Monday, October 03, 2005

Managing pulmonary nodules - Part Deux

Here is the second part of Doug's case:
So I agree with the two comments that you don't biopsy a lung nodule in an otherwise good surgical candidate, which this man was. He of course went on to receive chest wall radiation starting two weeks after his surgery and finishing in late July 2000, which is of course why I met him in September of 2000, about two months after completing his XRT. He had a mild case of radiation pneumonitis with dyspnea, and cough. I treated him with steroids for about 9 months because of a tendency for relapse when I tapered him. He was then doing well for about a year, when he came back to see me becuase of a CT showing mediastinal and hilar adenopthy. He had two unseuccessful attempts at Wang needle bx including a very large pre-tracheal LN, because of this I referred him for a mediastinoscopy, but first ordered another PET to see if he had any other evidence of distant disease (PET LN jpeg file below). When he returned to see me to discuss the PET a week later he complained of some redness and pain on his anterior chest wall which I treated as cellulitis.He was set up for a mediastinoscopy, but when he presented for this appointment 5 days later, he complained of increasing pain and redness over his anterior chest even after taking Cephalexin for the last week. He had an admission CXR that showed a large soft tissue density and had the following CT scan the day of his planned mediastinoscopy. (9-02 chest wall image below). Now what would you do?


Answer posted in the discussion below.

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

Mike L said...

This case keeps getting sadder.
I would ask the surgeons to biopsy the chest wall mass that is present on the CT scan.

How soon after the PET scan is the CT?

Baleeiro said...

Same question Re: the time between the 2 studies. There was not much on the chest wall in the PET-CT image so the mass on the second study could be inflammatory/infectious in nature (though with all the PET+ areas and the previous Hx that might be wishful thinking).

Jeff H said...

I agree with the chest wall biopsy for the possibility of infection. However, presumably this is a recurrence- however, chest wall invasion would not definitively exclude surgery, as (ignoring for the moment the pre-tracheal light-bulb on PET). So, if this patient would otherwise be a surgical candidate, the mediasteinoscopy would still be necessary for definitive staging.

Arenberg said...

OK, OK...enough of this. the punch line, which everybody suspected is that he did have a chest wall infection. The patient was sent for a CT guided biopsy of the chest wall mass...twice. Both of which were "non-diagnostic"

MICROSCOPIC DIAGNOSIS:
1. Anterior chest wall, biopsy: Acute and chronic inflammation, fibrosis and fat necrosis. Negative for neoplasm.

The second biopsy yielded abundant purulent fluid which eventually grew out Aspergillus. He then went to the OR for debridement. The surgical cultures also grew out atypical mycobacteria. He received about a years worth of anti-fungal and anti-mycobacterial therapy.

Many of you may remember this case as I have used it as an example of one (albeit rare) bad type of outcome from doing a biopsy which would not change the ultimate management of a lung nodule.

I can't tell you how many times I have presented this man's case in lectures and have people argue with me that such biopsies are OK. My sermon is that in a good surgical candidate, there is no benefit, and some potential for bad outcomes if you do a biopsy. His course eventually spanned two major operative procedures under general anesthesia, including eventual resection of BOTH costal cartilage arches, and an open draining would for close to 8 months. FOrtunately, he is alive and well today, with no known recurrence of what should have been a stage IB cancer.