Tuesday, July 25, 2006

New lung nodule

This is a 72 y/o man with a significant previous TOB Hx, moderate COPD who was referred to us for a new pulmonary nodule. He has had multiple urologic surgeries including a nephrectomy for transitional cell ca (it seems he had a "high" transitional ca of the calicial system). He has a new nodule on the contra-lateral (remaining) kidney and had a new CT and a pulmonary nodule was found. This is a LUL non-calcified nodule with no air-space disease and no thoracic adenopathy.
A bronch was non-diagnostic and a PET (see below) only showed intense uptake on the nodule and nowhere else (the remaining kidney had its usual physiologic uptake).
Do you think the two lesions are related? Would you try and FNA the lesion? His PFTs would tolerate a lobectomy. Would you just go straight to surgery?

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

Jeff H said...

I believe that even if this is a solitary met from a urothelial carcinoma, it would be resected. I could be wrong here, but I don't see a PET + nodule on the kidney anyway.

So, whether it is a stage 1 lung carcinoma or a solitary metastases from a urothelial carcinoma, I think resection is the best path.

Jennings said...

i agree`with resection too. I would bet that Dough will agree too but we'll see. TCC's *do* metastasize to the lungs (rarely) though...

Arenberg said...

Yeah...what they said. (Horowitz told me I had to agree with him or he'd annoy me through the shared office wall all day long). Anyway, I think the likelihood of this being a NSCLC is quite high, and if you plug it into Swensen's nomogram...

http://www.chestx-ray.com/SPN/SPNProb.html

...you get a pre-test probability of 80-90% depending on whether the thing is spiculated or smooth (even without the PET). With the PET, it is almost 100% likley to be a lung cancer.

With a solitary met from a tumor that has been controlled for a long time, a metastasectomy (did I spell that right?) is reasonable in a patient with good health otherwise.

The difference is between a wedge resection, and a lobectomy with lymh node sampling.

Baleeiro said...

I did the same algorithm calculation Doug did and came up with the same plan. The Pt is coming back to the office today and will be going to CT surgery next. I will keep you posted.