Search Results (76)

Coronary artery calcification (CAC) is a hallmark of advanced atherosclerosis and a major determinant of procedural complexity during percutaneous coronary intervention (PCI). Once considered a passive consequence of vascular degeneration, CAC is now recognized as an active, highly regulated process driven by inflammation, oxidative stress, extracellular vesicle release, osteogenic differentiation of vascular smooth muscle cells, and biomechanical remodeling. These mechanisms generate a spectrum of calcific phenotypes, ranging from microcalcifications and sheet calcium to nodular calcium and calcified nodules. Calcified nodules represent an advanced fibrocalcific plaque phenotype characterized by fractured calcific plates, luminal calcium protrusion, surface disruption, and variable thrombus formation. They can be characterized using intravascular ultrasound (IVUS), optical coherence tomography (OCT), and hybrid near-infrared spectroscopy–IVUS imaging, and are associated with coronary thrombosis, stent underexpansion, restenosis, target lesion failure, and the need for advanced calcium-modification strategies. A structured literature search of PubMed/MEDLINE, Web of Science Core Collection, and Scopus identified 83 publications published between 2020 and 2026 for inclusion in the narrative synthesis. This narrative review summarizes the biological and biomechaniclam mechanisms of coronary calcification and calcified nodule formation, compares multimodality intravascular imaging criteria, and discusses contemporary imaging-guided PCI strategies, including balloon-based modification, rotational and orbital atherectomy, excimer laser coronary atherectomy, intravascular lithotripsy, and hybrid approaches. By integrating pathobiology, intravascular imaging criteria, and lesion-specific PCI strategies, this review provides a clinically oriented framework for the assessment and management of calcified nodules. Future directions include standardized imaging definitions, prospectively validated morphology-guided treatment algorithms, and computational and artificial intelligence-assisted plaque characterization. Full article

Background: Cardiac calcified amorphous tumours (CATs) are rare non-neoplastic intracardiac masses characterized by calcified nodules within an amorphous fibrinous matrix and may clinically mimic thrombi or cardiac neoplasms. We report two uncommon cases of right atrial CAT occurring in young women and provide a narrative review of the literature. Methods: Two patients with right atrial CAT underwent multimodality imaging evaluation, including echocardiography, computed tomography, and cardiac magnetic resonance, followed by surgical excision and histopathological examination. A narrative review of published cases identified through PubMed and Embase between 1972 and 2025 was also performed. Results: The first patient presented with a calcified right atrial mass extending into the superior vena cava, associated with superior vena cava syndrome and autoimmune disease. The second patient, affected by end-stage renal disease on hemodialysis and thrombophilia, presented with a large calcified right atrial mass associated with a retained dialysis catheter fragment. Histopathological examination confirmed CAT in both cases. The literature review identified 112 published reports comprising 143 patients, including the two cases presented herein, highlighting frequent associations with end-stage renal disease, mitral annular calcification, and embolic complications. Conclusions: Cardiac CAT remains a rare and likely underrecognized entity with heterogeneous clinical presentation and significant embolic potential. Multimodality imaging is essential for diagnosis and surgical planning, while early surgical excision should be considered in symptomatic or high-risk patients. Full article

Growing evidence indicates that myocardial infarction (MI) is the clinical manifestation of heterogeneous plaque substrates with distinct molecular, cellular, and biomechanical mechanisms. Acute coronary thrombosis (ACT) most commonly arises from plaque rupture (PR), plaque erosion (PE), and calcified nodules (CNs), each associated with different inflammatory profiles, thrombus composition, clinical presentation, and prognosis. This comprehensive review provides a clinician-oriented synthesis of the pathophysiological mechanisms underlying these three principal plaque phenotypes and discusses their implications for the contemporary management of acute coronary syndromes (ACS). We examine the molecular and cellular determinants of plaque instability and highlight how systemic factors such as plaque burden, impaired healing responses, and myocardial jeopardy modulate clinical risk. The role of intracoronary and non-invasive imaging is discussed primarily as a tool to elucidate plaque biology with direct clinical relevance rather than merely as a procedural guide. Building on these insights, we propose a conceptual framework for integrating plaque biology into clinical decision-making across the acute phase, secondary prevention, and long-term follow-up. In particular, recognizing the biological heterogeneity of plaque substrates may support more personalized therapeutic strategies, enabling clinicians to tailor pharmacological and interventional approaches according to the underlying plaque phenotype and patient-specific risk profile. Finally, we briefly address emerging perspectives, including the potential role of artificial intelligence (AI) in refining plaque characterization, risk stratification, and precision cardiovascular prevention. Overall, recognition of PR, PE, and CNs as biologically distinct entities supports a shift toward mechanism-informed and personalized management of MI, aligning advances in plaque biology with the principles of precision cardiovascular medicine. Full article

