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Wednesday, April 23, 2014
5mm Noncalcified Solitary Pulmonary Nodule
My mother is a 73 year old, 100+ pack year former smoker (quit 4 years ago) with severe emphysema and recurrent bladder cancer (low grade, non-invasive, papillary transitional cell CA, recent recurrence x 2).
She was hospitalized in 2007 for an exacerbation of her COPD. Chest CT with contrast at that time did not show any pulmonary nodules.
She underwent fulguration and intravesical BCG treatment for a recurrence of bladder CA about 6 months ago and had symptoms of bacteremia (shaking chills, fever) afterward and so the BCG was discontinued. Surveillance cystoscopy 3 months later revealed another tumor, which was biopsied and fulgurated.
She underwent a screening low-dose helical CT without contrast in accordance with the results of the National Lung Screening Trial. The CT revealed a 5mm non-calcified, non-spiculated solitary pulmonary nodule in her right upper lobe.
Given her age, smoking history, extra-pulmonary malignancy, suspected bacteremia from BCG and the fact that chest CT with contrast 4 years ago showed no malignancy, should her nodule be biopsied or should she just have a follow-up CT scan in 6 months? What about a PET scan?
I have read the ACCP guidelines and understand that for the general high risk population since her lesion is under 8mm, they recommend follow-up CT in 6 months. Does the fact that her CT scan with contrast 4 years ago did not show this nodule change that? Does the fact that she was bacteremic from BCG change that?
I would agree with a CT in 6 months for a 5mm nodule. It's too small to biopsy and it would need to be at least double the size for PET to be useful. Most of these nodules, even in higher risk patients, are benign.
Sandra L Starnes, MD
Assistant Professor of Surgery
College of Medicine
University of Cincinnati