DrVirgo
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A 53 year old male presents to the ER complaining of chest pain localized to the left chest wall and following a linear pattern along the fifth intercostal space. His past medical history is significant for polycystic kidney disease and hypertension. His current meds are metoprolol, and amlodipine. he has a ten pack year smoking history but quit 14 years ago. he consumes alcohol occasionally. His blood pressure is 160/90 mmHg and his heart rate is 90/min. Physical exam in noncontributory. his lab findings are as follows:
Sodium: 142
Potassium: 4.2
Hgb: 9.5
WBC: 10,000
Creatinine: 1.9
BUN: 28
Chest x-ray reveals a solitary round lesion in the left upper lung field that measures 2cm in diameter. It does not abut the pleura. Which of the following is the best next step in managing this patient?
A. Pulmonary Function Testing
B. CT of the Chest
C. Percutaneous biopsy of the lesion
D. Bronchoscopy
E. Repeat chest x-ray in 2 months.
Please explain... and discuss when we would do option B. vs. C. vs. E.
Thanks.
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| Justice
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I (as thoracic oncologic surgeon) would go with B initially, to see structure of the lesion, lymph nodes, etc, which will use later on for stereotactic CT-guided biopsy of the lesion... CT will also help me to see what's up with 5th intercostal space... Never saw lung cancer mets into ribs...
E. Repeat chest x-ray in 2 months seems to be incorrect... I would rather ask for all CXR films...
So, my humble answer is B
Edited by Justice on 04/04/08 - 09:45 AM
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| Markus2009
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In this particular patient: age, PMH of smoking and the size of the nodule 2cm the diagnosis is cancer until proven otherwise...
Next step CT of the chest------->B
C if the nodule with malignant features is located peripherally
E if looks like a benign nodule: Age<35, no change from old films, central/uniform/laminated/popcorn calcification, size<2cm and smooth margins.
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| CocaCola
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B - his history warrants further studies
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| grechita12
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B. Is the best way to determinate characteristics of the lesion and decide management
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| Justice
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grechita12 wrote:
B. Is the best way to determinate characteristics of the lesion and decide management
 Well, I would say that it's still initial step because only PET scan may discriminate malignant tumor from benign, not CT... And you still need to do biopsy...
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| DrVirgo
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B is right.
However according to Kaplan,
"In high risk patients, <50years of age with a smoking history and a nodule are likely to have bronchogenic cancer. The best diagnostic procedure is open lung biopsy and removal of the nodule at the same time."
-No mention of CT!
-I chose percutaneous lung biopsy because open lung biopsy was not a choice.
For the other choice
E: In case of a young <35 year old, non smoker with a <6cm nodule -Do repeat CXR every 3 months for 2 years.
C. Percutaneous Lung Biopsy would be right only if a PERIPHERAL lung lesion -next to the pleura was discovered.
Thanks everyone.
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| DrVirgo
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In the high risk patient, should this pulm nodule be removed, or just biopsied, and then removed only if malignant?
Thanks. -still have doubts on this.
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| Justice
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DrVirgo wrote:
C. Percutaneous Lung Biopsy would be right only if a PERIPHERAL lung lesion -next to the pleura was discovered
That is stupid comment discrediting Kaplan...
First of all, the Qn does not say that this is a central (i.e. hilar) node, where I would not stick a needle... They say it is somewhere in the upper part of the lung... Now, there is no problem to get into the any node in the lung provided that it is not in the apex or by the mediastinum... Trust me...
Lastly, if you suspect lung cancer, you go for at least lobectomy (but usually pneumonectomy+mediastinal lymphadenectomy) not lumpectomy... No open biopsies of the lung nodes are done, because you have to stop lung blood/air circulation permanently... This is a rule in oncology to prevent dissemination of micromets, unless you pump in come cytostatics during the surgery...
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| DrVirgo
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Justice wrote:
That is stupid comment discrediting Kaplan...
First of all, the Qn does not say that this is a central (i.e. hilar) node, where I would not stick a needle... They say it is somewhere in the upper part of the lung... Now, there is no problem to get into the any node in the lung provided that it is not in the apex or by the mediastinum... Trust me...
Lastly, if you suspect lung cancer, you go for at least lobectomy (but usually pneumonectomy+mediastinal lymphadenectomy) not lumpectomy... No open biopsies of the lung nodes are done, because you have to stop lung blood/air circulation permanently... This is a rule in oncology to prevent dissemination of micromets, unless you pump in come cytostatics during the surgery...
Thanks for the explanation. UW also mentioned that if the patient's history and lesion's radiographic appearance leave the question of possible malignancy in doubt, biopsy and culture may be useful. and that biopsy may be obtained percutaneously or by VATS -video assisted thoracoscopic surgery...
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| peter90036
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after doing CXR/CT
When to chose Biopsy vs Sputum cytology?
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| Justice
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peter90036 wrote:
after doing CXR/CT
When to chose Biopsy vs Sputum cytology?
Sputum cytology is used very infrequently, and only when TBC/bacterial problem is suspected.
If you see a peribronchial mass - go for bronchoscopy+biopsy...
If mass is not peribronchial, then go with transthoracic needle biopsy...
CT is used for staging to decide if surgery is needed/feasible... Sometimes, cleaning mediastinum for 5-6 hours is simply useless...
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| DrVirgo
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Justice wrote:
If mass is not peribronchial, then go with transthoracic needle biopsy...
This is what I meant when I said to do Percutaneous biopsies for peripheral lesions... I guess I should have said "anything that is NOT peribronchial" instead of ONLY peripheral. 
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