Background/Objectives: Ultrasonographic microcalcifications are highly specific imaging features of malignancy in both thyroid nodules and metastatic cervical lymph nodes in papillary thyroid carcinoma (PTC). However, although their histopathological correlates in thyroid nodules have been extensively investigated, the pathological substrates underlying microcalcifications in metastatic lymph nodes remain poorly defined, particularly for ultrasound-based diagnostic interpretation. Methods: This retrospective sonopathological cohort study included 32 patients with PTC, contributing 70 metastatic cervical lymph nodes. Lymph nodes were classified based on the presence or absence of microcalcifications detected by ultrasonography. Histopathological features—psammoma bodies, hyalinization, stromal calcification, cystic degeneration, and papillary formation—were systematically re-evaluated by pathologists blinded to ultrasonographic findings using a predefined semi-quantitative grading protocol. Microcalcification-positive metastatic lymph nodes were additionally compared with a reference cohort of microcalcification-positive thyroid nodules (n = 30). Results: Ultrasonographic microcalcifications were identified in 30 of 70 metastatic lymph nodes (42.9%). Microcalcification-positive lymph nodes demonstrated significantly higher frequencies of psammoma bodies (56.7% vs. 17.5%, p = 0.001), moderate-to-extensive psammoma bodies (40.0% vs. 12.5%, p = 0.003), stromal calcification (30.0% vs. 0.0%, p < 0.001), and cystic degeneration (80.0% vs. 12.5%, p < 0.001) compared with microcalcification-negative nodes. Notably, 43.3% of microcalcification-positive nodes lacked moderate-to-extensive psammoma bodies, indicating heterogeneous pathological correlates. Comparative analysis revealed no significant differences between microcalcification-positive nodes and thyroid nodules in the prevalence or extent of psammoma bodies or stromal calcification; however, hyalinization was significantly more frequent and extensive in thyroid nodules (both p < 0.001). Conclusions: Ultrasonographic microcalcifications in metastatic lymph nodes of PTC reflect heterogeneous histopathological correlates beyond psammoma bodies alone. These findings highlight the importance of anatomically informed, context-specific interpretation of microcalcifications in ultrasound-based diagnostic practice. Full article

Background: Tracheobronchopathia osteochondroplastica (TO) is a rare benign disorder characterized by submucosal cartilaginous and osseous nodules of the tracheobronchial tree, typically sparing the posterior membranous wall. Involvement of the vocal cords is exceedingly rare and may result in critical airway obstruction. The underlying genetic and molecular mechanisms of TO remain largely unexplored. Case presentation: We report a rare case of TO extending from the vocal cords to the bronchi in a 76-year-old man who initially presented with pneumonia and later developed acute respiratory failure due to severe airway narrowing, necessitating emergency tracheostomy. Bronchoscopy and computed tomography revealed diffuse calcified nodules involving the anterior and lateral airway walls, including the subglottic region. Histopathology demonstrated chronic inflammatory cell infiltration with squamous metaplasia. To explore the molecular basis of this condition, whole-genome sequencing (WGS) was performed using peripheral blood samples—the first such application in TO. WGS identified 766 germline mutations (including 27 high-impact variants) and 66 structural variations. Candidate genes were implicated in coagulation and inflammation (KNG1), arachidonic acid metabolism and extracellular matrix remodeling (PLA2G4D), ciliary dysfunction and mineralization (TMEM67), vascular calcification (CDKN2B-AS1), smooth muscle function (MYLK4), abnormal calcification (TRPV2, SPRY2, BAZ1B), fibrotic signaling (AHNAK2), and mucosal barrier integrity (MUC12/MUC19). Notably, despite systemic germline mutations, calcification was restricted to the airway. Conclusions: This case highlights that TO with vocal cord involvement can progress beyond a benign course to cause life-threatening airway obstruction. Integrating clinical, histological, and genomic findings, we propose a novel pathophysiological model in which systemic genetic susceptibility interacts with local immune cell infiltration and fibroblast-driven extracellular matrix remodeling, resulting in airway-restricted dystrophic calcification. This first genomic characterization of TO provides new insights into its pathogenesis and suggests that multi-omics approaches may enable future precision medicine strategies for this rare airway disease. Full article

