We were asked to see this delightful 67 y/o woman with no respiratory symptoms for an abnormal CT scan of her chest. She has had some back pain and a nodule was found on a CxR. The CT scan above was obtained and she was referred to us. She quit smoking in 1992.
She has good lung function with normal FVC and FEV1~ 70%.
She was set up for a PET scan and the images are seen below:
I don't know if the writing projects well but the RUL lesion is positive and she has positive paratracheal and R hilar nodes. There was also a positive 4-mm R supraclavicular node that did not project well.
What would you do next?
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How specific is a PET @ 4 mm? Can that node be seen on the CT scan? If possible, that's the "ideal" site to biopsy, as it would accomplish complete staging and diagnosis with one procedure. However, at 4mm, I'd think it would be difficult to find surgically.
So, the next question is: Is the right paratracheal node accessible by Wang? If not, I think you'd have to proceed with a mediastinoscopy. Again, a positive result here would be N2, giving this a clinical 3A. Not an absolute contraindication for surgery, but I think it still hinges on how you treat the supraclavicular node. If it is truely positive, that is an N3 node, staging this as a 3B, and resection is out.
Of course, this is all assuming it's a malignancy, which has not been established definitively. So, I'd start by bronch with Wang of the right paratracheal node.
I'd love to hear Doug's input here, and maybe he can comment on a possible role for neo-adjuvant chemo for a 3A and/or 3B lung carcinoma.
I will give you the preliminary answer to some of your suggestions:
I did a bronch, no endobronchial lesions, lots of inflammation on biopsies, but essentially non-diagnostic.
The supraclavicular node is seen (very small) on CT, and we tried CT-guided Bx as you thought (important for Dx and staging) but with limited accessibility because of its small size it was also non-diagnostic.
Her lung function is actually pretty decent.
I will post an update tomorrow.
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