Solitary Pulmonary Nodule in a 58-Year-Old Male (Case 42)

Chapter 61 Solitary Pulmonary Nodule in a 58-Year-Old Male (Case 42)

Dennis F. Zagrodnik, II, MD

Differential Diagnosis

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Speaking Intelligently

When I’m asked to see a 58-year-old male who presents with a solitary pulmonary nodule, my careful history will usually help me know how to proceed with the workup. I ask if the abnormality was found during a routine screening chest x-ray or if the patient has symptoms of cough, hemoptysis, or recent pneumonia. I determine if the patient is a smoker or previous smoker and if he has had any occupational exposures, has traveled recently, has had exposure to tuberculosis, or carries a diagnosis of previous malignancy. Lastly, I ask if he has ever been told that he has a nodule in his lung or if he has had previous chest x-rays or CT scans of his chest that could help establish the duration of his nodule’s existence.

PATIENT CARE

Clinical Thinking

• Keep in mind that age greater than 50 years, male gender, and a history of smoking increase the probability of lung cancer; however, lung cancer now ranks as the leading cause of cancer-related mortality in both men and women.
• As you proceed with the examination, remember that the clinical hx along with the radiological appearance will help you determine the probability of malignancy. As the average 5-year survival for all lung cancer is a dismal 5% to 10%, remember it is only the patient who is diagnosed early with a stage I cancer who can benefit from the 60–70% 5-year survival rate for stage I disease.

History

• Consider why the patient was found to have an SPN—screening CXR, infectious symptoms, or preoperative evaluation.
• Inquire about smoking hx; risk increases for duration and quantity.
• Inquire about occupational exposures, specifically asbestos, heavy metals, radon, or dust.
• Travel hx or previous habitation is important for fungal exposures like coccidioidomycosis in the Southwest or histoplasmosis in the Midwest. Foreign travel or any tuberculosis exposures are also important.
• Most SPNs are usually clinically silent without pain or physical findings. Non–small cell cancer and small cell cancer may present with hemoptysis, dry cough, or even chest pain, if pleural based. Most commonly, patients have nonspecific symptoms of fatigue and weight loss if any symptoms at all. Granulomas are usually preceded by some acute infectious symptoms of fever, cough, and malaise, which may have occurred several years earlier. Congenital lesions are usually asymptomatic unless secondarily infected. Metastases are also asymptomatic unless associated with other sites of recurrence.

Physical Examination

• Physical examination rarely gives insight to the etiology of an SPN. However, the examination should focus on several things: search for potential spread of metastatic lung cancer; thorough examination for comorbid or congenital disease, and examination for signs of an asymptomatic extrathoracic primary malignancy.
• Pulmonary function testing and functional status should be assessed in all patients.
• The search for spread of a metastatic lung cancer involves examination of the cervical region and supraclavicular lymph nodes. Musculoskelatal examination should look for bone tenderness, soft tissue masses, clubbing, or hypertrophic osteoarthropathy, which may suggest a paraneoplastic syndrome (most common with small cell cancer). A focused neurological examination should be performed for potential CNS metastasis or a neurological paraneoplastic syndrome.
• Abdominal masses, breast masses, abnormal skin lesions (melanoma), or soft tissue masses (sarcoma) and, in males, testicular masses (germ cell tumor) may diagnose an asymptomatic extrathoracic malignancy with single pulmonary metastasis.
• A simple test to gauge pulmonary reserve: ask the patient to walk up several flights of stairs; upon completion, see if the patient can speak in full sentences.

Tests for Consideration

• Pulmonary function test (PFT) with arterial blood gas (ABG): Necessary to establish tolerance for operative biopsy.
 $26
• Fiberoptic bronchoscopy with biopsy: Flexible lighted scope under conscious sedation sometimes with fluoroscopic assistance. May help r/o synchronous airway lesions; diagnostic yield lower for peripheral nodules and small size nodules. Diagnostic only, and a nonmalignant pathology finding is inconclusive.
 $401
• Transthoracic needle biopsy: CT-guided biopsy fine-needle aspiration or core needle. Risk for pneumothorax 20%. Higher risk in patients with coagulopathy and emphysematous changes. Diagnostic only and nonmalignant dx not definitive.
 $950
• Video-assisted thoracic surgery (VATS) or open biopsy: Necessary when bronchoscopy or image-guided biopsy is nondiagnostic and imaging/risk factors make malignancy likely.
 $1,912

IMAGING CONSIDERATIONS

→ CXR (PA and lateral erect): CXR usually discovers SPN. It is critical to track down old studies to determine the stability of the nodule over time. Benign nodules usually have dense calcifications, but these may not be readily shown by plain radiographs alone.
 $125
→ CT of the chest with IV contrast: Modality of choice to evaluate the pulmonary nodule. High-resolution thin sections can show benign calcifications. Malignant nodules are ill defined and have irregular, spiculated margins. If multiple other nodules not visible on the CXR become apparent, then metastasis is a concern. Accurate size measurement is critical and can be performed by 3D computer programs. Nodules 6 mm or less in size may be candidates for image-only follow-up depending on certain, now well accepted criteria: Fleischner Society Guidelines.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Solitary Pulmonary Nodule in a 58-Year-Old Male (Case 42)

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