Background/Objectives: This study aimed to evaluate the relationship between preoperative clinical, ultrasonographic, and cytologic findings and postoperative histopathology in patients with thyroid nodules, and to determine diagnostic factors associated with malignancy. Materials and Methods: A retrospective analysis was conducted on 100 patients who underwent thyroid surgery between September 2012 and April 2014. Preoperative data—including clinical examination, thyroid function tests, and high-resolution ultrasonography—were compared with fine-needle aspiration biopsy (FNAB) results and final histopathology. Ultrasonographic features (echogenicity, calcification, vascularity, and margin) were analyzed for their association with malignancy. Statistical tests included chi-square, t-test, and correlation analysis (p < 0.05 considered significant). Results: Among 100 patients (79 females, 21 males; mean age 47.5 ± 13.9 years), 29 (29%) had benign and 71 (71%) malignant histopathology. Malignancy was significantly associated with older age (p = 0.025), smaller nodule size (p = 0.019), hypoechogenicity (p = 0.001), microcalcifications (p = 0.014), and irregular margins (p = 0.017). FNAB showed a strong correlation with final histopathology (r = 0.65, p = 0.001). The overall sensitivity and specificity of FNAB were 25.4% and 82.8%, respectively. Conclusions: Hypoechogenicity, microcalcifications, and irregular margins were the most reliable ultrasonographic predictors of malignancy. FNAB remains a highly specific but variably sensitive diagnostic tool, and its accuracy increases when interpreted in conjunction with ultrasonographic findings. Integrating cytology with structured imaging systems such as ACR TI-RADS and Bethesda classification enhances diagnostic precision in thyroid nodule evaluation. Full article

Background/Objectives: Bladder carcinoma (BC) is strongly associated with tobacco exposure, a major shared risk factor for several smoking-related diseases (SRDs), including pulmonary disorders and coronary atherosclerosis. However, the prevalence of SRDs in patients with high-grade (HGBC) or muscle-invasive bladder carcinoma (MIBC) has not been systematically investigated. We aimed to evaluate SRD prevalence and to assess the potential role of chest high-resolution computed tomography (HRCT) in a population with histologically confirmed HGBC or MIBC. Methods: We retrospectively analyzed 166 patients with histologically confirmed HGBC/MIBC who underwent staging HRCT. SRDs—including emphysema, suspicious pulmonary nodules, airway disease, interstitial lung disease (ILD), and coronary artery calcifications (CAC)—were assessed. Associations between smoking status and SRDs were evaluated using binary logistic regression, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: Overall, 60.2% of patients had at least one SRD. Smokers showed a significantly higher SRD prevalence than non-smokers (p < 0.05). Pulmonary SRDs were observed in 31.9% of patients, with emphysema being most strongly associated with smoking (p < 0.01). Suspicious pulmonary nodules (Lung-RADS ≥ 3) were detected in 6.6% of patients, more commonly among smokers (72.7%), though the difference was not statistically significant. Histological confirmation, available for 45% of these nodules, revealed primary lung cancers rather than metastatic bladder carcinoma in all verified cases. Conclusions: Patients with HGBC/MIBC demonstrate a high prevalence of SRDs, supporting the integration of chest HRCT into staging protocols. HRCT may enable early detection of clinically relevant comorbidities and help identify candidates for lung cancer screening. Full article

