary nodule

52-year-old man with a solitary pulmonary nodule

52-year-old man with a solitary pulmonary nodule

52-year-old man with a solitary pulmonary nodule

Click here for the answer

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    17 Responses to : Dr. Pepe’s Diploma Casebook: Case 42 – SOLVED!

    1. genchi bari italia says:

      Opacità nodulare a contorni irregolari, dendritici con area di ground-glass( da linfangite carcinomatosa):nodulo maligno sino a dimostrazione contraria (3)

    2. Bahnassy says:

      The right upper lobar nodule has definitely irregular spiculated outline and surrounded by GG opacity(Halo sign)The size looks around 10-15 mm diameter (50% possibility )of malignancy.
      Advice previous films if present or follow up within 1 and 3 months if there is increase in diameter by 0,26 % (doubling time for the volume )after 1 month it is likely infection (?fungal as invasive aspergillosis )/or TB) after 3 month it is most likely malignant and should be biopsied.
      NB : PET/CT can help if no metabolic activity it is benign..if there is activity it can be either infection or malignat.

    3. Mark says:

      I think in this case the first step should be a comparison to previous films to determine if the nodule is new or old. If the nodule is old, it’s important to determine if the nodule is getting larger. If getting larger, this could be suggestive of a malignancy depending on how much time has passed between the two radiographs. Therefore, if the question is “what is the best next step?” I would answer #4 – need previous films. Subsequently, CT shows an irregular spiculated mass in the periphery of the right lung without cavitation or internal calcifications. This could be suggestive of adenocarcinoma. However, there is no way to be 100% sure without biopsy, therefore, answer #3 – indeterminate – would be the best answer.

    4. I Rehman says:

      Right upper zone opacity with irregular margins and a possible satellite in right lower zone, likely malignant. Tissue diagnosis can be obtained under CT guidance. No adenopathy is appreciable on plain film/single CT slice. No effusions.
      Left lung is clear.

    5. genchi bari italia says:

      Mi scuso per la errata numerazione: la risposta è il numero1.Nodulo probabilmente maligno sino a prova contraria

    6. Alberto Montemayor says:

      Se observa una opacidad nodular de bordes irregulares y patron dendritico sin calcificacione ni cavitacion en el lobulo superior derecho. Ademas se identifica otro nodulo mas pequeño de forma redonda en la base pulmonar derecha, sin calcificaciones. Tambien se observa atelectasia del lobulo inferior izquierdo con desplazamiento inferior del hilio izquierdo y opacidad triangular retrocardiaca. Por todos estos datos no se descarta que existan metastasis pulmonares.

    7. Katerina says:

      According to the ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) (http://journal.publications.chestnet.org/article.aspx?articleid=1211609),

      1.In every patient with an SPN that is visible on CXR, we recommend that previous CXRs and other relevant imaging test be reviewed. Grade of recommendation, 1C.
      2. In patients who have an SPN that shows clear evidence of growth on imaging tests, we recommend that tissue diagnosis be obtained unless specifically contraindicated. Grade of recommendation, 1C.
      3. In a patient with an SPN that is stable on imaging tests for at least 2 years, we suggest that no additional diagnostic evaluation be performed, except for patients with pure ground-glass opacities on CT, for whom a longer duration of annual follow-up should be considered. Grade of recommendation, 2C

      So,regardless of the probably malignant appearance of the nodule I choose
      4. Need previous films

    8. András says:

      Just looking at these two images: probably malignant. Quite large with spiculated margins.

    9. gus says:

      We can see a peripheral nodulal opacity with spiculated margins and ground-glass infiltration with satelite centolobular nodules.We see apical caps too.
      Could be a tb?… but we need to compare with previous films to exclude the malignacy (that is important).
      i would like too see the profile view first.
      The nodules of the lung bases i think is the breasts nipples.

      • gus says:

        (i think centrolobular is wrong):)
        A HRCT is indicated to characterize the nodule and the infiltrations of the lung before biopsy.

    10. Pat says:

      My answer is 1 probably malignant.

      In the chest x-ray shows 2 NP´s The big one in the Right Upper Lobe and the small one in Right Lower Lobe. Also shows caudal retraction of the right pulmonar hilum (atelectasis) and in the left lower lobe a trinagular opacity.

      On the CT the NP has a “corona radiata” and ground glass sorrounding, malignant characteristics.

      So in conclusion, in a man over de >50 years old, with 2 NP´s in the chest x´ray and with non bening morphology characteristics on the CT. My first choice is to think in probably malignant.

    11. cornelia gherghe says:

      du fait des characteristiques radio et CT (contour, dimensions, densité – pas de cavité central -), mesieur, age, plutot malign. mais tout ca devrait etre evoquer aussi en fonction de la clinique (symptomes, durée, etat generale, antecedent perssonnel et en famille etc).

    12. Ibrahim says:

      Findings: Spiculated nodule surrounding by patchy ground glass is seen in the anterior segment of RUL peripherally.
      The best answer is No.4; need previous film …..why?
      Because the Pt.Age is > 30 to see if there is increasing in size ==> biopsy or not ==> follow up.
      If previous films are not available ==> HRCT Chest to see if there is benign/malignant calcification or fat and so.
      Finally, I think this is a malignant bx the age,irregular border and peripheral location.
      One thing more on PA-CXR there is Lt.Retrocardiac opacity but there is no Lat.View to rule out LLL collapse.

    13. Dr. Pepe says:

      Most of you are offering sensible discussions about the approach to solitary pulmonary nodules. Congratulations and wait for the answer on Friday.