tag:blogger.com,1999:blog-12660458.post112774169570655458..comments2023-09-01T10:33:09.297-04:00Comments on Pulmonary Roundtable: Obstruction and a nodule in a non-smokerUnknownnoreply@blogger.comBlogger7125tag:blogger.com,1999:blog-12660458.post-1127934079713004162005-09-28T15:01:00.000-04:002005-09-28T15:01:00.000-04:00Actually, no.They can simply have findings on the ...Actually, no.<BR/>They can simply have findings on the CT that look like classic emphysema. Their disease likely starts as bronchiolitis, so I suppose that you can see a mosaic pattern on the expiratory images if you obtained a HRCT. <BR/>Another diagnosis to consider if you are still not sure is idiopathic bronchiolitis obliterans. A SLB would be necessary to diagnose this.Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127852946987041862005-09-27T16:29:00.000-04:002005-09-27T16:29:00.000-04:00Well, there's nothing on history to suggest HP and...Well, there's nothing on history to suggest HP and the CT does not show anything like ground glass. I admit thought that I didn't get an HP panel. In patients with obstructive HP, do those patients have classic ground glass findings like the restrictive cases?Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127847945079469232005-09-27T15:05:00.000-04:002005-09-27T15:05:00.000-04:00Jennings measurement of 17 mm gives a pretest prob...Jennings measurement of 17 mm gives a pretest prob of 22%.<BR/>That gives a post test prob of 4% malignancy.<BR/><BR/>What is a nice learning point for me in this case is how the size of a nodule really affects the decision pathway.<BR/><BR/>Even in lung cancer, size does matter.<BR/><BR/>As for the patient, any chance she may have HP? A subset of patients with HP will have both obstructive and restrictive physiology. In Farmers lung, for ex, obstruction is more common than restriction<BR/>Cormier et al. ERJ 2000. 16(1) 56-60Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127827046263449362005-09-27T09:17:00.000-04:002005-09-27T09:17:00.000-04:00Well, I see carlos has posted his case so hopefull...Well, I see carlos has posted his case so hopefully you all won't give up on my case just yet. Here in answer to your comments. We will start with the PFT's.<BR/>1. regarding asthma; she has had 2 post-bronch studies that showed no significant respponse (FEV1 from 0.87 (43%) to .99 (49%)). We did put her on inhaled steroids anyway, but repeat spiro showed no change in the severe obstruction. It's a good point about post-op and surgery, but repeat sprio a year later showed the same defect. Also, her FEV1/SVC ratio was no differetn than the FEV1/FVC ratio. <BR/>2. regarding emphysema; the rest of the CT does not show any emphysema or bullae. The alpha 1 globulin level was normal, making A1AT deficiency unlikely. Her occupational and social history are unremarkable. <BR/>2. As for the suggestion that she also has a restrictive defect; there's not much on history to suggest an etiology; she has no weakness, she has no heart failure, her CT shows no parenchymal disease. She did have some pleural effusions in the setting of the abdominal surgery but a CT later showed complete resolution without evidence of pleural abnormalities. Actually, come to think of it, I never repeated that TLC - maybe there was some residual effusion during that sprio - I will have to check. good point lazar.<BR/><BR/>Her abdominal story is she presented with n/v with gastroenteritis. Found to have a partial bowel opbstruction and got laparotomy with lysis of adhesions. No one knows waht caused the obstruction as far as I can tell from the notes. <BR/><BR/>As for PET discussion: doug asked about change in size in order to help figure out the pre and post test probabilities; the latest CT shows it to be 1.7 x 1.0 cm with no change at all compared to the one 6 months ago. BTW a CXR from 7/2004 was negative. <BR/>A CT (her first) from 12/04 is not available to check for change in size; the report says it is "about 1.5 cm" but I am not sure if this is a true change.Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127825778709991312005-09-27T08:56:00.000-04:002005-09-27T08:56:00.000-04:00I actually put in a "non-malignant" growth rate as...I actually put in a "non-malignant" growth rate as the nodule had not changed in 6 months.<BR/>If I put in a "not known" the risk of malignancy is 3%<BR/>Here is my criteria:<BR/>Pretest prob 18%<BR/>Nonsmoker, no hemoptysis, no prev malignancy<BR/>1.1-2cm, lower lobe, spiculated, growth rate not known, no cavitation, no calcification<BR/>contrast enhance not performed, neg PET.<BR/>Did I enter something incorrectly?Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127761039937598312005-09-26T14:57:00.000-04:002005-09-26T14:57:00.000-04:00www.chestx-ray.com is really a great resource and ...www.chestx-ray.com is really a great resource and the stats help put things in perspective for some patients. Any chance she has had unrecognized asthma and now has airway remodelling? <BR/>Any Hx of second-hand TOB or interesting occupational exposures?Baleeirohttps://www.blogger.com/profile/03993066135160692535noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1127760102118249222005-09-26T14:41:00.000-04:002005-09-26T14:41:00.000-04:00In conjunction to Doug's reference, I refer you to...In conjunction to Doug's reference, I refer you to a website:<BR/>www.chestx-ray.com<BR/><BR/>On this site, you can calculate the pretest prob of malignancy (the bottom calculation) and plug the patients' characteristics and nodule information in the top to get a post-test probability of malignancy. <BR/>When done for this patient, the post-test prob of malignancy is 0%. This is a nice program to allow you to get some objective info on a patient and a nodule.<BR/><BR/>Now the case... she has a restrictive vent defect too as her TLC is 75% predicted. Can we have some more history?<BR/><BR/>Given the degree of obstruction she has on spiro, I would expect that she has more air trapping or a reduction in her DLCO. Maybe this is asthma and would get better with steroids.Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.com