A 60-year-old woman with hypertension and hyperlipidemia was referred for an incidentally detected gastric subepithelial mass during screening endoscopy. Esophagogastroduodenoscopy revealed a 10 mm dimple in the antrum, and contrast-enhanced CT showed a 2.5 cm enhancing oval lesion. Laparoscopic partial gastrectomy with intraoperative endoscopic guidance was performed. Gross examination revealed a 3.0 × 2.0 × 1.0 cm pale, firm nodule. Histology showed small round cells arranged in nests and trabeculae within the muscularis propria, with numerous vessels and focal calcification. Immunohistochemistry was negative for CD117, HMB45, and chromogranin A, but demonstrated strong smooth muscle actin positivity, weak synaptophysin reactivity, and focal CD56 staining. The findings confirmed a gastric glomus tumor with neuroendocrine features. Smooth muscle actin immunostaining is essential to distinguish gastric glomus tumors from neuroendocrine tumors when biopsy material is limited, ensuring accurate diagnosis and appropriate management. Full article

Background/Objectives: Accurately distinguishing malignancy in thyroid micronodules (≤10 mm) is crucial for clinical management, yet it is challenging due to the limitations of conventional ultrasonography-guided biopsy. This study aims to evaluate the predictive value of dual-layer spectral computed tomography (DSCT)-derived arterial enhancement fraction (AEF) in diagnosing thyroid microcarcinomas. Methods: In the study, 321 pathologically confirmed thyroid micronodules (benign = 131, malignant = 190) from Chongqing General Hospital underwent preoperative DSCT. Quantitative parameters of DSCT, including the normalized iodine concentration (NIC), normalized effective atomic number (NZ_eff), and slope of the spectral Hounsfield unit curve (λHU_(40–100)), were assessed. Both single-energy CT (SECT)-derived AEF (AEF_S) and DSCT-derived AEF (AEF_D) were calculated. Conventional image features included microcalcifications and enhancement blurring. Correlation between AEF_D and AEF_S was determined using Spearman’s correlation coefficient. Diagnostic performance was evaluated by calculating the area under the curve (AUC) using receiver operating characteristic (ROC) analysis. Results: Malignant micronodules exhibited significantly lower AEF_D (0.958 vs. 1.259, p < 0.001) and AEF_S (0.964 vs. 1.436, p < 0.001) versus benign nodules. Arterial phase parameters—APλHU_(40–100), APNIC, APNZ_eff—differed significantly between groups (all p < 0.001), whereas venous phase parameters (VPλHU_(40–100), VPNIC, VPNZ_eff) showed no differences (all p > 0.05). Multivariate analysis revealed that λHU_(40–100) as an independent predictor of malignancy, with an odds ratio (OR) of 0.600 (95% confidence interval (CI): 0.437–0.823; p = 0.002) and an AUC of 0.752 (95% CI: 0.698–0.806). A significant positive correlation was identified between AEF_D and AEF_S (r = 0.710; p < 0.001). For diagnosing malignancy, AEF_D demonstrated superior overall performance (AUC: 0.794; sensitivity: 70.5%; specificity: 81.7%; accuracy: 75.1%) to AEF_S (0.753; 71.1%; 74.0%; 72.3%), APλHU_(40–100) (0.752; 68.9%; 75.6%; 71.7%), and calcification (0.573; 21.6%; 92.4%; 50.5%). Clinically, AEF_D reduced the unnecessary biopsy rate to 18.3%, preventing 107 procedures in our cohort. Conclusions: AEF_D and AEF_S demonstrated strong correlation and comparable diagnostic performance in the evaluation of thyroid micronodules. Furthermore, AEF_D showed favorable diagnostic efficacy compared to both spectral parameters and conventional imaging feature. More importantly, the application of AEF_D significantly reduced unnecessary biopsy rates, highlighting its clinical value in optimizing patient management. Full article

