NYU Medicine Grand Rounds Clinical Vignette

David Altszuler, MDPGY-2

December 11, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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

• 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

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

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

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

2013 CT scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

2011 CT scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

2011 2013

PET/CT

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

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