Pulonary nodules--help!

Trauma Columnist · Oct 18, 2016

Here is what I found in UpToDate:

DIFFERENTIAL DIAGNOSIS

Malignant versus benign â€” Multiple pulmonary nodules may be caused by malignant or benign diseases.

In patients without a known primary malignant tumor, the following characteristics help differentiate multiple malignant nodules from multiple benign nodules:

â—Multiple pulmonary nodules that are â‰¥1 cm in diameter or detected by conventional chest radiography are most likely due to metastatic disease from a malignant solid organ primary tumor [1,2].

â—Multiple pulmonary nodules that are 1-3].

In contrast, in patients with a known malignant primary tumor, multiple pulmonary nodules exceeding 5 mm in diameter are more likely to be malignant than benign [1].

AND:

Assessment â€” Once the nodules have been characterized by helical CT, the radiographic information should be considered in the context of the history and physical examination. This is usually sufficient to narrow the differential diagnosis and determine whether the nodules can be followed up with imaging only or need to be sampled.

Serial CT scans â€” Multiple pulmonary nodules can be followed by serial CT scans if the clinician has confidence that benign disease is the likely etiology. As an example, a patient with multiple cavitating lung lesions in the context of positive blood cultures would not require a biopsy unless the radiographic evolution of the nodules was incongruous with the clinical course after antimicrobial therapy was initiated. Similarly, granulomatosis with polyangiitis (Wegener's) can usually be diagnosed without pathologic confirmation in a patient who has multiple cavitary nodules, red cell urinary casts, and a positive test for anti-proteinase 3 antibodies (c-ANCA). Such patients may be followed with serial CT scans to insure that the nodules improve as the underlying disease is treated. The approach to serial imaging in patients with multiple pulmonary nodules is similar to that for patients with a solitary pulmonary nodule, which is discussed separately. (See "Diagnostic evaluation and management of the solitary pulmonary nodule", section on 'CT surveillance'.)

The Fleischner Society has proposed guidelines for the management of multiple subsolid pulmonary nodules [7,47].

â—When multiple nodules with a purely ground glass appearance are noted and all are â‰¤5 mm in diameter, follow-up CT is suggested at two and four years. The differential diagnosis includes foci of atypical alveolar hyperplasia (AAH), adenocarcinoma in situ (formerly known as bronchioloalveolar carcinoma or BAC), early pneumonia, respiratory bronchiolitis, and hypersensitivity pneumonia. The likelihood of any one of the nodules evolving into lung cancer is thought to be low.

â—For multiple nodules with a purely ground glass appearance with at least some >5 mm, but without a dominant lesion, initial follow-up at three months is recommended since 20 to 40 percent will have cleared. If unchanged, annual surveillance CT scans for two to four years are suggested to ascertain continued stability. If growth of one or more nodules is detected, further evaluation is indicated. 18-fluorodeoxyglucose positron emission tomography (FDG-PET) has limited value and is potentially misleading in this setting since adenocarcinoma in situ is not always glucose-avid. (See 'Tissue sampling' below.)

â—For multiple nodules with a part-solid component, initial follow-up at three months is suggested to confirm continued presence. If nodules are persistent, further diagnostic evaluation (eg, biopsy, excision) is suggested. FDG-PET is advisable for evaluating the likelihood of malignancy when the overall diameter of individual part-solid nodules is 8 to 10 mm or larger. (See 'Tissue sampling' below.)

â—When a dominant lesion is identified among multiple pulmonary nodules, the characteristics of that lesion determine further management.

So - whats the H&P?

YoutubeTheNP · Oct 19, 2016

For some reason I'm having a hard time finding the answer to this question. When a patient returns with a CT showing small calcified nodules, do you treat for latent TB? And, how frequently do you monitor these with repeat imaging? Patient is asymptomatic. I finding recommendations to leave it alone, some say do sputum cultures, some say treat.... Please help.

Use the Fleischner society pulmonary nodule recommendation chart. Why would you treat for latent TB upon seeing a calcified pulm nodule? Do they have hx of TB? If so, that is probably just from previous infection. I see those things all the time.

[h=1][/h]

TicTok411 · Oct 19, 2016

What was the reason for the chest CT? You mentioned he was asymptomatic so why CT?

allnurses Guide · Oct 19, 2016

It makes me nervous that questions like this get asked here.

AAC.271 · Oct 19, 2016

This is a fairly basic quesiton that most NP/MD/DO'S/PA's should know easily.. Im also shocked that you got away without leanring how to identify/manage somehting so common.

Your H&P is lacking and I would certainly hope you got a CXR before and know the identifying features of say TB vs like say Silicosis.

Please let us know their history. Their IGRA/PPD. Remember IGRA>PPD especially since PPD fails sometimes.

Also, how do. You not know the treatment for latent TB? Did they not teach you anything in Pharmacology?

TicTok411 · Oct 20, 2016

i do not think we need to shame someone for asking a question, especially before having all the facts. The question begs for more informations to determine what is going on. I may ask a dumb question from time to time but better ask to learn than to be harassed for asking.

Trauma Columnist · Oct 20, 2016

...which is why I provided info instead of asking why are they asking?

HBrnGirl · Oct 27, 2016

Is this real? And you wonder why I'm against independent practice. This is scary!