Background/Objectives: Thyroid cancer encompasses distinct histological subtypes with varying biological behavior and treatment implications. Accurate preoperative subtype differentiation remains challenging. Although ultrasound (US) is widely used for thyroid nodule evaluation, qualitative assessment alone is often insufficient to distinguish between papillary (PTC), follicular (FTC), and medullary thyroid carcinoma (MTC). Methods: A retrospective analysis was performed on patients with histologically confirmed PTC, FTC, or MTC. A total of 224 standardized B-mode ultrasound images were analyzed. A set of fully quantitative features was extracted, including morphological characteristics (aspect ratio and perimeter-to-area ratio), internal echotexture (echogenicity and local entropy), boundary sharpness (gradient measures and KL divergence), and structural components (calcifications and cystic areas). Feature extraction was conducted using semi-automatic algorithms implemented in MATLAB. Statistical differences were assessed using the Kruskal–Wallis and Dunn–Šidák tests. A Random Forest classifier was trained and evaluated to determine the discriminatory performance of individual and combined features. Results: Significant differences (p < 0.05) were found among subtypes for key features such as perimeter-to-area ratio, normalized echogenicity, and calcification pattern. The full-feature Random Forest model achieved an overall classification accuracy of 89.3%, with F1-scores of 93.4% for PTC, 85.7% for MTC, and 69.1% for FTC. A reduced model using the top 10 features yielded an even higher accuracy of 91.8%, confirming the robustness and clinical relevance of the selected parameters. Conclusions: Subtype classification of thyroid cancer was effectively performed using quantitative ultrasound features and machine learning. The results suggest that biologically interpretable image-derived metrics may assist in preoperative decision-making and potentially reduce the reliance on invasive diagnostic procedures. Full article

Purpose: This study aimed to compare: the performance of K-TIRADS, EU-TIRADS and ACR TIRADS when used by observers with different levels of experience compared with the gold standard of cytology, and to evaluate the diagnostic performance of CAD (computer-aided design) compared with TI-RADS systems. Methods and Materials: In total, 323 thyroid nodules were evaluated in patients who were candidates for needle aspiration. Three observers with different levels of experience evaluated the diagnostic accuracy of three risk stratification systems (ACR TI-RADS, EU-TIRADS and K-TIRADS) and CAD software (S-Detect, made by Samsung) in characterizing the nodules. The results were compared with cytology examination. All nodules were characterized in terms of shape, margins, composition, calcifications, size, echogenicity and microcalcifications, and by stratifying individual nodules by using the three TIRADS systems; then S-detect software was applied and the data were compared with each other and with the gold standard. Results: Through cytology, 308 benign and 33 malignant nodules were identified. ACR-TIRADS showed a sensitivity of 100%, a specificity of 86%, a positive predictive value of 43% and a negative predictive value of 100%. EU-TIRADS showed a sensitivity of 100%, a specificity of 79%, a positive predictive value of 33% and a negative predictive value of 100%. K-TIRADS showed a sensitivity of 100%, a specificity of 89%, a positive predictive value of 50% and a negative predictive value of 100%. S-Detect combined with EU-TIRADS showed a high agreement (>95%) with the gold standard. Conclusions: K-TIRADS’s positive predictive power was slightly better than the other TIRADS, suggesting greater accuracy in correctly diagnosing positive cases. S-DETECT combined with EU-TIRADS has similar results to S-Detect with ACR- and K-TIRADS in terms of sensitivity, specificity and negative predictive power. However, it has a slightly better positive predictive power, suggesting greater accuracy in correctly diagnosing positive cases than the ACR- and K-TIRADS classification systems. In general, S-Detect cannot yet be considered a substitute for the human observer but only as an important support for human evaluation and an excellent and fast help to provide a comprehensive and complete report. Clinical Relevance/Application: S-Detect is a valuable tool for characterizing thyroid nodules when integrated with radiologist evaluation. It is also an important support tool for less experienced observers. Particularly interesting is the approach of use in integrated combination of the K-TIRADS by the human observer with S-Detect using EU-TIRADS, which could increase the overall diagnostic efficiency of the systems. Full article

