Unfortunately, our computer is not letting me retrieve the PET images on this patient so I'll try and describe it without puppets.
This is a 71 y/o man with long TOB Hx but still good mechanics (FEV1~78%) with a new lung mass. He was found to have a 2.5-cm mass in the RML and had a CT-guided Bx which was + for adenoCa. He then had a PET and came to see us: the mass was obviously hot but he had FDG-avid subcarinal and L hilar nodes and a 1-cm FDG-avid LUL peripheral lesion. I bronch'ed him and sampled his nodes and got lots of giant cells and lymphocytes but no malignancy (from both sites). A LUL BAL was non-Dx.
Would you Bx the LUL separately? And if so how would you approach this (synchronous vs metastatic lesions, etc.)?
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Did CT also show significant subcarinal, lt hilar adenopathy and LUL lesion ?
I would try EBUS guided FNA, especially lt hilar adenopathy if not done previously.
If you practice in a histo country, specificity of PET really suffers.
The adenopathy was mostly subcarinal, where we got the lymphocytes/giant cells on FNA. We are indeed in histo country.
If the patient is fit, I would consider Mediastinoscopy and targetted sampling of adenopathy. If it is negative, he could potentially undergo curative resection of both LUL and RML mass assuming them to be synchronous lesions.
"in histo country" as what he has is histoplasmosis???
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