Endgames Case Report

Diagnosis and management of the solitary pulmonary nodule

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4866 (Published 13 December 2011) Cite this as: BMJ 2011;343:d4866
  1. Graeme Weir, interventional radiologist1,
  2. Sebastian Kos, interventional radiologist1,
  3. Josh Burrill, interventional radiologist1,
  4. Peter Salat, interventional radiologist1,
  5. Stephen Ho, interventional radiologist1,
  6. David Liu, interventional radiologist1
  1. 1Radiology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
  1. Correspondence to: G Weir graeme.weir{at}gmail.com

A 67 year old woman presented with a worsening cough and a two month history of a small amount of blood in her saliva. She had no history of weight loss, pleuritic pain, or constitutional symptoms. In addition, she had shortness of breath secondary to chronic obstructive pulmonary disease, and she was on supplemental oxygen at home. Her medical history included myocardial infarction, moderate to severe peripheral vascular disease, and type 2 diabetes. She continued to smoke one pack of cigarettes a day and had a cumulative 130 pack year history of smoking.

Chest radiography showed a 2.7 cm single pulmonary nodule in the right middle lobe adjacent to the mediastinum. The lesion was confirmed to be non-small cell lung carcinoma by a computed tomography guided lung biopsy. As part of the staging process, a positron emission tomography-computed tomography (PET-CT) scan was done, which confirmed a malignant right middle lobe lesion, stage IA (T1b), with no nodal or pleural involvement.

Pulmonary function testing showed that an operative resection would not be suitable. Treatment options were combined chemoradiotherapy and percutaneous ablation. Percutaneous radiofrequency ablation was performed, and the post-procedural PET-CT scan at one year showed no clinically relevant residual disease.

Questions

  • 1 What is the most common clinical presentation of lung cancer?

  • 2 What are the indications for biopsy of a lung mass?

  • 3 What is the value of PET-CT in investigating a lung nodule?

  • 4 What are the current management guidelines for non-resectable non-small cell lung carcinoma?

Answers

1 What is the most common clinical presentation of lung cancer?

Short answer

Cough.

Long answer

Lung cancer is the second most commonly diagnosed cancer in the United Kingdom. Because of the cancer’s insidious presentation, symptoms are not usually evident until the disease is advanced. At presentation 90% of patients are symptomatic.1 The most common presenting symptom is cough (8-75%),1 then weight loss, dyspnoea, chest pain, and …

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