1 / 26

Solitary Pulmonary Nodule

Solitary Pulmonary Nodule. Victor Ghobrial, MD Balkison Maharajh, MD Botrous Zeidan, MD. HPI. 61 F presented with black stools & hematemesis , a week before was treated for gastric ulcer by cauterization

vlad
Download Presentation

Solitary Pulmonary Nodule

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Solitary Pulmonary Nodule Victor Ghobrial, MD Balkison Maharajh, MD Botrous Zeidan, MD

  2. HPI • 61 F presented with black stools & hematemesis, a week before was treated for gastric ulcer by cauterization • Also gave Hx of abnormal mammography and recent exicional Bx which was +ve for malignancy

  3. PMH • PUD • Pneumonia a year ago multiple F/U CXR • TIAs • Lumpectomy Lt breast benign tissue • Hysterectomy • Appendectomy • Urinary bladder suspension

  4. Meds • Servent • Vanceril • Mevacor • Prilosec • Alprazolam • Premarin • NKDA

  5. Social Hx • Smoked 1 pack/day over 40 years • Lives with family • Takes care of 3 handicapped persons

  6. Family Hx • Positive colon cancer, CAD, stroke • Negative DM, HTN

  7. ROS • Lost 40 lbs over one year • Positive for lightheadedness, abd pain • Negative for CP, SOB, fever

  8. Physical Exam • Looks older than stated age • Vitals WNL • Recent well healing scar Rt breast • Otherwise unremarkable

  9. Labs • Hgb Hct WBCs Plt MCV 8.8 26 13.3 495 91 • PT INR PTT 11.0 1.1 30 • Lytes, BUN/ Cr: WNL

  10. X-Ray • CXR • CT

  11. Pathology • Low grde in-situ Rt breast cancer without involvement of axillary lymph nodes

  12. Hospital Course • Transfused with PRBCs; Hgb 11.3 • EGD: Erosive gastric ulcer was cauterized, AVM of duodenum was cauterized & Bx for CLO was done

  13. CT Guided Bx • Negative for cancer cells • Dense neutrophil infiltrate suggestive of abscess formation

  14. Solitary Pulmonary Nodule • Basic strategy is to identify malignant versus benign • Definition: Opacity with diameter < 3cm • Larger lesions are called masses • It occurs in 1 every 500 CXR

  15. Solitary Pulmonary Nodule • Nodules prove to be malignant in 40% of cases • Most often Bronchogenic carcinoma • Most common benign is hamartoma • Benign lesions: rheumatoid granuloma, healed infarct, pulmonary anurysm, Wagner’s granulomatosis

  16. Early Resection • Studies have proven that early resection results in 5-year survival rate of 50% • If nodule is 1cm or less rate is about 80% • Survival rate after discovery of bronchogenic carcinoma is 15% and hence the importance of early discovery in terms of cure

  17. Growth of a Nodule • Malignant nodules grow at a constant rate expressed as doubling time • This usually falls between 25 and 450 days with a median of 120 days • An increase of 28% in nodule diameter indicates doubling

  18. Growth of a Nodule • Benign lesions grow slowly with doubling time exceeding 500 days • It is almost conclusively a benign lesion if size is stable for 2 years ( doubling time exceeding 720 days ) • A doubling time of less than 20 days signifies inflammatory process

  19. Calcification • Radiographic pattern of calcium deposition is helpful • Benign lesions tend to have central, laminated (bull’s eye), diffuse or popcorn pattern • Malignant lesions have speckled or eccentric pattern

  20. High Resolution CT • HRCT is the most sensitive and specific for assessing the size, shape, calcification and edge of a nodule • Type 1 Type 2 Type 3 Type 4

  21. PET Scan • Highly valuable noninvasive tool • It is 95% sensitive for identifying malignancy and 85% specific • False positive results may occur in lesions that contain active inflammatory tissue (histoplasmomas)

  22. Biopsy • Bx has a high yeild in establishing Dx • Bronchoscopy can not access a nodule if it is peripheral and small • If CT shows a bronchus entering a nodule its yeild is much higher • Transthorathic needle aspiration (NAB) has a sensitivity of 80% to 90%

  23. Surgery • Thoracotomy to resect a malignant nodule carries significant death of 3% to 4% but for a benign lesion it is 0.3% • Thoracoscopy carries less significant morbidity and lessens hospital stay • It is not known if the 5-years survival is different between the two approaches

  24. Age <48 nodule diameter<1.5 never smoked nodule edge type1 doubling time >500 d calcification in benign Needle Bx: benign dis Needle Bx: Nonspecific >48 >1.5 ever smoked type3 30 to 400 days indeterminate pattern malignant disease suspicious cells Benign vs Malignant

  25. Decision Making • Review all prior CXR • Get CT scans • If probability of cancer is <10% wait and watch • If it is high thoracotomy should intervene • Bronch & NAB reserved for pt who are reluctant to go for surgery before Dx

  26. Decision Making • If results are intermediate: Thoracotomy, NAB and PET are equal in terms of 5-years survival • PET is slightly more effective,noninvasive • If PET is +ve but other criteria are low for malignancy, then ANB is needed to R/O infectious granulomas

More Related