Objective To discuss the main pathological types and imaging features of pulmonary nodules highly suspected to be malignant in clinical practice but pathologically confirmed to be benign. Methods A retrospective analysis was conducted on the clinical data of the patients with pulmonary nodules, who were initially highly suspected of malignancy but were pathologically confirmed as benign, treated at the First Affiliated Hospital of Xiamen University from December 2020 to April 2023. Based on the results of preoperative discussions, the patients were divided into a benign group and a suspicious malignancy group. The clinical data and imaging characteristics of the two groups were compared. Results Finally, 232 patients were collected, including 112 males and 120 females, with an average age of (50.7±12.0) years. There were 127 patients in the benign group, and 105 patients in the suspicious malignancy group. There was no statistical difference in age, gender, symptoms, smoking history, or tumor history between the two groups (P>0.05). However, there were statistical differences in nodule density, CT values, margins, shapes, and malignant signs between the two groups (P<0.05). The analysis showed that in the suspicious malignancy group, the solid nodules were mainly characterized by collagen nodules and fibrous tissue hyperplasia (33.3%), tuberculosis (20.4%), and fungal infection (18.5%), while the non-solid nodules were primarily composed of collagen nodules and fibrous tissue hyperplasia (41.2%) and atypical adenomatous hyperplasia (17.7%). ConclusionThe benign pulmonary nodules suspected of malignancy are pathologically characterized by the presence of collagen nodules and fibrous tissue hyperplasia, tuberculosis, atypical adenomatous hyperplasia, and fungal infections. In terms of imaging features, they typically are present as non-solid nodules, accompanied by signs of malignancy such as spiculation, lobulation, cavitation, and pleural retraction.