0:00

Here we have a 64-year-old woman

0:02

with a 30 pack year history of cigarette smoking

0:05

who quit a few years ago

0:07

and meets the eligibility criteria

0:08

for lung cancer screening.

0:10

We're gonna scroll through the lungs, of course, looking

0:13

for abnormality in the lung parenchyma.

0:15

First we see a couple of tiny little nodules,

0:18

these little two millimeter sometimes called dizel

0:21

nodules or dizel.

0:23

Keep scrolling through the lungs.

0:24

And some of these little tiny nodules keep popping out.

0:27

Two millimeter in size, another one here.

0:30

But so far all sub four millimeters,

0:34

there's one here along the pleural surface,

0:36

but as we scroll into it, we see it solidly calcified.

0:40

That's consistent with the benign granuloma

0:42

for which we don't need to do anything.

0:44

And then here we have an actionable nodule.

0:47

Here is a 12 by 16 millimeter nodule.

0:50

We can look at its density, it's noncalcified.

0:54

It has some little s speculations around it.

0:57

So it's mildly speculated. It's fairly central.

1:00

We can see a bronchus going right into it right here.

1:03

And we can see another one

1:04

of these micro nodules here about a three millimeter nodule,

1:08

which when I keep scrolling through the lungs

1:10

and make sure we're not missing any other substantive

1:13

nodules that are actionable.

1:15

But we continue to see a a few

1:17

of these little two millimeter micro nodules popping out

1:19

mostly in the right lung

1:21

as we look at the soft tissue windows.

1:23

To go along with that calcified granuloma,

1:26

we have some calcified right hial lymph nodes.

1:29

And that pairing of a calcified granuloma

1:32

with calcified lymph nodes in the draining pathway,

1:35

of course, is common related to prior granule disinfection,

1:39

which could be old tuberculosis in the

1:41

histoplasmosis belt of the Midwest.

1:43

We see it commonly with histo

1:45

and with other fungal types in the southwest, depending on

1:49

what your endemic fungus is.

1:52

So to summarize what we've seen so far,

1:54

we have this 12 x 16 millimeter speculated central right

1:58

upper lobe nodule, and a number of these tiny micro nodules

2:02

by size with an average diameter of 14 millimeters.

2:05

This makes it a long RADS four A

2:07

and the recommended follow-up

2:08

by lung rads would be a three month low dose nodule CT

2:13

in three months to check for stability.

2:16

Now in this case, there was concern

2:18

because of all these little micro nodules

2:21

and it might be easy to say, well,

2:22

they're all in the right lung

2:24

and we have calcified granuloma

2:25

and calcified lymph nodes on the right side as well.

2:28

Maybe it's just all prior granulomas infection.

2:31

Maybe this nodule is even related to that.

2:33

But this nodule is out of proportion

2:35

to the other little micro nodules

2:37

and it hasn't calcified like the other one.

2:39

So this is suspicious for lung cancer, but

2:42

because of those micro nodules, there was concern

2:45

and they didn't wanna wait for three months.

2:48

So they're tailoring individual patient decision making

2:50

based on some of these other features of the micro nodules.

2:54

So this patient underwent a pet ct

2:56

and you can see there's intense

2:58

FDG uptake in the nodule, which we can see with cancer.

3:02

We can also see it with active infection

3:05

and we can't distinguish between the two.

3:07

But the important part is here we have a high risk patient

3:10

for lung cancer based on age and smoking history,

3:13

and a nodule that meets the criteria for lung RAD four, a

3:16

high probability of cancer in this patient.

3:19

So instead of continuing to do watchful waiting

3:23

to do short-term followup ct,

3:25

this patient underwent a thoracoscopic right upper lobectomy

3:29

where the nodule was removed.

3:31

And this was an invasive,

3:32

poorly differentiated adenocarcinoma.

3:35

And as to these little tiny micro nodules,

3:37

they found histoplasmosis.

3:39

So this patient had, um, active histoplasmosis in addition

3:43

to having a lung cancer.

3:45

So if you live in an area where there's endemic fungus,

3:48

this is something that you might

3:49

come across in your practice.

3:50

You might have a dominant future that looks like cancer,

3:53

but you may have micro nodules

3:55

or other small nodules that are related

3:56

to the endemic fungus in your area

3:58

and how it might impact the lung.

4:00

But when you have these additional nodules,

4:02

it increases concern

4:04

that there could be tumor spread in the right lung

4:07

with these other nodules

4:08

or other foci of adenocarcinoma in particular.

4:11

And I believe they did the right thing by the patient

4:14

by increasing the likelihood that this was cancer

4:16

above the normal four, a recommended three month interim CT

4:20

and going to a surgical resection diagnosis.

4:23

And patient is now disease free six years later.