The Correct Answer is C!

 

A 60-year-old female, who has a 30-year history of cigarette smoking (still smoking), presents for evaluation of chronic cough. Chest radiography shows a 1.5-cm left upper lobe nodule posteriorly that was not present on chest X-ray obtained 3 years ago.

She has no exposure history and the results of the physical examination and routine laboratory testing are unremarkable. Spirometry demonstrates moderate airflow obstruction with significant response to bronchodilator administration. The nodule is spiculated and enhances significantly on positron emission tomography scanning (PET).

Which one of the following is the most appropriate next step in the evaluation of this pulmonary nodule?

A. Bronchoscopy with transbronchial biopsy
B. Repeat CT scan 1 year
C. Surgical resection
D. Transthoracic needle aspiration

Rationale:

The correct answer is surgical resection. The diagnostic yield of bronchoscopy with nodules smaller than 2cm is poor. This patient with a significant smoking history and airflow obstruction presents with a new spiculated pulmonary nodule that was not present three years earlier as assessed by previous chest radiography and, enhances on PET scanning.

Thus, this nodule should be surgically resected, since malignancy is very likely. Similarly, because of the high probability of malignancy, observation with repeating CT scans would not be appropriate. Transthoracic needle biopsy although likely to provide diagnosis would not ameliorate the need for surgery even if non-diagnostic because of the high probability of malignancy.

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