Correct!
3. The chest CT shows an indeterminate lesion in the right upper lobe
The enhanced chest CT shows a spiculated lesion with a pleural tail in the right apex. While the lesion shows some features associated with pulmonary malignancy- soft tissue, spiculation, and a pleural tail- the lesion also shows at least one feature suggesting a benign etiology- the presence of calcium. Note, however, while the presence of calcification within a pulmonary nodule is far more commonly associated with a benign etiology than a malignant one, the pattern of calcification (Figure 4), not the mere presence or absence of calcium, within a nodule, is a feature that has been regarded as an absolute indicator of a benign cause for a nodule at chest radiography (the other being clear evidence of nodule stability for more than 2 years).
Figure 4. Patterns of nodule calcification- illustrations and CT examples: Benign patterns of calcification within a solitary pulmonary nodule include diffuse, or homogenous, nodule calcification, central (“bull’s-eye”), laminar, or “target” calcification (presenting as concentric rings of calcification), and chondroid, or “popcorn,” calcification. When calcification is found within a pulmonary malignancy, it usually manifests in either a stippled or eccentric pattern; the latter is thought to result from a pulmonary malignancy engulfing a granuloma.
In this case, the patient’s nodule does contain calcium, which portends that the lesion is more likely benign than malignant (as does her relatively young age and lack of smoking history), but this observation alone is not an absolute indicator of benignity because some malignancies, such as neuroendocrine tumors, mucinous carcinomas, and cartilage or bone-forming metastatic lesions, may contain calcium or bone. Furthermore, while the nodule does contain central calcification, there is a substantial amount of non-calcified soft tissue, which renders the lesion radiologically indeterminate. The chest CT shows neither peribronchial nor mediastinal lymph node enlargement, and the lungs appear clear otherwise.
Which of the following represents an appropriate next step for the patient’s management? (Click on the correct answer to be directed to the ninth of thirteen pages)