How to correctly interpret pulmonary function tests? With the increasing prevalence of multiple pulmonary nodules, including simultaneous and metachronous multiple primary cancers, the choice of surgical approach in clinical practice faces significant challenges. Should all nodules be removed at once, or should the focus be on specific areas? Should the surgery involve lobectomy, segmentectomy, or wedge resection? If the pathology report indicates invasive adenocarcinoma, how should the decision be made? This is one of the reasons for the current confusion in the diagnosis and treatment of pulmonary nodules, especially multiple nodules. It seems that any approach is correct, supported by guidelines and consensus; yet, none seem correct, each appearing to have its own rationale, making the choice a dilemma. This case study shares our clinical approach to analyzing multiple nodules confirmed by surgery, for the reference of colleagues and fellow nodule sufferers. It is important to emphasize that our choices were made after thorough communication and careful consideration by the patient. Patient A, female, 54 years old, was admitted to the hospital due to bilateral pulmonary nodules discovered two years ago. Two years ago, lung nodules were discovered during a local examination. This year's examination report showed multiple ground-glass nodules in the upper lobe of the left lung, which had increased in size compared to June 2021; and multiple small nodules in the upper right lobe, which were similar in size to the previous scan. The patient then sought treatment at Hangzhou Cancer Hospital, affiliated with Zhejiang University School of Medicine. Let's first look at the imaging she had done at our hospital this year: Lesion 1: A ground-glass nodule appeared in the apex of the left lung, with a relatively clear outline. The lesion is close to the chest wall, and the pleura seems to be slightly affected. There is no gap between the lesion and the pleura, and the density is slightly uneven. The side closer to the pleura seems to have a slightly higher density component. There are microvessels running along the edge of the lesion (orange arrow). There is no gap between the lesion and the chest wall, and there is a slight pulling sensation. The lesion outline is clear, and the tumor-lung boundary is clear. Lesion 2: A light ground-glass nodule in the posterior segment of the left upper lobe, with a clear outline (lesion circled in pink). Microvessels entered lesion 1 (orange arrow), and the overall density is relatively high. Microvessels also entered lesion 2 (orange arrow), and the density is pure ground-glass. The outline and boundary are clear. Lesion 1 has a higher density. Blood vessels entered and passed through lesion 2 (thin orange arrow). The overall outline is clear, and the tumor-lung boundary is also clear. The appearance of the edge of lesion 1. Lesion 2 is obviously ground-glass density with clear boundaries, which is considered to be in the category of tumor. Lesion 2 shows the presence of microvessels (orange arrow), and the tumor border is clear. Lesion 3 appears (circled in orange), but it is very small, only about 2 millimeters.
