Imaging: Pulmonary Nodules |

Multiple Lung Nodules in Elderly Patient: What to Do? FREE TO VIEW

Siva Sivakumar, MD; Salim Surani, MD; Aparna Sivakumar
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Baystate Wing Hospital, East Longmeadow, MA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A253. doi:10.1016/j.chest.2016.02.264
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SESSION TITLE: Pulmonary Nodules

SESSION TYPE: Case Report Slide

PRESENTED ON: Saturday, April 16, 2016 at 01:00 PM - 02:00 PM

INTRODUCTION: Lung nodules are commonly seen on imaging studies. Only 5.9% lung nodule measuring 5mm to 9mm are malignant. With new recommendations to do low dose annual chest CAT scans for high risk smokers, incidence of lung nodule detection will rise.

CASE PRESENTATION: 80-year-old Hispanic female with past medical history of irritable bowel syndrome, hypertension and osteoporosis underwent CAT scan of abdomen for abdominal discomfort, which revealed 1 cm right lower lobe nodule. Dedicated chest CAT scan revealed additional 11 mm right upper lobe nodule and 5 mm left lower lobe nodule. Patient had 30 pack-year smoking history and had quit smoking 10 years ago. PET scan showed no hypermetabolic activities in both nodules. Follow-up CAT chest at one-year showed doubling in size of right upper lobe nodule and a new 5 mm right middle lobe nodule. PFTs were normal for age. She was referred for VATS biopsy. Right upper lobe lesion showed granuloma and cultures were positive for Mycobacterium Avium Complex. Right middle lobe lesion showed typical carcinoid. In view of the patient being asymptomatic, it was elected to monitor patient clinically, without treatment.

DISCUSSION: High risk factors for our patient included age > 70 years, smoking history, growth over one year, and location of nodule in upper and middle lobe.1 Approval of low dose CT scan for early detection of lung cancer in high-risk patients places a tremendous challenge for the clinician in the management of lung nodule.2 Studies have also suggested to increase the size of the lung nodule cut-off to decrease false positive screening rates.3 ACCP and Fleischner Society guidelines are available for the management of sub-centimeter lung nodule(s). Many clinicians may be unaware of these guidelines. Moreover, the guidelines fail to address multiple lung nodules and when to biopsy them, especially if one benign and one malignant is suspected.

CONCLUSIONS: Possibility of dual or multiple pathologies need to be considered when caring for a patient with multiple lung nodules. Familiarity with guidelines is important.

Reference #1: Likelihood of malignancy in a solitary pulmonary nodule: comparison of Bayesian analysis and results of FDG-PET scan. Chest. 1997 Aug;112(2):416-22.

Reference #2: Reduced lung cancer mortality with low dose CT scan. NEJM. 2011;365:395-409.

Reference #3: Projected outcomes using different nodule sizes to define a positive CT lung cancer screening examination. J Natl Cancer Inst. 2014;18:106(1).

DISCLOSURE: The following authors have nothing to disclose: Siva Sivakumar, Salim Surani, Aparna Sivakumar

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