Correct!
4. CT pulmonary angiography

Enhanced thoracic MRI is useful for cardiovascular disease assessment, the evaluation of chest wall masses, and characterization of mediastinal masses, but the rather poor signal typical of the pulmonary parenchyma at MRI renders this modality less suitable than CT for pulmonary nodule evaluation, as discussed previously. 68Ga-Dotatate scanning is usually employed for neuroendocrine malignancy detection and staging, which may ultimately prove useful in this patient should that diagnosis be established, but that diagnosis is probably unlikely given the morphology of the pulmonary lesions seen at chest radiography. 18F-Fluciclovine (anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid) scanning is an amino acid tracer used for the detection of recurrent prostatic malignancy, typically after therapy when elevated prostatic specific antigen levels are detected. This tracer has the ability to image prostatic malignancy because prostatic malignancies are associated with over-expression of several amino acid transporter systems, and has advantages over 18FDG-PET scanning for prostatic carcinoma detection because hormone-naïve prostate carcinomas are often associated with low glucose metabolism and the 18F-Fluciclovine tracer has lower urinary excretion compared with the 18FDG-PET tracer (which allows improved visualization of pelvic organs, such as the prostate gland). Bronchoscopy with transbronchial biopsy may prove necessary during the course of this patient’s evaluation, but is premature at this point; typically this procedure is more rewarding following characterization of pulmonary opacities with CT scanning. CT scanning, in this case with a CT pulmonary angiogram protocol, is the correct choice.

The patient subsequently underwent thoracic CT pulmonary angiography (Figure 3) for further characterization of the pulmonary nodule seen at chest radiography.

Figure 3. Left A-F: Axial enhanced thoracic CT performed using a CT pulmonary angiography protocol. Right video of thoracic CT scan.

Regarding the thoracic CT, which of the following statements is most accurate? (Click on the correct answer to be directed to the sixth of ten pages)

1. The thoracic CT shows that the nodule seen at presentation chest radiography is associated with vessels
2. The thoracic CT shows that the nodule seen at presentation chest radiography is associated with cystic change
3. The thoracic CT shows that the nodule seen at presentation chest radiography displays the “reverse halo” or “atoll” sign
4. The thoracic CT The thoracic CT shows that the nodule seen at presentation chest radiography is associated with a surrounding ground-glass opacity “halo”
5. The thoracic CT The thoracic CT shows that the nodule seen at presentation chest radiography is cavitary

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