Wednesday, March 19, 2008

lesion in a 45 year old woman

A 45 y/o woman presented with atypical chest pain that led to a ct showing the following:


Although a benign lesion/resolving pneumonia were possibilities, I was concerned about bronchoalveolar carcinoma in this young non-smoker. A bronch was done - BAL cytology and tbbx were negative. We were in the right area (posterior segment RUL) and Fluoro did support this, but the biopsies came back as unremarkable pulmonary parenchyma.

What would you do next? Some options would be follow with serial CT's - q 3 months, open lung, repeat bronch, or another course.

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

Doug said...

IF you treat with abx and it does not go away I'd send her to your colleague who does superdimension electromagnetic navigation guided biopsy. This would be easy to get. Alternatively you could just take it out (VATS wedge) if it persists after a course of abx. The latter may be what I would want if this were me. I agree with your concern for BAC as it looks very much like it could be that, but again I'd start with a course of treatment to see if it improves.

Anonymous said...

Why bother with the superdimension. If it persists after antibiotics, it should come out. A negative biopsy (even superdimension-guided) and it comes out. A positive biopsy and it comes out. I'd favor antibiotics, and then resection if it persists.

Doug said...

Like I said, if it were me, I'd want it out, and in formalin. I see a lot of patients who, even after explaining to them the meaning of a "negative biopsy", they still want proof before they will see a surgeon. I presume one of the reasons Jeff posted this was because (perhaps) the lady was reluctant to have surgery. I think it is gettting easier in the last few years to convince people to have "diagnostic" wedge (or more) resections now that the majority of cases here are being done thoracoscopically.

Anonymous said...

Has any of you ever heard of a transthoracic needle biopsy?? What about that as a next step!

zolt said...

CT guided transthoracic fnac is a reasonably good option.