BACKGROUND. Incidental findings are frequently encountered during lung cancer screening (LCS). Limited data describe the prevalence of suspected acute infectious and inflammatory lung processes on LCS and how they should be managed. OBJECTIVE. The purpose of this study was to determine the prevalence, radiologic reporting and management, and outcome of suspected infectious and inflammatory lung processes identified incidentally during LCS and to propose a management algorithm. METHODS. This retrospective study included 6314 low-dose CT (LDCT) examinations performed between June 2014 and April 2019 in 3800 patients as part of an established LCS program. Radiology reports were reviewed, and patients with potentially infectious or inflammatory lung abnormalities were identified and analyzed for descriptors of imaging findings, Lung-RADS designation, recommendations, and clinical outcomes. Using the descriptors, outcomes, and a greater than 2% threshold risk of malignancy, a follow-up algorithm was developed to decrease additional imaging without affecting cancer detection. RESULTS. A total of 331/3800 (8.7%) patients (178 men, 153 women; mean age [range], 66 [53-87] years) undergoing LCS had lung findings that were attributed to infection or inflammation. These abnormalities were reported as potentially significant findings using the S modifier in 149/331 (45.0%) and as the dominant nodule used to determine the Lung-RADS category in 96/331 (29.0%). Abnormalities were multiple or multifocal in 260/331 (78.5%). Common descriptors were ground-glass (155/331; 46.8%), tree-in-bud (56/331; 16.9%), consolidation (41/331; 12.4%), and clustered (67/331; 20.2%) opacities. A follow-up chest CT outside of screening was performed within 12 months or less in 264/331 (79.8%) and within 6 months or less in 186/331 (56.2%). A total of 260/331 (78.5%) opacities resolved on follow-up imaging. Two malignancies (2/331; 0.6%) were associated with these abnormalities and both had consolidations. Theoretic adoption of a proposed management algorithm for suspected infectious and inflammatory findings reduced unnecessary follow-up imaging by 82.6% without missing a single malignancy. CONCLUSION. Presumed acute infectious or inflammatory lung abnormalities are frequently encountered in the setting of LCS. These opacities are commonly multifocal and resolve on follow-up. Less than 1% are associated with malignancy. CLINICAL IMPACT. Adoption of a conservative management algorithm can standardize recommendations and reduce unnecessary imaging without increasing the risk of missing a malignancy.

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