What does the X-Ray show? 🫁 Multiple Pulmonary Nodules: Approach & Case Breakdown When finding multiple bilateral pulmonary nodules on a chest radiograph, I always follow one simple rule: treat as metastatic disease until proven otherwise Here is how to approach the differential and next steps: 1. Primary malignancies to think about Breast carcinoma Colorectal carcinoma Renal cell carcinoma (RCC) Melanoma Sarcoma 2. Non-Malignant differentials The list is long but some options to consider depending on the clinical picture: Atypical/fungal infections Septic emboli Sarcoidosis Granulomatosis with polyangiitis (GPA/vasculitis) 3. Distinguishing Factors ➡️Distribution & Size: Hematogenous metastases present with variable-sized, bilateral nodules which can be randomly distributed but can be lower lobe oredominant ➡️Imaging Features: Check the size (miliary nodules measure 1-3 mm and carry their own differential), look out for cavitation (seen in squamous cell carcinoma mets, GI primaries, or septic emboli) ➡️Clinical Context: Acute fevers point toward infection/septic emboli, whereas history of malignancy heavily favours metastases 4. What to Do Next? CT Chest/Abdomen/Pelvis: next step to find the primary, tumour burden and guide any tissue sampling. Tissue Sampling: Biopsy of an accessible pulmonary nodule or suspected primary lesion for histological confirmation - in this case a radiologist biopsied a lung nodule with ultrasound 5. Case Focus: Pancreatic adenocarcinoma While breast, colon, RCC, and melanoma top the statistical frequency list for lung metastases, pancreatic carcinoma can present with widespread hematogenous spread ➡️Key CT Findings: Low attenuation mass in the pancreas with possible upstream pancreatic ductal dilation/cutoff, double duct sign (dilatation of both main pancreatic duct and common bile duct), encasement of mesenteric vessels and associated retroperitoneal lymphadenopathy ✅Patient consent obtained 👉17000+ people have already downloaded my free CXR signs PDF: get it for yourself before it goes by tapping on the link in bio @theradiologistpage - @theradiologistpage