Correct!
1. The nodules at chest radiography are associated with a tubular configuration
The nodules seen on the presentation chest radiograph have sharply circumscribed margins where the margins are visualized (see the lateral projection of Figure 1 in particular); the margins are not spiculated. There is no clear evidence of increased attenuation within the nodules to suggest the presence of calcium within the opacities. The nodules show acute angles where they contact the pleural surface- this morphology is been seen for the right middle lobe nodule on the lateral projection of Figure 1, where the anterior margin of the lesion can be seen to approach the posterior cortex of the sternum. In general, when a parenchymal opacity forms an acute angle with the pleural surface, a parenchymal location, as opposed to an extraparenchymal location (such as a pleural or chest wall location), is favored. This contrasts with the obtuse angle typically formed between a lesion and the adjacent chest wall when the lesion resides in an extraparenchymal position. The nodules are located peripherally- the right middle lobe lesion is even frankly subpleural- and hence gas trapping, which would manifest with hyperlucency peripheral to the nodule- is not seen. The nodules, particularly the right middle lobe lesion, are associated with a faintly visualized tubular morphology- see Figure 2.
Figure 2. Detail image of the lateral chest radiograph shown in Figure 1 shows the circumscribed subpleural right middle lobe nodule (arrow); note how nearly the entire circumference of the nodule is visualized, and that the anterior margin of the lesion makes an acute angle (see angle) with the pleural surface / anterior chest wall, typical of a lesion located within the lung parenchyma. A faintly visualized tubular opacity (arrowheads) is seen extending towards the nodule.
Which of the following courses of action is the most appropriate next step for the management of this patient? (Click on the correct answer to be directed to the fifth of ten pages)