Hello's not working (no "publish" button anymore), so the pics are stored elsewhere for this post. Anyway, what would you do with a 64 year old heavy previous smoker with mild/moderate emphysema with a lung nodule; here are 3 CT's. CT 2003. CT from March 2005. Here is this month's . Basically, there is a few mm size change c/w 2003, but no change compared with march 2005. The mediastinum has some unchanged calcified nodes. The nodule is not calcified but the cuts are only 5 mm.
Now here is the thing. He is PPD positive and was exposed maybe back in the 50's.
With that PPD history and the CT findings, BUT with a possibility of it being cancer also, how would you proceed? Are you worried about TB (but this wouldn't be "active" tb) or ignaore that and work up the nodule in the usual way when considering cancer?
3 comments - CLICK HERE to read & add your own!:
First, I think the (+)PPD is a red-herring. Reactivated TB should not give you a solidary nodular density that began in 2003 and has not progressed (more nodules, etc.), caused symptoms or enlarged lymph nodes. Why was the PPD performed?
Anyway, if the nodule is above 1 cm, I would probably ask the surgeons to take it out. Assuming the nodule is between 1 and 2 cm, it has a 73% chance of being malignant according to the site:
http://www.chestx-ray.com/SPN/SPNProb.html
Even if I have slightly miscalculated, this high probability of being malignant is worrisome enough for me to have a surgical opinion.
If he is a boarderline surgical candidate for any reason, I would consider a PET scan. However, in this patient, a PET may be very unhelpful as you have already demonstrated a slow-growing nodule.
Well I went with the PET because I know in this institution the surgeons like that in all but the most straight forward SPN cases. I also got a CT with thin cuts through the nodule. If there is central calc, I'll just follow q 3 mos.
I was curious about what to do with the TB exposure history. I tend toagree with your viewpoint; lets see what others think...
I agree with Mike L about the nodule. PET might be useful in convincing the surgeons. The PPD appears to be true and unrelated. The risk of TB reactivation is greatest within the first 2 years after exposure so his overall risk might be a bit down but if it turns out that he has a bronchogenic Ca and especially if he gets adjuvant ChemoTx it might be worth giving him Tx for LTBI.
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