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  #1  
Old 10-30-2011
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Arrow Solitary pulmonary nodule

A 61-year-old man receives a preoperative chest radiograph before elective arthroscopic surgery. A 3-cm, isolated pulmonary nodule is seen on the chest radiograph. No lymphadenopathy, effusion, or other lesions are noted. The lesion has spiculated margins and a dense, irregular pattern of calcification. The patient is referred to you for evaluation of this lesion. He reports no recent illnesses, and has had no pulmonary symptoms. He does not take any medications, has not traveled out of the country in 30 years, and has no sick contacts. A review of systems and past medical history yields no further information. The patient admits a 60-pack-year history of smoking. Which of the following is the most appropriate next step in the evaluation of this patientís pulmonary finding?
A. Order a contrast-enhanced CT of the thorax
B. Order a positron emission tomography scan
C. Perform a flexible bronchoscopy with biopsy
D. Send sputum for cytology
E. Try to obtain previous chest radiographs
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  #2  
Old 10-30-2011
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First go with E, then B.
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  #3  
Old 10-31-2011
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try to obtain past radiographs even if he has 30 years smoking history
if past radiographs do not show this lesion we can do bronchoscopy
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Old 10-31-2011
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The correct answer is E. The first step in the workup of a solitary pulmonary nodule is to examine old radiographs. Approximately 35% of isolated pulmonary nodules are bronchogenic carcinoma. On average, malignant lesions double in volume in less than 18 months. Old radiographs that reveal a lesion of similar size will dramatically increase the likelihood that the lesion is benign.

Contrast CT (choice A) is an excellent method to further evaluate a nodule, and is the next step after evaluating old films. If the old radiographs do not show a lesion, then a CT will be necessary. The greater the enhancement of the lesions, the more likely the lesion is to be malignant.

Positron emission tomography (PET) scan (choice B) is a sensitive modality, but one that is not always available and is still under investigation.

Flexible bronchoscopy (choice C) can provide tissue diagnosis if the mass is near an airway. If not, CT-guided percutaneous biopsy is necessary. Before getting tissue, however, the lesion should be confirmed to be new, and then further visualized with CT.

Sputum cytology (choice D) can provide diagnosis in only approximately 20% of instances of solitary pulmonary nodule. If this is a new lesion, sputum cytologies should be sent.
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Old 11-01-2011
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Quote:
Originally Posted by sonu.agarwall View Post
The correct answer is E. ......sputum cytologies should be sent.
sonu absolutely rit man spot on.....
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Old 11-13-2011
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From Murray and Nadel's Textbook of Respiratory Medicine, 5th ed. (2010)

Solitary pulmonary nodule-solitary_nodule2.jpg

From:
The Solitary Pulmonary Nodule: Approach for a General Surgeon
Surgical Clinics of North America
Volume 90, Issue 5 , Pages 1003-1018, October 2010

Solitary pulmonary nodule-solitary_nodule1.jpg
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  #7  
Old 11-14-2011
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E should be the right answer.
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Figures-, Internal-Medicine-, Pulmonology-, Step-2-Questions, Surgery-

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