Saturday, January 28, 2006

RLL mass - lobectomy or more workup?

Elizabeth send the following:

45 year old male smoker w/hx 2ppd for 20 years otherwise healthy with no prior hx of pulmonary disease.or medical history. Suddenly experiences trickling right chest sensation causing gagging coughs bringing up bright red blood with each cough. Persisted for approx 10 min. Would subside and return every 2 hours. E.R. sent home with cough meds and antibiotic w/dx of bronchitis. No cough or blood for 3 days w/bed rest and meds. 4th day cough and blood returned. New E.R. complete workup including CT Chest plain and repeat CT w/contrast which both described ill defined 3cm mass RLL. NO more hemoptysis during hospital stay. Other lab values: Blood Gas ph7.3, PC02 49, 02-68, Saturation 94%BUN 20, Creatine 0.8, Potassium 4.2, PT 10.9, PTT 36.4. CBC-WBC 9300, H&H 15 & 42, Platelet 371,000. LFT's nl.

Would you do additional workup or go right to lobectomy?

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

Jennings said...

Unless there is a feature on CT that points to an obvious benign etiology (for instance central calcification, or fluid to suggest cyst or sequestion), I would choose resection. His age may be on the young side, but not young enough to rule out malignancy. I assume his lung function and exercise tolerance is acceptable and thus he would tolerate the procedure.
Others might suggest following for 3 months since benign inflammatory causes are still on the list, but my choice again would be resection.

Anonymous said...

This is Elizabeth...the patient underwent bronchoscopy/negative, mediastinoscopy/6 lymph nodes negative for malignancy, RLL lobectomy/Pathology..4x2.5x2cm hemorrhagic area. Within inferior lobe, there is a 6x4x4cm dark purple area. Intra-alveolar hemorrhage, no malignancy was found.
Post operatively the patient has undergone thoracentesis for pleural effusion. Last x-ray revealed persisting effusion with consolidation right lung base. Patient complains of shortness of breath when speaking or over-exertion and occasional tightness of chest. Only other complaint, evening low grade fevers between 99.5-100.8.

Jeff H said...

Were the mediastinal lymph nodes enlarged on the CT scan? If not, I'm not sure I would have done the mediastinoscopy prior to resection. In any case, with the negative (or non-enlarged) lymph nodes, and a 3 cm mass, I absolutely agree with resection.

I'm not sure why this patient would have focal alveolar hemmorhage as described on the pathology. Although I would expect it to be more diffuse in the case of collagen-vascular associated alveolar hemorrhage, it has to start somewhere. So, I would screen for undiagnosed collagen-vascular disease, including Wegeners (ANA, ANCA, urine sediment, etc.)

The etiology of the pleural effusion likely depends on how far out the patient is from surgery. What was the nature of the fluid obtained by thoracentesis. This could easily be a post-op pneumonia with or without empyema. With a lower lobectomy, there may be a chronic transudative effusion, but I would not expect the fever or chest tightness.

Thanks for submitting this interesting case. I'm looking forward to seeing some more input from our colleagues!

Baleeiro said...

I like Jeff Hs suggestion on the vasculitides/collagen-vascular disease front. Any micro isolates from biopsies or bronch to point to a necrotizing infectious agent?