A 65-year-old man is found to have a lung nodule on chest x-ray performed for evaluation of a dry cough. The cough has since resolved, and he has no other symptoms. The patient has a 30-pack-year smoking history but quit 2 years ago. He has no family history of cancer. CT scan of the chest reveals a 2-cm, peripheral, round lesion in the right lower lung lobe that is surrounded by lung parenchyma. The borders are irregular and no calcification is present. There are no other lung lesions or enlarged lymph nodes. Which of the following is the best next step in management of this patient's lung lesion?

Question

A 65-year-old man is found to have a lung nodule on chest x-ray performed for evaluation of a dry cough.  The cough has since resolved, and he has no other symptoms.  The patient has a 30-pack-year smoking history but quit 2 years ago.  He has no family history of cancer.  CT scan of the chest reveals a 2-cm, peripheral, round lesion in the right lower lung lobe that is surrounded by lung parenchyma.  The borders are irregular and no calcification is present.  There are no other lung lesions or enlarged lymph nodes.  Which of the following is the best next step in management of this patient's lung lesion?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d949_76ec_bc81_3127d9979271_MD0003_00 A solitary pulmonary nodule (SPN) is defined by the following features: Rounded opacity ≤3 cm in diameter (>3 cm is considered a "mass") Surrounded by pulmonary parenchyma No associated lymph node enlargement The size of an 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 (eg, regular versus irregular borders). Nodules >0.8 cm that are intermediate or high probability for malignancy (ie, ≥5% risk) based on these factors require tissue diagnosis with biopsy or surgical excision. This relatively large SPN with irregular borders in a 65-year-old patient with a significant smoking history has high malignant probability and should be biopsied or surgically excised. 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) Infectious granulomas (eg, tuberculosis, histoplasmosis, atypical mycobacteria) are the most common cause of benign pulmonary nodules; however, the nodules are typically multiple rather than solitary and, in the absence of active (symptomatic) disease (eg, fever, cough, weight loss), are relatively small (ie, <1 cm). (Choice B) Sputum cytology has low sensitivity for detecting malignancy and is generally not helpful in evaluating an SPN. (Choice C) Reassurance alone is not appropriate, as this SPN has a high chance of being malignant. (Choice E) 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 the relatively large nodule in this 65-year-old patient 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.

A 65-Year-Old Man Is Found to Have a Lung Nodule