Tuesday, October 18, 2005

Pulmonary nodule

This is a 65 y/o former smoker who was sent to us for evaluation of a pulmonary nodule. She has COPD, has baseline DOE and while having an AECB had a CxR (outside films). The CxR revealed a nodule which is better characterized on the CT below.

She has had no F/C/NS, no hemoptysis.
Her exam was fairly benign. Her FEV1 however, was only 700cc on Combivent?
What would you do next?

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

Arenberg said...

In a smoker with bad FEV1 this appears to be a non-calcified RUL nodule (if I squinch my eyes really hard and use my imagination, I can pick out some heterogeneity in the density of the nodule, maybe even some fatty density, which would make this a hamartoma, not worth going after if the radiologist agrees with this. I'll assume that my imagination is overactive), so you have a couple choices. A PET scan, if negative, can be used to justify following this thing. If positive, you have to go further. One option is treat with steroids, tiotropium, & salmeterol for a couple weeks and see how much better the PFTs get-if at all-while you await the PET. Meanwhile, you can order a quantitative VQ and/or a CPET (I am assuming that, with an FEV1 of 0.7 liters, the % predicticed is quite low, so correct me if I am wrong). Without lung windows, its hard to know what you'd be taking out in terms of healthy lung.

If you can not make this person look like a surgical candidate with any of the above, you can try to biopsy this thing, and give him/her a pneumothorax.

Jeff H said...

yea, what he said.

I agree with a PET scan and maximal treatment of her COPD to see if there is some reversibility.

If she's not a surgical candidate based on PFT's, quant V/Q, and CPET, than I'd agree with a CT biopsy. Presumably this is a stage IA (looks small, no nodes), so "definitive" XRT would be an option...

Baleeiro said...

We are really on the same page here: I started her on Spiriva, Serevent and gave her 2 weeks of prednisone and got her FEV1 up to 800 cc... There were no nodes on CT and the densities on the CT did not favor a hamartoma.
Her PET scan lit up nicely on the nodule (SUV 7.3) and nowhere else.
A quantitative Q scan revealed 16% perfusion to the R upper lung.
Now what?

Mike L said...

A residual FEV1 of ~570 cc is probably too little to resect. Still you could get a CPET to see her VO2(max). I imagine that the surgeons would still find another reason not to operate.
Then, I agree with a CT guided needle biopsy.

Arenberg said...

Two questions C.

What is the % predicted?

Have you ordered a CPET?

She is truly borderline with the PFTs you have showed so far, and if she is very small, the bad absolute numbers could overestimate her post-operative risk. A recent article in chest comfirms that CPET is better if you use the % predicted of VO2 max, much like other measures of pulmonary function.

Baleeiro said...

Her % of predicted was equally low (<35%)... Her PFTs didnot look good at all for resection. The surgeons, as Lazar suggested were not thrilled with the possibility of resection. I will post the final results later today.

Arenberg said...

Our guys have talked about stereotactic XRT for cure in cases like this, and are trying to get off the ground with radiofrequency ablation of peripheral nodules as well. I am sure, if she was presented in our tumor board, this would come for her (assuming you can prove its cancer, and she wants therapy).