Wednesday, September 06, 2006

Multiple pulmonary nodules

The patient is a 69-year-old African-American woman who came to pulmonary clinic for multiple pulmonary nodules that were picked up in the course of abdominal CT for workup for abdominal pain with increased LFTs (which have since normalized). She has a history of hypertension, diabetes, peripheral vascular disease, and hyperlipidemia. She is a nonsmoker. No fever chills cough SOB, diaphoresis or constitutional symptoms.
Exam: A pleasant woman in no acute distress. WT of 197, BP 185/83, P is 65, R 18, O2 sat is 97% on room air. Trachea midline. No lymphadenopathy and no supraclavicular adenopathy. No thyromegaly. Lungs: Clear to auscultation. No wheezing, rales, or rhonchi. No dullness to percussion. No egophony, symmetric chest wall on inspiration. Heart: Regular rate. S1, S2. Abdomen: Positive bowel sounds. No masses. No liver edge felt. No clubbing, cyanosis, or edema.

Data:
PFT's: FEV1/FVC 81, FEV1 76% predicted, FVC 73% predicted.
CBC with hemoglobin of 10.3, MCV of 94.6. Plts normal. Lytes-7 normal. ANA and rheumatoid factor negative



These nodules are all non-calcified. The largest is 8 mm. There is interval growth of left lower lobe nodule and right apical nodule compared to a CT 6 months prior. The subcarinal soft tissue is "prominent" but ambiguous whether it's enlarged.

On abd CT, the spleen, pancreas, kidney, gallbladder and adrenals are unremarkable.
2 calcified hepatic granulomas are seen.

Any thoughts on workup or management?


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

Arenberg said...

These look worrisome, and even more so in light of what you describe as progression. One has a ground glass like periphery to it, and I'd be very concerned about cancer. You could take it out, but at HFHF (I presume where you are seeing this lady, your colleague can probably get this with the EMN guided bronch system. If they are both cancer, it is reasonable to take them both out of there is no evidence of mediastinal LN involvement on a med'scope.

Anonymous said...

Well, with the calcified granuloma in the liver, can't this be fungal? Also, she's a non smoker and the abdominal CT didn't show any cancer in terms of worrying about metastitic disease.

some lung guy said...

If it was metastasis (i.e.from the breast) and they were present 6 months ago, one would think she would be sicker. Also, post mentioned no adenopathy although I agree that fact alone does not necessarily rule out metastatic cancer.

redneck pulmonary said...

My suspicion for mitotic process is not high either. Starting with routine cancer screening (i.e. mammogram, pap smear, colonscopy) may be an option if not done recently.

Arenberg said...

If they are growing, you better figure out what they are. "Fungal" doesn't grow slowly over 6 months, and metastases can & do grow like this without making people look sick. My money is still on cancer IF they are truly growing over 6 months. Having said that, it is a very rare radiologist that can accurately discern true growth in something this small.

Dr. Rakesh Gupta said...

In view of the finding as described the chances of metastasis or primary lung cancer are high. It possible and one can go for CT guided FNAC coorectoly can sove the problem to some extent. In the mainwhile the work to find the primary somewhere else is worth doing as mentioned by rednec pulmonary.