Thursday, January 18, 2007

Solitary pulmonary nodule

I recently saw a 62-year-old woman with a past medical history of fibromyalgia who received a CT scan for chest pain, which picked up an incidental pulmonary nodule.
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".....

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

Anonymous said...

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.

Arenberg said...

Some would say treat with abx and repeat at a very short interval, where others might attempt a biopsy, which if negative would prompt me to follw it, but I hate doing a biopsy of an otherwise resectable nodule. Because of the odd contour and subpleural location, I think the pre-test probablilty of this being a cancer is less than 15%, so this is one rare occasion where I'd say follow this, and a shorter interval than 6 months (say 3) is probably what I'd do.

Anonymous said...

How large was the nodule?

What about this article (check out the recommendations in the table)?

Anonymous said...
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.

Jennings said...

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...

Anonymous said...

You did the right thing.
VATS may treat her nicotine dependence as well.