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NYU Medicine Grand Rounds Clinical Vignette
David Altszuler, MDPGY-2
December 11, 2013
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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•79 year old woman with prior tobacco use (55 pack-years, abstinent since 2009) presents for evaluation of an abnormality seen on her most recent chest CT.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Began annual surveillance chest CT in 2004• A few small (<5mm) nodules were found and remained stable on follow-up images• In 2009 she began undergoing chest CT scans every two years• 2011 scan showed a new left upper lobe oblong lesion likely representing a thick walled bronchiole, otherwise stable• 2013 scan showed that left upper lobe lesion had progressed to a 1.9 x 1.7cm groundglass opacity with areas of solid attentuation, concerning for malignancy
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Additional History
•Past Medical History: •HTN•Dyslipidemia•Osteoporosis
•Past Surgical History:•Ovarian cyst removal
•Social History:•55 pack year tobacco use, abstinent since 2009. Denies other illicit drug use. Weekly alcohol use•Denies any occupational or toxic exposures
•Family History:•Coronary artery disease in both parents
•Allergies: •Sulfa
•Medications:•Aspirin 81mg daily•Hydrochlorothiazide 25mg daily•Simvastatin 20mg nightly•Calcium and vitamin D3
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Physical Examination
•General: Well appearing, ambulatory, woman appearing stated age
•Vital Signs: T:98.6 BP:140/90 HR:88 RR:16 and O2 sat:95% on ambient air
• Chest with normal AP diameter, decreased breath sounds throughout, no wheezing, rhonchi or rales
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Laboratory Findings
•CBC: Hemoglobin 15.5, Hematocrit 48.3•Remainder of CBC was within normal limits
•Basic Metabolic panel: Potassium 3.4•Remainder of basic was within normal limits
•Hepatic panel: Total and indirect bilirubin 1.3•Remainder of hepatic panel was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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2013 CT scan
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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2011 CT scan
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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2011 2013
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PET/CT
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• PET/CT obtained without evidence of metastatic disease or nodal involvement
• Patient was referred to thoracic surgery for evaluation
• Underwent left upper lobe wedge resection via video-assisted thoracoscopy and lymph node dissection April 2013, 1.7cm tumor removed
• Intra-operative frozen section showing invasive adenocarcinoma
• Clear margins, nodes negative for malignancy
Treatment Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Invasive adenocarcinoma of the lung, moderately differentiated, with lepidic (60%), acinar (30%) and papillary (10%) growth. Stage 1a.
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS