0:00

Okay, so case six. All right, so we're going to start with the

0:10

chest x ray this time. So this is a

0:14

patient in his mid 40s and he's got right sided

0:20

back pain. This was the chest x ray.

0:25

As we know, I think previously, even back when I trained, a patient

0:30

presented like this into the ED and had a chest x ray and

0:33

said they had a fever and right hand we thought

0:36

this is pneumonia, you treat for pneumonia and get a follow up chest x

0:39

ray in six weeks to make sure it resolves. And it was interesting,

0:43

I left the country and was working in teleradiology in Australia and then

0:47

working in New Zealand for about seven years and came back and that

0:51

process had completely changed. And now if you get a chest x ray

0:54

in the ED like this, you instantly get

0:58

a CT. And the problem with that is that pneumonia, as we know,

1:01

can look really scary and so often get a CT right away,

1:09

often doesn't change the diagnosis much. So this patient, of course,

1:14

immediately got a CT after this chest x ray, which looked like this.

1:26

And let me see what my question was for this one.

1:34

So this is a 60 year old male.

1:40

Sorry, let me just catch up with my notes for a moment.

1:42

Right. So this is a 60 year old male, sorry, and he presented

1:49

with fever and chills. We saw the chest x ray initially,

1:53

he had the CT then. And right now what we're seeing is an

2:00

area of consolidation, kind of similar to that other case I showed you.

2:03

Now this doesn't have contrast on board, but we see that similar area

2:09

of inflammation adjacent. We see a little locule of air in there,

2:14

very similar to that other one. And if I put it on

2:19

soft tissue, it looks to me like there's a little bit of low

2:22

density fluid area, kind of round. So I was trying to think this

2:26

is a pneumonia with a lung abscess. So given the fact that he's presented

2:32

acutely with a fever and chills, I'd be happy for him to have

2:36

antibiotics and then have a follow up CT.

2:40

This is what happened. And as we come down,

2:48

we again see that it's much smaller, right? I mean, it's kind of

2:52

going through that linear collapsed lung with a little bit of residual inflammation

2:58

adjacent. We do still have that little cavity, you know, it's a little

3:02

bit fuller here. And I came in at this point

3:07

when one of the ID doctors called me and said, oh,

3:12

"What do you think of that? Do you think that that's malignancy or are you

3:15

happy that this is all infection?" And so that's the next question to

3:18

you. Question six, are the findings on the follow up CT concerning for

3:24

an underlying malignancy? So we have a majority saying not really,

3:31

recommend another follow up CT in three to six months. So quite a

3:34

few thinking, no, I'm worried about cancer. So let's have...

3:39

Let's look at it a little more. So I would choose B,

3:45

which is what I did say, because that happened. I said,

3:49

you know, I'm not really worried about cancer, but you know, I think

3:52

a follow up in three to six months would be reasonable.

3:56

So as I scroll through this, there is that little cavity from the

4:00

abscess and the overall size is much smaller. Yes, we are seeing some

4:06

of what someone might call speculations here, but

4:10

they're fairly long and they have a little bit of inflammatory change.

4:15

The overall configuration of this is really quite linear, whereas usually

4:20

cancer is more of a round, is more round and pushing rather than

4:25

linear and retracting. So I feel pretty comfortable that this is going to

4:30

be inflammatory. I think so much of that other case, I think we

4:35

did get a PET CT that we would show some low level uptake

4:38

and that our differential would not be changed. It would still be,

4:41

well, this is either infection or cancer. So

4:48

I don't think a PET CT would advance us much. You could biopsy,

4:53

but I think again, I think the behavior is going to be helpful.

5:01

And a biopsy is invasive. So, you know, and

5:06

if this is simply infection, which at least in part it was,

5:08

you know, a biopsy infected lung is often not what

5:16

interventional radiologists really want to do. So I think, you know, other

5:21

choices would be, if you're not comfortable with three to six months,

5:23

just do a shorter followup. So this had already remarkably improved in one

5:29

month. And so you could even say, oh,

5:31

let's get another one in two months. Generally I think you can always

5:35

double the time of followup if things are going in the right direction.

5:38

So if it was fine in one month, you can move it up

5:40

to two months. I think that would be really reasonable.

5:45

One thing that I think was reassuring was I read a paper looking

5:49

at lung cancer recommendations from screening over the past 20 years.

5:55

And this is a broader pool than just the Conrad's pool.

6:00

And they found that for, even in the high risk lung cancer screening

6:04

group, the lesions that were in the four category, 4A and 4B, which are

6:08

the most suspicious, that by doing a three month follow up,

6:12

they actually didn't find any more progressed cancers, but they had a marked

6:20

reduction in the number of procedures, interventional procedures that got

6:26

done. So I think that's worth keeping in the back of your mind

6:30

that by putting your foot on the gas pedal, really, are you subjecting

6:35

your patients to procedures that are not going to be necessary.

6:42

Now, it does take some comfort. I mean, I think a lot of

6:47

people would look at this and think that's too ugly. But as I

6:50

said, I think, honestly, I think an infection can look really ugly.

6:54

I think that's one of the issues we have now with overall in some CT rather

6:59

than on chest x ray. If this person had had a chest x

7:02

ray and followup, I think we would have also thought, "Oh,

7:05

wow, that's way better." I think you wouldn't see those little scary markers

7:09

and you think, "Wow, that's way better. Let's get another chest x ray."

7:13

And it would have been fine. So that's one of the challenges we

7:17

face.