SIGNIFICANCE OF AN INCIDENTALOMA IN CHEST – OUR EXPERIENCE

DR ANIL

(Resident – DNB General Surgery)

DR H.V. RAJA SHEKARA REDDY

(Consultant – Thoracic Surgery)

INCIDENTALOMA - WHAT IT IS ?

Definition :- Tumor found by coincidence (incidentally) without

clinical symptoms or suspicion .

Definition excludes :- Patients undergoing imaging procedures as a part of staging &

workup for cancer. 

With increase of “whole – body CT scanning “ as a part of screening programs – incidence of incidentaloma expected to increase.

37% patients receiving whole body CT scan may have abnormal findings which need further evaluation.

INCIDENCES

Up to 20-50% of mediastinal tumors are detected incidentally.

Most of the Solitary Pulmonary Nodules are incidentally detected ( 0.2% of chest X-rays images).

According to the American Cancer Society, lifetime odds to develop lung cancer –

1 in 13 – men 1 in 16 – woman

Of these between 20% and 30% will present as an Solitary Pulmonary Nodule.

Master Health Check up at patient request

Carefully studied routine investigations – probably essential to pick some life threatening conditions at early ( probably curable ) stage .

HOW WE DETECTED….

Study period :- February 2008 to July 2013

We reviewed the record of the patients retrospectively.

Asymptomatic and Routine Master Health Checkup

As part of pre employment

As part of requirement for VISA

Symptoms – non specific

TOTAL NUMBER OF PATIENTS WITH DETECTED INCIDENTALOMAS - 23

MEDIASTINAL INCIDENTALOMAS – 16

LUNG INCIDENTALOMAS – 7

RIGHT LUNG (3)

LEFT LUNG (4)

(7) (2)

(7)

(7)

(7)

(2)

Mediastinal mass

Number procedure Final HPE Diagnosis

Lymphadenopathy 7 Mediastinoscopy and biopsy

Tuberculosis- 3Sarcoidosis- 3Lymphoma - 1

Thymoma 4 VATS and total thymectomy

Thymoma

Thymolipoma 1 Thoracotomy and total thymectomy

Thymolipoma

Morgagni hernia 1 VATS –thoracotomy ,laparotomy and mesh repair

Bronchogenic cyst 2 VATS- thoracotomy , partial excision and marsupialisation

Bronchogenic cyst

Teratoma 1 Thoracotomy and excision Teratoma

Solitary lung nodule

Numbers

Procedure Final HPE Diagnosis

Right lung lesion 3 Lobectomy/ Pneumonectomy and mediastinal lymphadenectomy

Non Small Cell Carcinoma – 2Fibroma - 1

Left lung lesion 4 Lobectomy and mediastinal lymphadenectomy

Non Small Cell Carcinoma

Asymptomatic and Routine MHC

55Y/F Husband admitted

for hemorrhoid surgery

Easy Fatigability noted by family members, no chest symptoms

MHC

Diagnosed with right sided thymoma with cyst

VATS with Aspiration of Cyst , Excision and Thymectomy

Histopathology Thymic Cyst

SYMPTOMS – NON SPECIFIC 45y/M Fever 2 months On ATT for 1.5 months No relief Generalized itching of

1 month LFT – N CXR & CT mediastinal

nodes Mediastinoscopy –

Hodgkin’s lymphoma

SYMPTOMS – NON SPECIFIC 40/F – abdominal

discomfort

Bronchoscopy – no endobronchial lesion

CT guided biopsy – not possible

On table frozen section – malignancy

Pneumonectomy with lymphadenectomy

NSCLC – Moderately differentiated squamous carcinoma

T2N2M0

AS PART OF PRE EMPLOYMENT MHC32y/M with Occasional fever

Large Dermoid cyst on left pericardium

ROUTINE INVESTIGATION FOR OTHER CAUSE

SIGNIFICANCE OF DETECTING AND ??? MANAGEMENT

For Patients :- Potentially lethal conditions can be diagnosed

early. Can be treated with curative intent Decreases the morbidity Improves outcome and survival.

For Doctors :- Medico –Legal consequences

WHAT DO I MEAN ?

Medico – Legal consequences ……

A 44-year-old female received a routine chest X-ray prior to hernia surgery; an incidental finding of a lung nodule was not reviewed by the ordering clinician, and was never followed up, resulting in a delayed cancer diagnosis and a poor prognosis

Allegation

The patient’s estate sued the surgical resident and the hospital, alleging that negligent failure to act upon an abnormal chest X-ray resulted in a three-year delay in diagnosing the cancer. The suit claimed that the delay allowed a potentially very treatable/curable cancer to advance to a terminal stage for this patient.

Disposition

This case settled for more than $2 million against the hospital and the surgical resident.

CONCLUSION

Routine full body health check up’s may not necessarily be unnecessary.

Even the tiniest of the lesion can be devastating if not addressed appropriately

REFRENCES

Telles A C, Mendoza D . Relevance of an incidental chest finding. Lung India. 2012 ; 29(1): 50–52.

MacMahon H, John H M , Herold C J et al. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 ; 237(2): 395-400.

LaValley D. Incidental Finding on Routine X-ray Not Pursued By Radiologist or Ordering MD. 2011.

Christian S. A mediastinal mass. The Journal of Family Practice. 2010 ; 59(6): 347-350.

Thank you