Thursday, July 21, 2005

Nodules?

This is a 69 y/o man seen today in my office. He has very mild COPD (FEV1~75%) but continues to smoke. He had had some AECB and a CxR revealed some small pulmonary nodules. A CT scan (see below) confirmed B/L non-calcified, upper-lobe nodules (the two largest are seen on the CT slices below with no adenopathy and an adrenal mass.
I bronch'ed him and found some chronic bronchitis but nothing endobronchial. His TBBx and cyto (BAL and washings) were only significant for some inflammation. He is now assymptomatic and a PET scan showed no increased pathologic FDG-uptake anywher. What would you do next?

5 comments - CLICK HERE to read & add your own!:

D. Obeid said...

was TB ruled out?
Does he have any previous CXR or CT scans to compare to?

Mendez said...

Agree w/ PPD and checking old radiographs. I'm concerned about bilateral adrenal nodules and whether or not we are catching metastatic disease since PET scan can be false negative for some tumors with low metabolic acitivity.

Since there are multiple nodules - I don't see the point in surgery to remove multiple nodules. Given the recent infection - I wonder if the pulmonary and adrenal nodules are unrelated.

I would
- assess for signs/symptoms of functional adrenal nodules
- be sure that he is up to date on his routine health maintenance (colonoscopy, PSA, etc).
- repeat CT scan in ~3 mos to reassess pulm nodules
- FNA of adrenal nodule to r/o metastatic disease

Jennings said...

Well, with the finding on adrenal and the nodules on chest, I agree with the ddx including TB (does fungal go to adrenal glands?) and adenocarcinoma. But with the negative PET of the adrenals, the latter is less likely actually. So I would probably do a CT-guided bx of the adrenal lesion and send it for micro (afb fungal) and pathology.

Jeff H said...

Endemic fungi can involve the adrenals. I'd biopsy the adrenals. If there is carcinoma (which I agree is less likely given the neg PET), the workup is done. If the biopsy is negative, I'd wait for the cultures and re-image, while investigating benign adrenal masses.

Baleeiro said...

He did not have any infectious symptoms. He is even cough-free now. Radiology felt quite comfortable with all the various modalities of imaging that the adrenal mass was an adenoma (labs are normal).
We chose the Mendez approach: adrenal functiona was normal, sent him back to PCP for health maintenance and he is coming back in 3 months with a repeat CT scan.