Breast cancer for internists

Amit Jain, MD, MPHTMH Cancer CenterMay 2016Lung Cancer Board Review for Internal medicine residents

Case 1A 57-year-old woman is evaluated in the ED for shortness of breath associated with wheezing and pain with inspiration. She has a 25-pack-year smoking history of cigarette smoking. She takes no medications. On physical examination, temperature is normal, blood pressure is 138/82 mm Hg, and respiration rate is 18/min. Wheezing is heard on pulmonary examination. The remainder of the examination is normal. Laboratory studies are normal. A chest radiograph is normal, and a spiral CT scan reveals multiple bilateral pulmonary emboli in addition to several bilateral pulmonary nodules, each measuring 2 to 4 mm. The patient is admitted to the hospital, and heparin and warfarin therapy is begun.

Which of the following is the most appropriate next diagnostic step in the evaluation of the patients pulmonary nodules?

Bronchoscopy with cytologic analysisCT-guided biopsy of the largest nodule after withdrawal of anticoagulationFollow-up CT in 12 monthsPET/CT now

Lung cancer screeningSputum cytology, Chest X rays, other imagingAll negative studies

Recent NLST studyLow dose screening spiral CT yearlyMinimum 30-pack-years smoking20% reduction in lung cancer mortality

Pulmonary nodules evaluationNon-calcified nodules >4mm require further evaluationHigh risk individuals with nodules < 4 mm require f/u imagingLow risk individuals with nodules < 4mm, no f/u imaging recommended

PET/CT scan unlikely to detect lesions 7cm)N1 M025%IIIAT1-T3N2 (mediastinal nodes) or T4N1M019%IIIBT1-T4N3 (contralateral mediastinal/hilar nodes)M010%IVAny TAny NM1