Tuesday, September 27, 2005

Managing lung nodules

Doug's case:

This is a 53 year old man whom I initially met when he was referred to me for dyspnea and cough which developed in the setting of recently completing adjuvant radiation therapy for lung cancer. He initially had a left upper lobe nodule, 2.5 cm in diameter, discovered on a "routine" physical exam with a CXR. A CT showed no lymphadenopathy, and he had normal PFTs. He had a CT guided biopsy showing a carcinoma. He was referred for lobectomy, which was done in March 2000. At the time of surgery, all of his lymph nodes were negative, but the surgeon noted a tiny fibrinous adhesion between the lung and chest wall, corresponding to the track taken by the biopsy needle. This was sent to pathology and was positive for carcinoma cells. Feel free to comment on the case so far, as far as what you would do for him now (recognizing that in 2000, the thought of adjuvant therapy for lung cancer was not on anyone's radar), and whether you would have done a biopsy. I'll pull a Paul Harvey and come back with the rest of the story later.

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

Mike L said...

This is truly a sad case.
It seems as if you had someone with a T1N0M0 (stage IA) lesion that someone decided needed a diagnosis before removing the abnormal lung. Unless this guy was not a surgical candidate for another reason (i.e. cardiac, PFTs, etc), this biopsy should not have been obtained. Even now, he would not have received adjuvant chemo.
However, this track is seeded and he has disease to his chest wall and has a T3 lesion (stage IIB).
I would offer chemo and XRT to the tract.
Just out of curiosity, did the surgeons stage his mediastinum with a mediastinoscopy prior to his resection or did he have them staged during the lobectomy?

Baleeiro said...

What was the time frame between the lobectomy and now getting xRt?
Mike raised several good points. I think the key one is whether we would have biopsied it in the first place. At that size with hs Hx I would have sent him straight to resection as well.
Now with regards to the dyspnea, how recent is the xRt?