0:00

All right, so let's go to our next case, case five. This is

0:08

a little bit of a different scenario. This is actually on a routine

0:13

lung cancer screening. Excuse me, let me just go to here. There we

0:20

go. And there's this finding. And I think after we saw some of

0:25

those other inflammatory findings and how they're healing, we might have

0:29

a little bit of a view on what you think this might be.

0:33

Now, this was his baseline scan. I think he had a prior from

0:38

many years before, but there was no recent imaging and no recent history,

0:43

just that he was a smoker and this was the baseline.

0:49

So my next question, question five A. So what would your management recommendation

0:57

be? Granted that you're... If you're within lung cancer screening, this

1:02

was a 4a lesion. But in any case, even if you just saw

1:07

this come across your desk outside the lung cancer

1:11

screen protocol, you might be asked, "Well, what's the next step?"

1:14

Would you recommend a PET CT at this point, a biopsy,

1:17

or would you recommend short term follow up? Short term follow up, I

1:23

agree. I think there is a tendency to feel like, okay,

1:27

if there's at all a chance it could be cancer, we better work

1:30

it up right now. And I tend to disagree with that approach because

1:34

I think we can spend a lot of our patient's money.

1:40

And and in the case of PET CT, I think often PET CT can

1:44

be used to ask the question of is this cancer or not?

1:48

And unfortunately, PET CT is not very good at answering that question.

1:53

So this patient actually did have a PET CT and I'll show you

1:57

what that looked like. Since it's just the raw imaging rather than the overlay.

2:01

You can see here that there is a little bit of uptake similar to

2:05

or even less than vessels, less than mediastinum. So there's mild FDG uptake.

2:11

And can I have my next question? So now you have a PET

2:16

CT, what is your differential? Is it well, this could be infection, inflammation

2:20

or cancer. Is it definitely infection, inflammation or is it definitely

2:24

cancer? And I guess what I'm trying to really get at with this

2:27

question is, how much has this has the PET CT helped you

2:31

with your with your differential? Yeah, so I agree that, I think,

2:38

certainly just based on the PET CT alone, you really haven't moved away

2:42

from your differential of infection, inflammation or cancer.

2:48

And I also agree that you would not be wanting to call this

2:52

definite cancer. We know that adenocarcinomas can have low level uptake,

3:02

but they aren't usually linear, are they? And we did see quite

3:06

a few cases where as we go through a healing process,

3:11

we have linear opacity in the lungs. So I think that's what this

3:15

was, but this patient went ahead and actually had a wedge resection of

3:19

this and it was an organizing pneumonia on wedge resection, which

3:25

is something you might see in the setting of a resolving pneumonia.

3:31

So so I would say that with finding like this, a short term follow

3:36

up is best because although when we suspect cancer, often we want to get

3:42

the answer right away and not miss it. I think that really what

3:45

we're after is the behavior and given them more linear morphology,

3:50

I would be confident that cancer would be unlikely, and a three month follow

3:55

up would hopefully show us that this would get a little bit thinner

3:59

and smaller in volume and continue to resolve and reassure us that it

4:05

was simply inflammatory.