Evaluation of Left Hilar Fullness

Primary Causes and Diagnostic Approach

The American College of Radiology recommends that smoking history, particularly more than 20 pack-years, significantly increases the risk of lung cancer and warrants aggressive workup 1, 3, 4
The American College of Chest Physicians suggests that lung cancer is the most concerning etiology of left hilar fullness, particularly in patients with smoking history, and that the most common sites of intrathoracic spread in lung cancer are hilar and mediastinal lymph nodes 1
The American College of Radiology states that CT chest with IV contrast is the gold standard for evaluating left hilar fullness, as it improves detection of mediastinal and hilar adenopathy and provides superior spatial localization for detecting small pulmonary nodules 4, 6, 7
The American College of Chest Physicians recommends that endobronchial ultrasound-guided needle aspiration (EBUS-NA) be used for accessible hilar/mediastinal nodes when malignancy or lymphoma are suspected 1
Pulmonary hypertension causes enlargement of the left descending pulmonary artery with associated pruning of peripheral vessels, according to the American College of Cardiology 2

The American College of Radiology advises against relying on chest radiography alone when hilar fullness is identified, as sensitivity is inadequate and up to 72% of lesions may be missed 6, 7
The American College of Chest Physicians warns against assuming malignancy without histological confirmation, as benign conditions like sarcoidosis and tuberculosis can present as hilar masses with high PET-CT uptake 1
The American College of Radiology recommends against ordering CT without and with contrast (dual-phase), as there is no supporting literature for this approach in hilar mass evaluation 6, 7