Background and Objectives: In vivo data on healed coronary plaques (HCPs), the hallmark of previous plaque disruption, remains scarce. The study aimed to use optical coherence tomography (OCT) imaging to assess the prevalence, morphological features, and clinical significance of culprit HCPs in patients with acute coronary syndrome (ACS). Materials and Methods: A total of 87 ACS patients (74.3% non-ST-segment elevation ACS) who underwent pre-procedural OCT imaging of the culprit vessel at a single center were retrospectively analyzed. A pilot subgroup of patients with intracoronary thrombi at the culprit site, in various stages of organization and healing, enabled a detailed morphological characterization of HCP despite the absence of histological validation. Three distinct HCP imaging aspects were identified: type I—overlaying fibrous tissue, type II—overlaying lipid tissue, and type III—overlaying calcific tissue. HCP presence was subsequently assessed in the entire population. Clinical correlations included associations with post-stenting outcomes, particularly edge dissections (ED). Results: Culprit HCPs were identified in 78 patients (89.7%): type I—30.8%, type II—51.3%, and type III—17.9%. Regarding the underlying substrate and complication mechanism, type I HCP was associated with pathological intimal thickening (70.8%) and plaque erosion (75%), type II with lipid-rich plaque (80%) and plaque rupture (PR) (82.5%), and type III correlated with calcific plaque (92.9%, p < 0.0001) and both PR and calcified nodule (p < 0.0001). A unique signal-rich ring was observed at the HCP–tissue interface in both type II (77.5%) and type III (78.6%, p < 0.0001). There was a significant correlation between stent ED and HCP presence at landing zones (LZ) (HR 4.14, 95% CI: 1.79–9.55; p < 0.001). Conclusions: OCT analysis of intracoronary organizing fresh thrombi allowed detailed characterization of culprit HCPs and in vivo classification into three imaging types. This approach likely contributed to the high observed detection rate of HCP by enhancing recognition of subtle OCT features. HCP may create mechanical vulnerability if located at the stent LZ. Our improved HCP detection techniques may help optimize stent-related outcomes of OCT-guided procedures by choosing an HCP-free LZ or longer stents. Full article

Background/Objectives: Spread through air spaces (STAS) is defined as the spread of tumor cells into the parenchymal alveolar space beyond the margins of the main tumor, and it is associated with worse clinical outcomes in resected lung adenocarcinoma. This study aimed to evaluate the preoperative computed tomography (CT) findings of primary lung adenocarcinoma in surgically resected T1 cases and to compare CT findings with and without STAS. Methods: A total of 145 patients were included in this study. The following factors were evaluated on CT images: nodule type (pure ground-glass nodule [GGN], part-solid nodule, or solid nodule), margin (smooth or irregular), the presence of lobulation, spicula, cavity, calcification, central low attenuation, peripheral opacity (well-defined or ill-defined), air bronchogram, satellite lesions, pleural retraction, pulmonary emphysema, and interstitial pneumonia; CT values (maximum, minimum, and mean); volume (tumor and solid component); and diameter (tumor and solid component). CT criteria were compared between the presence and absence of STAS. Results: Lobulation and central low attenuation were significantly more frequent in patients with STAS (p < 0.05). The mean CT value, and the volume, rate, and diameter of the solid component were significantly larger in cases with STAS (p < 0.05). A multiple logistic regression analysis identified central low attenuation as an indicator of the presence of STAS (p < 0.001; odds ratio, 3.993; 95% confidence interval, 1.993–8.001). Conclusions: Quantitative and qualitative analyses are useful for differentiating between the presence and absence of STAS. Full article

