A 59-year-old man comes to the office due to cough and mild dyspnea. His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days. However, the cough, productive of white sputum, has persisted. He has also had an episode of blood-streaked sputum. The patient has a history of hypertension and stable coronary artery disease. He is a current smoker with a 20-pack-year history. The patient is a car salesman and has not traveled recently. Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min. Lung examination shows scattered wheezes bilaterally. Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe. No prior chest imaging is available. CT scan of the chest confirms a 2.2-cm, peripherally located nodule in the left lower lobe surrounded by lung parenchyma. The nodule has spiculated borders and eccentric calcification on the periphery, and no lymphadenopathy is present. CT scan of the abdomen reveals no abnormalities of the liver or adrenal glands. Which of the following is the best next step in management of this patient's lung lesion?

Question

A 59-year-old man comes to the office due to cough and mild dyspnea.  His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days.  However, the cough, productive of white sputum, has persisted.  He has also had an episode of blood-streaked sputum.  The patient has a history of hypertension and stable coronary artery disease.  He is a current smoker with a 20-pack-year history.  The patient is a car salesman and has not traveled recently.  Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min.  Lung examination shows scattered wheezes bilaterally.  Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe.  No prior chest imaging is available. CT scan of the chest confirms a 2.2-cm, peripherally located nodule in the left lower lobe surrounded by lung parenchyma.  The nodule has spiculated borders and eccentric calcification on the periphery, and no lymphadenopathy is present.  CT scan of the abdomen reveals no abnormalities of the liver or adrenal glands.  Which of the following is the best next step in management of this patient's lung lesion?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c081_438c_8f63_cbfb960b2648_MD0005_00 The size of a solitary pulmonary nodule (SPN) 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, location of the nodule in the lung, and radiographic appearance of the nodule. 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. Based solely on its large size (>2 cm), this patient's SPN has >50% probability of being malignant (far exceeding 5%). This probability is further increased by the patient's smoking history and the spiculated appearance of the nodule. For a nodule with such high malignant probability, timely surgical excision is most appropriate; 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 demonstrating high metabolic activity on PET scan are more likely malignant than benign and warrant biopsy or surgical excision. (Choice A) Fiberoptic 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) This SPN requires additional intervention, as it has a high chance of being malignant. (Choice E) Surveillance with repeat CT scan in 3, rather than 6, 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 the relatively large, spiculated nodule in this man with a significant smoking history. 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: Diagnosis and management of solitary pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/20477238) The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. (http://www.ncbi.nlm.nih.gov/pubmed/19484354)

A 59-Year-Old Man Comes to the Office Due to Cough