She is asymptomatic; no shortness of breath or cough. She is a 35 pack-year smoker and has not been able to quit. Her spirometry is normal.
A CT is shown here
What would you do?
1. refer to CTS for resection
2. Get a PET (and what would you do with that info?)
3. Follow radiographically, say, with a repeat CT in 3 months?
I'll tell you what I did after comments.
Feel free to enter your name as "anonymous".....
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Presuming there are no mediastinal nodes, I think either of two approaches is reasonable: The boards answer here would be to refer to CT surgery for a wedge resection and, if the frozen or final path are + proceed with a lobectomy.
And that's what I would recommend to the patient.
That said, it looks small, and I don't think that I would argue with close, serial radiographic follow-up.
How large was the nodule?
What about this article (check out the recommendations in the table)?
http://radiology.rsnajnls.org/cgi/content/full/237/2/395
http://cweblog.usuhs.mil/SPN/
I often use above SPN calculator (Gurney’s version) on my Palm in a case like this.
Pretest probability of cancer in this case ranges somewhere between 50-90% depending on how you interpret the nodule (margin, calcification, size etc). So I would be more inclined to send the pt for VATs.
Fleischner’s guidelines mentioned above may be too conservative in the current medicolegal climate which they also admit.
As it turns out, I sent the pt to CTS because she was very anxious about walking around with a spot on her lung. On frozen, it was a lymph node...
You did the right thing.
VATS may treat her nicotine dependence as well.
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