A 53-year-old man comes to the office due to nonspecific chest pain localized to the left chest along the fifth intercostal space. His other medical problems include autosomal dominant polycystic kidney disease and hypertension. He has a 10-pack-year smoking history but quit 14 years ago. He consumes alcohol occasionally and does not use illicit drugs. Blood pressure is 160/90 mm Hg and pulse is 90/min. Physical examination shows no abnormalities. Laboratory results are as follows: Chest x-ray reveals a solitary round lesion in the left upper lung field 1 cm in diameter with sharp borders. The lesion does not touch the pleura. A chest x-ray from 3 years earlier was normal. Which of the following is the most appropriate next step in evaluating this patient's pulmonary findings?

Question

A 53-year-old man comes to the office due to nonspecific chest pain localized to the left chest along the fifth intercostal space.  His other medical problems include autosomal dominant polycystic kidney disease and hypertension.  He has a 10-pack-year smoking history but quit 14 years ago.  He consumes alcohol occasionally and does not use illicit drugs.  Blood pressure is 160/90 mm Hg and pulse is 90/min.  Physical examination shows no abnormalities.  Laboratory results are as follows:  Chest x-ray reveals a solitary round lesion in the left upper lung field 1 cm in diameter with sharp borders.  The lesion does not touch the pleura.  A chest x-ray from 3 years earlier was normal.  Which of the following is the most appropriate next step in evaluating this patient's pulmonary findings?

Quizplus · Accepted Answer

11ec25c8_d109_7f5a_bc81_911f47050eee_MD0003_00 A solitary pulmonary nodule (SPN) is defined as a round opacity up to 3 cm in diameter within and surrounded by pulmonary parenchyma. By convention, there must be no associated pleural effusion, adenopathy, or atelectasis. SPN is often discovered incidentally on chest x-ray and can be due to many causes. The first step is to compare previous x-rays or scans. An SPN with stable size and appearance for 2 to 3 years has a low malignancy risk and the patient may be given reassurance without further workup. Ground-glass lesions have a higher malignancy risk and likely require yearly assessment, even with stable appearance and size. causes Unstable or new lesions require further assessment for malignancy risk. The main objective in assessing SPNs is to promptly detect and surgically resect malignancies and to leave benign lesions intact. Nodules <0.8 cm with smooth margins are less likely to be malignant; nodules ≥2 cm with irregular or spiculated margins are more likely to be malignant. Other factors to consider are age and smoking status. Patients age >60 have a higher likelihood of malignancy. In addition, current smokers have increasing malignancy risk as the daily cigarette consumption increases. This patient has a new SPN since a previous chest x-ray and requires chest CT scan to further assess the malignancy risk. CT scan is more sensitive than chest x-ray to identify these features and also can detect other small nodules that may represent metastasis. If the CT scan findings are suspicious for malignancy, biopsy followed by likely surgical excision should be performed. Lesions that appear less likely to be malignant on CT scans can be followed with serial CT scans for 2 to 3 years to monitor for growth. (Choice B) Bronchoscopy can be used to biopsy accessible lesions (central lesions) but is not as sensitive as percutaneous biopsy unless the lesion is >2 cm. In general, percutaneous biopsies and surgical excision carry a superior diagnostic yield. (Choice C) Percutaneous biopsy is recommended for lesions that appear malignant and in patients with high clinical suspicion for malignancy. If the CT findings are suspicious for malignancy, a biopsy can be attempted by CT guidance. An initial CT scan will also help evaluate whether the lesion can be accessed percutaneously without risk for pneumothorax. (Choice D) Pulmonary function testing will provide no additional information regarding the biologic behavior of the mass. It is often obtained as part of the routine follow-up of chronic obstructive pulmonary disease and in patients with lung cancer who are evaluated for surgical fitness. (Choice E) CT scan offers better resolution and growth detection than chest x-ray (0.5 mm versus 3.5 mm) and is preferred for following an SPN. Educational objective: Evaluation of a solitary pulmonary nodule detected on chest x-ray includes comparison with old imaging studies, if available, followed usually by chest computed tomography. The decision to observe, biopsy, or surgically resect the nodule is based on its size and characteristics as well as the patient's age and smoking history. References: The solitary pulmonary nodule-deciding when to act? (http://www.ncbi.nlm.nih.gov/pubmed/24258565)

A 53-Year-Old Man Comes to the Office Due to Nonspecific