A 39-year-old man presents after tripping over his child’s toy and subsequently falling down the stairs. The patient reports landing on his chest and now complains of pain over certain regions of his right chest wall. He endorses some mild pain on deep inspiration. The patient is otherwise healthy and denies alcohol or smoking. Physical examination demonstrates pain on palpation over the sternum. A chest x-ray is ordered which confirms two right rib fractures. The radiologist notes an incidental 2.25-cm coin-shaped lesion on the left upper lung. There is no associated adenopathy or atelectasis noted.
Which of the following is the most appropriate next step with respect to the solitary lung lesion?a. CT scan of the chest
Review of an old chest x-ray. The patient in this question is presenting with rib fractures as well as the incidental finding of a solitary pulmonary nodule (SPN), which is defined as a discrete rounded opacity less than or equal to 3 cm in diameter. In addition, it must be completely surrounded by lung parenchyma and must not touch the hilum or mediastinum. Of note, lesions greater than 3 cm in diameter are considered malignancies until proven otherwise. The majority of SPNs are benign, especially if there are features such as calcifications and smooth edges. In low-risk patients (typically nonsmokers less than 40 years of age), the appropriate next step in management is to ask for an old chest x-ray (preferably within the last 12 months). If no change in the x-ray is noted, it is considered benign. It should then be followed every 3 months for the next year.
(A) If this patient were a smoker, a CT scan of the chest would be the best next step in workup after reviewing an old chest x-ray. (B) Typically after a CT scan of the chest is performed, a fine needle aspiration (FNA) is preferred to lung biopsy, but a biopsy can be considered if FNA does not generate significant results. (D) Although this patient is low risk, reassurance is not appropriate.