A 53-year-old woman comes to the physician for evaluation of a pulmonary nodule detected on a chest x-ray performed for atypical central, burning chest pain. Her pain resolved with omeprazole. The patient has hypertension and chronic low back pain for which she takes hydrochlorothiazide and as-needed ibuprofen. She has a 30-pack-year smoking history and quit 3 years ago.
Blood pressure is 142/88 mm Hg and pulse is 78/min. The lungs are clear to auscultation, and the remainder of the examination shows no abnormalities.
CT scan of the chest reveals a 2.1-cm spiculated nodule with peripheral punctate calcifications in the periphery of the right upper lobe. There is no mediastinal lymphadenopathy. No previous radiographs are available for comparison.
Which of the following is the best next step in management of this patient's lung lesion?

Question

A 53-year-old woman comes to the physician for evaluation of a pulmonary nodule detected on a chest x-ray performed for atypical central, burning chest pain.  Her pain resolved with omeprazole.  The patient has hypertension and chronic low back pain for which she takes hydrochlorothiazide and as-needed ibuprofen.  She has a 30-pack-year smoking history and quit 3 years ago.
Blood pressure is 142/88 mm Hg and pulse is 78/min.  The lungs are clear to auscultation, and the remainder of the examination shows no abnormalities.
CT scan of the chest reveals a 2.1-cm spiculated nodule with peripheral punctate calcifications in the periphery of the right upper lobe.  There is no mediastinal lymphadenopathy.  No previous radiographs are available for comparison.
Which of the following is the best next step in management of this patient's lung lesion?

Quizplus · Accepted Answer

11ec193a_98cb_4abb_853d_6ddedb9a47ae_MD0002_00 This patient has a solitary pulmonary nodule (SPN), defined as: Rounded opacity≤3 cm in average diameter (>3 cm is considered a "mass")Surrounded by pulmonary parenchymaNo regional lymphadenopathy Rounded opacity ≤3 cm in average diameter (>3 cm is considered a "mass") Surrounded by pulmonary parenchyma No regional lymphadenopathy The size of a nodule strongly correlates with the chances of it being malignant. Nodules <0.6 cm are unlikely to be malignant and generally do not require follow-up; however, nodules >0.8 cm require additional management or surveillance. In addition to size, other factors that influence the probability of an SPN being malignant include patient age, sex, smoking history, family history, nodule location, and radiographic appearance. Nodules >0.8 cm that are intermediate or high probability for malignancy (ie, ≥5% probability) based on these factors require tissue diagnosis with biopsy or surgical excision. This relatively large upper lobe SPN with spiculated borders in a woman with a significant smoking history has high malignant probability and should be biopsied or surgically excised as soon as possible. Surgical wedge resection by thoracotomy or video-assisted thoracoscopy (VATS) can be both diagnostic and curative. For patients in whom the need for tissue diagnosis is unclear, positron emission tomography (PET) scan can be helpful; nodules without high metabolic activity can be monitored with serial CT scans. (Choice A) Bronchoscopy with transbronchial biopsy can be appropriate for obtaining tissue diagnosis prior to surgery; however, it is typically useful only for centrally located nodules. This peripherally located nodule would require percutaneous biopsy. (Choice B) Induced sputum cytology has a low sensitivity for detecting malignancy and is generally not helpful in evaluating an SPN. (Choice C) Surveillance with repeat CT scan in 3 months is appropriate for nodules >0.8 cm that are low probability for malignancy (eg, 1 cm nodule in a 50-year-old man with no smoking history). However, expedient tissue diagnosis is needed for this relatively large, spiculated nodule in a woman with a significant smoking history. (Choice E) Infectious granulomas (eg, tuberculosis, histoplasmosis, atypical mycobacteria) are the most common cause of benign pulmonary nodules. The nodules are often multiple rather than solitary and in the absence of active disease, are relatively small (ie, <1 cm). Educational objective: Solitary pulmonary nodules <0.6 cm are unlikely to be malignant, whereas those >0.8 cm require additional management or surveillance. Nodules that are intermediate or high probability for malignancy (ie, ≥5% probability) based on clinical factors (eg, nodule size, patient age, smoking history) should be biopsied or surgically excised. __________ References: The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. (http://www.ncbi.nlm.nih.gov/pubmed/19484354)

A 53-Year-Old Woman Comes to the Physician for Evaluation of a Pulmonary