Multiple Pulmonary Nodules and Masses in an Asymptomatic Patient

The incidental detection of abnormalities at screening thoracic imaging examinations performed in asymptomatic patients, such as lung cancer screening with computed tomography or computed tomographic coronary artery calcium scoring for cardiac risk stratification, is a common event. Most such abnormalities, while often indeterminate, are nevertheless of no significance and can be approached conservatively. The detection of multiple nodules and masses in the screening setting is exceptional and usually mandates an aggressive approach toward establishing the diagnosis. Leading diagnostic considerations for such a presentation include granulomatous infections, rare nonmalignant proliferative disorders, and lymphoproliferative diseases. Lymphomatoid granulomatosis (LYG) is a rare, Epstein-Barr virus-driven angiodestructive malignant B-cell lymphoproliferative disorder that is often associated with immunosuppression, preferentially affects men and often manifests in the fifth and sixth decades of life. LYG is commonly characterized by a relapsing course, but may transition to a frank, malignant, high-grade lymphoma and can prove fatal. The lungs are the most commonly affected organ in patients with LYG, with the skin and nervous system also being frequently involved. Thoracic imaging findings in patients with LYG are nonspecific, but typically show multiple variably sized nodules and masses, occasionally with an appearance suggesting infarction, and showing tracer uptake at ¹⁸fluorodeoxyglucose-positron emission tomography, with the bulky lymphadenopathy characteristic of lymphoma noticeably lacking in patients with LYG. The diagnosis of LYG is made through tissue sampling, and may be performed through a minimally invasive approach, but often ultimately requires surgical biopsy. Treatment of LYG focuses on combination chemotherapy, anti-B-cell-targeted therapy, and interferon α-2 therapy.