Friday, October 14, 2005

Multiple pulmonary nodules (case#2)

86 yo male with PMH of colon cancer dx 30 years ago s/p Left hemicolectomy presented to the hospital after a syncopal event. He had an URI about 1 week prior to admission and that had largely resolved with conservative treatment (OTC AH/DC).
His syncope was probably related to orthostasis (frankly orthostatic on presentation).

On hospital day #2, he complained of abd pain. A CT of the abd showed bilateral pulmonary nodules. A corresponding CT of the chest (cuts below) showed multiple small pulmonary nodules.

He is a lifetime non-smoker.
His colon cancer was "cured" with surgery; an exploratory lapartomy 10 years ago for a PSBO showed adhesions but o/w was normal. A colonoscopy 1 year ago was completely normal.

No other important findings

CT scan:

Now what?

Answer below.

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

Arenberg said...

Mike, these look metastatic, but maybe you are throwing a curve ball here, and I'd be on a pretty thin limb if I guessed he had metastatic colon cancer after all these years. I think a PET scan might be useful only to the extent that it told you where these are coming from. How sure are we that these are new? If they are, then I'd stick a needle in one of them.

On the other hand, at age 86, there isn't much you could tell me about his performance status that would make me want to treat him with chemotherapy, so if I was sitting with him, I'd give him the option of doing nothing but watching them.

In all of this I am assuming that they are unrelated to his abdominal pain. I would lean towward doing more than watch & wait if these were related to whatever was causing his abdominal pain. There...I have completely waffled to both ends of the spectrum. Are you happy now?

Baleeiro said...

I agree with some of Doug's waffling. I have a very similar casde, Mike: 84 y/o non-smoker, previously "cured" colon Ca. He presented with multiple nodules and we tried a CT-guided Bx since they were all peripheral. He opted for conservative f/up and didn't want chemo or Xrt. I have been monitoring him since 11/04 and the nodules have started to grow and some are clear large masses now but he has been happy with his choice and has just come back from a trip to Florida and is planning another one...

Mike L said...

Just to close out this case, as no one seems to want to engage further (or even in the beginning)...
A CT guided biopsy of these lesions was performed. It yielded Squamous cell CA.
To me, the learning point was how to proceed with this diagnosis.
Oncology wanted a "triple endoscopy" (i.e. Laryngoscopy, EGD and bronch). The first two were negative.
Although happy to do the bronch, the primary attending felt that it would not add anything. Oncology admitted that they would treat for lung cancer as the primary anyway, so it did not make clinical sense to do an airway exam. He had no evidence of an endobroncial lesion (atelectasis, visualized lesion in a proximal bronchus, etc).

Arenberg said...

Mike, I understand the recommendation for upper endoscopy, as that would be the most likely place for a squame to originate if it was proven to be a met to the lung. Just so its clear, the oncologists made this referral after detecting the SCCa in the lung?

It sure does look like metastatic disease to me. I'd still want to be sure the path was truly squamous cell, and get a PET to look for another primary.

Baleeiro said...

Mike, to me the interesting question was not so much the DDx (looked like mets) but whether to put this 86 y/o through chemo for stage IV disease (of either primary site). Is he symptomatic with the nodules?

Anonymous said...

I am a 53 yr old male with multile bilateral pulmonary nodules with a hx of smoking for over 40 yrs.
9 biopsies were all inconclusive. My pulmonoligist says it is not cancer and that I should not be worried. The nodules are slowly growing and new ones are spotted at the rate of 3 or 4 per year. My father died of lung cancer. Should I seek a second opinion?