Neoplasms of the Lung II

Author: Paul Schipper, MD
Institution: OHSU
Date Reviewed: March 2025
Original Case: Stephen C. Yang, MD
Learning Domain: General Thoracic
Learning Objective: Stage I Staging, including all staging tools, Stage I survival and recurrence patterns. Advanced level concepts focus on Stage I treatment and Multimodality
PowerPoint File: File Neoplasms of the Lung II.pptx

 

History 

  • 64-yo was found to have an apical RUL lung nodule on a screening CXR ​
  • Patient has no pulmonary symptoms​
  • Former 30 py smoker, quit 10 years ago​
  • PMH: hypertension, arthritis​
  • No prior surgeries​
  • ECOG PS0

 

Physical Exam

  • Gen: WNWD NAD, appears stated age​
  • CV: RRR no m,g,r​
  • CHEST: BS equal and clear​
  • ABD: soft, flat non tender​
  • EXT: no edema

 

Work Up 

  • Labs WNL​
  • Coags WNL​
  • PFTs
    • FEV-1 = 1.84 L (87% predicted)
    • FVC = 2.21 (81% predicted)
    • DLCO = 14.5 (68% predicted)

 

CT Scan

3 cm mass apex of RUL. No hilar or mediastinal adenopathy. Upper cuts of abdomen normal​.

 

Differential Diagnosis?

  • Neoplasm
  • Infection
  • Congenital
  • Trauma
  • Other
  • Next steps?

 

PET/CT Scan

Integrated scan showing hypermetabolic activity only in the lung mass. No uptake elsewhere.

 

Outcome

  • Underwent VATS RUL lobectomy
  • Uncomplicated postoperative course
  • Final path shows a 3.3 cm adenocarcinoma, lymph nodes in 4R, 7, 9R, and 10 R negative (3+1)
    • What stage is this?
    • Adjuvant therapy?
    • Surveillance?
    • 5 year survival?

3.3 cm = T2a

T2aN0M0 = Stage IB

No adjuvant therapy offered other than clinical trial

Journal of Thoracic Oncology, Volume 19, Issue 7, July 2024, Pages 1007-1027.

Journal of Thoracic Oncology, Volume 19, Issue 7, July 2024, Pages 1007-1027.

 

History 

  • A 78 year-old M presents with a 2cm spiculated mass in the lingular tip found on w/u for dry cough
  • Former 30 py smoker, quit 20 years ago
  • PMH: rheumatoid arthritis, HTN, DM 
  • No prior surgeries
  • ECOG PS0

 

Work Up

  • PE: Normal
  • Labs WNL
  • CXR and CT confirm the same 2 cm mass in the lingular tip.  
  • There is a 1.5 cm AP window node, no other hilar or mediastinal adenopathy
  • PFTs:
    • FEV-1 = 1.7 L (65% predicted)
    • FVC = 2.1 (71% predicted)
    • DLCO = 20.5 (88% predicted)
  • Next steps?

 

Discussion Points

  • Role of PET scanning? EBUS? Mediastinoscopy? Chamberlain Procedure? Needle aspiration?
  • Role of mediastinal lymph node dissection?
  • Lung sparing options?
  • What if left upper lobe rather than just lingula?
  • What if lymph node positive on mediastinoscopy? 
    • After final path report?

 

Outcome

  • PET showed avidity in the lung nodule only
  • EBUS stations L4, 7, and L10 negative
  • Mediastinoscopy negative
  • Left VATS lingulectomy, mediastinal LN dissection
  • What if AP window was positive intraop?
  • Final path T1N0 adenocarcinoma

 

History

  • A 75 yo M is referred for a PET positive lung mass found on w/u for SOB
  • Former heavy smoker
  • PMH: CAD, PVD, HTN
  • No prior surgeries
  • ECOG PS0
  • PFTs:
    • FEV1 40% predicted,
    • DLCO 45% predicted
    • ECHO: LVEF 55%,
    • PAS est 40 mmHg, mild TR
  • PET:  avidity only in lung mass
  • What are options?