Wednesday, August 09, 2006

Proceed or watch? Is it CA?

Here is a case submitted to us:

8/1/06 49 YO Caucasion male, married with minor children, comfortably employed professional, USAF Gulf War Veteran, 2-3 PPD smoker X30 years, ETOH dependent (averages 6-10 beers daily)presents with R clavicular pain after home remodeling project. Well developed, well nourished, muscular, athletic body type. VS WNL. Non remarkable EKG. Clavicle XR demonstrates shoulder separation with incidental 1.75cm diameter spiculated nodule mid upper right lobe lung, mild emphysematous changes. CT confirms nodule. PET eyes to knees results no demonstrative uptakes. CBC, Metabolic panels normal. CEA and CA125 WNL. PFTs near normal, demonstrates ability to tolerate surgery.

Family HX: Maternal died d/t +NSCL CA with brain, liver mets. Paternal +adenocarcinoma colon, in remission post colectomy and chemo. No other significant family HX or disease.

Smoking Cessation in process with nicotine patch use. ETOH use diminishing. Pt. wants no invasive surgery or BX unless absolutely indicated. Lesion is not near bronch, no bronchoscopy in plan. What next?

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

Arenberg said...

I'd love to see a CT, but if it is truly a spiculated nodule in a heavy smoker, you know what my preference would be.

The negative PET is one situation where a CT guided bx might be reasonable if its is feasible. If the bx was negative, and of decent quality, you could follow. If it was my lung, I'd want it taken out.

Baleeiro said...

I'd have it taken out too. If you plug his data on an SPN calculator, without the PET result his probability of malignancy is ~97% but even with the PET it is still ~70% (!).

Anonymous said...

Could someone tell us where to find a SPN calculator? I take it SPN means solitory pulmonary nodule. Is it a freeware application?

Baleeiro said...

I use the one from chest-xray.com: http://www.chestx-ray.com/SPN/SPNProb.html . It is a free application.

Anonymous said...

(im just a pre-med student, so dont take what i say too seriously)what about the ct scan enhancement??? since the nodule is relatively small a false negative pet might be considered. and yea the spiculated feature and the >25years of tabaco use definitely increase the risk of malignancy! Any pfts information??? if it was my brother
i would send him to surgery right away!

Anonymous said...

Yes ... based on size .. I would biopsy ... even with a negative PET ... BAC can be negative on PET so.. it would be prudent ...