A 35-year-old woman slipped and fell on her side 2 days ago when going downstairs. Since then, she has been having pain in her right shoulder. Ibuprofen provides some relief. She does not use tobacco or alcohol. Examination suggests a shoulder sprain. An x-ray reveals a normal shoulder and a 1.5-cm coin-shaped lesion in the periphery of the right lung with well-aerated surrounding lung. What is the next best step in management of this lung lesion?

Question

A 35-year-old woman slipped and fell on her side 2 days ago when going downstairs.  Since then, she has been having pain in her right shoulder.  Ibuprofen provides some relief.  She does not use tobacco or alcohol.  Examination suggests a shoulder sprain.  An x-ray reveals a normal shoulder and a 1.5-cm coin-shaped lesion in the periphery of the right lung with well-aerated surrounding lung.  What is the next best step in management of this lung lesion?

Quizplus · Accepted Answer

11ec25c8_d4bb_634d_bc81_8142244dd379_MD0003_00 A solitary pulmonary nodule (SPN) is defined by the features of round opacity, up to 3 cm in diameter, and surrounded by pulmonary parenchyma. By convention, there must be no associated pleural effusion, adenopathy, or atelectasis. Most incidentally discovered SPNs are benign (eg, infectious granuloma, hamartoma). However, it is important to differentiate benign from malignant nodules (eg, bronchogenic carcinoma, metastasis). The first step in evaluating an SPN is comparison with previous x-rays. If a solid lesion revealed on prior imaging is stable in size for >2 years, malignancy is effectively ruled out and no further testing is necessary. Malignant nodules tend to double in size over the course of a month to a year. If no previous radiographs are available for comparison, a CT scan (Choice D) should be performed to further characterize the lesion. CT provides greater detail of a lesion's size, borders, and density. Large nodule size, low density, spiculated borders, and eccentric calcification favor carcinoma. Other clinical characteristics suggesting malignancy include age >40, history of smoking, weight loss, and previous malignancy. Nodules with high overall risk for malignancy should be excised (Choice F). Those with low malignant potential should be followed with serial CT scans. The exact interval of imaging depends on patient and nodule characteristics. risk for malignancy (Choices B, C, and E) 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) or tissue biopsy is warranted when clinical and radiographic data indicate an intermediate probability of malignancy. Choice of diagnostic technique depends on the clinical situation and patient and physician preferences. PET scanning is less invasive and generally preferred. Bronchoscopy is best for biopsy of centrally located lesions, and CT-guided percutaneous biopsy is best for peripheral lesions. Educational objective: The first step in evaluation of solitary pulmonary nodules is to obtain any previous radiographic lung images. Absence of growth over 2-3 years rules out malignancy. If previous films are not available, a CT should be performed to further characterize the lesion. References: The solitary pulmonary nodule-deciding when to act? (http://www.ncbi.nlm.nih.gov/pubmed/24258565)

A 35-Year-Old Woman Slipped and Fell on Her Side 2