Background/Objectives: In 2024, Lithuania developed a national lung cancer screening program (the Program), targeting individuals aged 50 to 70 years, regardless of their smoking history, with screenings conducted once every three years. The Program aims not only to actively detect lung nodules (lung cancer) but also to identify clinically significant concomitant findings. The pilot study aimed to evaluate the screening process’s feasibility and organizational efficiency of the screening process, as well as its potential clinical effectiveness. Methods: Three family medicine centers were selected for participation. The Coordinating Center contacted individuals aged 50 to 70 sequentially and invited them to participate, regardless of smoking status. In total, 1014 individuals were prospectively enrolled and underwent low-dose chest computed tomography (LDCT) screening between 26 September 2024 and 14 February 2025. Results: Of the individuals invited, 76.1% agreed to participate. Lung-RADS v2022 category 4 nodules were identified in 1.4% of participants (n = 14), including six smokers and eight non-smokers. Additionally, one participant with a Lung-RADS category 2 nodule was diagnosed with squamous cell carcinoma originating from peripheral lung changes. Newly identified significant incidental findings were detected in 25.9% of participants: 5.1% had pulmonary or mediastinal findings (most commonly emphysema, interstitial lung changes, and bronchiectasis), 18.7% had cardiovascular findings (usually coronary artery calcification, aortic valve calcification, and aorta dilation), and 2.1% had other clinically relevant conditions (e.g., thyroid nodules, diaphragmatic changes). Following assessment by family physicians, 17.6% of all participants were referred to medical specialists, including pulmonologists, cardiologists, and others. Conclusions: This pilot study demonstrated that the Lithuanian lung cancer screening model is feasible, well-organized, and clinically valuable. The findings support the Program’s readiness for broader implementation at the national level. Full article

Background/Objectives: The surveillance of patients with incidental pulmonary nodules overloads existing respiratory and lung cancer clinics, as well as multidisciplinary team meetings. In our clinical setting, until 2018, we had numerous patients with incidental pulmonary nodules inundating our outpatient clinics; therefore, the need to develop a novel service and dedicated clinical pathway arose. The aims of this study are to 1. provide (a) a model of setting up a novel pulmonary nodule service, and (b) a pragmatic clinical pathway to address the increasing need for surveillance of patients with incidental pulmonary nodules. 2. share real-world data from a dedicated pulmonary nodule service running in a tertiary setting with existing resources. Methods: A retrospective review of established processes and referral mechanisms to our tertiary pulmonary nodule service was conducted. We have also performed a retrospective collection and review of data for patients reviewed and discussed in our tertiary pulmonary nodule service between April 2018 and April 2024. Results: Our tertiary pulmonary nodule service (PNS) comprises a dedicated pulmonary nodule clinic, a nodule multidisciplinary team (MDT) meeting and a dedicated proforma referral system. Due to the current national health system legislation and relevant processes, patients are required to physically attend clinic appointments. There are various sources of referral, including other departments within the hospital, other hospitals, various specialties in primary care and self-referrals. Between 15 April 2018 and 15 April 2024, 2203 patients were reviewed in the pulmonary nodule clinic (903 females, 1300 males, mean age 64 ± 19 years). Of those patients, 65% (1432/2203) were current smokers. A total of 1365 new patients and 838 follow-up patients were reviewed in total. Emphysema was radiologically present in 72% of patients, and 75% of those (1189/1586) already had a confirmed diagnosis of chronic obstructive pulmonary disease (COPD). Coronary calcification was identified in 32% (705/2203), and 78% of those (550/705) were already known to cardiology services. Interestingly, 27% (368/1365) of the new patients were discharged following their first MDT meeting discussion, and 67% of these were discharged as the reason for their referral was an intrapulmonary lymph node which did not warrant any further action. Among all patients, 11% (246/2203) were referred to the multidisciplinary thoracic oncology service (MTOS) due to suspicious appearances/changes in their nodules that warranted further investigation, and from those, 37% were discharged (92/246) from the MTOS. The lung cancer diagnosis rate was 7% (154/2203). Conclusions: The applied pathway offers a pragmatic approach in setting up a service that addresses an increasing patient need. Its application is feasible in a tertiary care setting, and admin support is of vital importance to ensure patients are appropriately tracked and not lost to follow-up. Real-world data from pulmonary nodules services provide a clear overview and contribute to understanding patients’ characteristics and improving service provision. Full article