Transcript Significance of an Incidentalloma in chest – our experience

SIGNIFICANCE OF AN
INCIDENTALOMA IN CHEST – OUR
EXPERIENCE
DR ANIL
(Resident – DNB General Surgery)
DR H.V. RAJA SHEKARA REDDY
(Consultant – Thoracic Surgery)
INCIDENTALOMA - WHAT IT IS ?
Definition :Tumor found by coincidence (incidentally) without
clinical symptoms or suspicion .
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Definition excludes :
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Patients undergoing imaging procedures as a part of staging &
workup for cancer.
With increase of “whole – body CT scanning “ as a
part of screening programs – incidence of
incidentaloma expected to increase.
37% patients receiving whole body CT scan may have
abnormal findings which need further evaluation.
INCIDENCES
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Up to 20-50% of mediastinal tumors are detected
incidentally.
Most of the Solitary Pulmonary Nodules are
incidentally detected ( 0.2% of chest X-rays images).
According to the American Cancer Society, lifetime
odds to develop lung cancer –
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1 in 13 – men
1 in 16 – woman
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Of these between 20% and 30% will present as an
Solitary Pulmonary Nodule.
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Master Health Check up at patient request
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Carefully studied routine investigations –
probably essential to pick some life threatening
conditions at early ( probably curable ) stage .
HOW WE DETECTED….
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Study period :- February 2008 to July 2013
We reviewed the record of the patients
retrospectively.
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Asymptomatic and Routine Master Health Checkup
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As part of pre employment
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As part of requirement for VISA
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Symptoms – non specific
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TOTAL NUMBER OF PATIENTS WITH DETECTED
INCIDENTALOMAS - 23
MEDIASTINAL INCIDENTALOMAS – 16
(7)
(7)
(2)
(7)
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LUNG INCIDENTALOMAS – 7
RIGHT LUNG
(3)
LEFT LUNG
(4)
(2)
(7)
Mediastinal mass
Number
procedure
Final HPE
Diagnosis
Lymphadenopathy
7
Mediastinoscopy and biopsy
Tuberculosis- 3
Sarcoidosis- 3
Lymphoma - 1
Thymoma
4
VATS and total thymectomy
Thymoma
Thymolipoma
1
Thoracotomy and total
thymectomy
Thymolipoma
Morgagni hernia
1
VATS –thoracotomy
,laparotomy and mesh repair
Bronchogenic cyst
2
VATS- thoracotomy , partial
excision and
marsupialisation
Bronchogenic
cyst
Teratoma
1
Thoracotomy and excision
Teratoma
Solitary lung
nodule
Numbers Procedure
Final HPE
Diagnosis
Right lung lesion
3
Lobectomy/
Pneumonectomy and
mediastinal
lymphadenectomy
Non Small Cell
Carcinoma – 2
Fibroma - 1
Left lung lesion
4
Lobectomy and
mediastinal
lymphadenectomy
Non Small Cell
Carcinoma
Asymptomatic and Routine MHC
55Y/F
 Husband admitted for
hemorrhoid surgery
 Easy Fatigability
noted by family
members, no chest
symptoms
 MHC
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Diagnosed with right sided thymoma with cyst
VATS with Aspiration of Cyst , Excision and Thymectomy
Histopathology
Thymic Cyst
SYMPTOMS – NON SPECIFIC
45y/M
 Fever 2 months
 On ATT for 1.5 months
 No relief
 Generalized itching of 1
month
 LFT – N
 CXR & CT mediastinal
nodes
 Mediastinoscopy –
Hodgkin’s lymphoma
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SYMPTOMS – NON SPECIFIC
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40/F – abdominal
discomfort
Bronchoscopy – no
endobronchial lesion
 CT guided biopsy –
not possible
 On table frozen
section – malignancy
 Pneumonectomy with
lymphadenectomy
 NSCLC – Moderately
differentiated
squamous carcinoma
 T2N2M0
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AS PART OF PRE EMPLOYMENT MHC
32y/M with Occasional fever
Large Dermoid cyst on left pericardium
ROUTINE INVESTIGATION FOR OTHER
CAUSE
SIGNIFICANCE OF DETECTING AND
??? MANAGEMENT
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For Patients :Potentially lethal conditions can be diagnosed early.
 Can be treated with curative intent
 Decreases the morbidity
 Improves outcome and survival.
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For Doctors :
Medico –Legal consequences
WHAT DO I MEAN ?
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Medico – Legal consequences ……
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A 44-year-old female received a routine chest X-ray
prior to hernia surgery; an incidental finding of a
lung nodule was not reviewed by the ordering
clinician, and was never followed up, resulting in a
delayed cancer diagnosis and a poor prognosis
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Allegation
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The patient’s estate sued the surgical resident and
the hospital, alleging that negligent failure to act
upon an abnormal chest X-ray resulted in a threeyear delay in diagnosing the cancer. The suit claimed
that the delay allowed a potentially very
treatable/curable cancer to advance to a terminal
stage for this patient.
Disposition
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This case settled for more than $2 million against the
hospital and the surgical resident.
CONCLUSION
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Routine full body health check up’s may not
necessarily be unnecessary.
Even the tiniest of the lesion can be devastating
if not addressed appropriately
REFRENCES
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Telles A C, Mendoza D . Relevance of an incidental
chest finding. Lung India. 2012 ; 29(1): 50–52.
MacMahon H, John H M , Herold C J et al.
Guidelines for Management of Small Pulmonary
Nodules Detected on CT Scans: A Statement from the
Fleischner Society. Radiology 2005 ; 237(2): 395-400.
LaValley D. Incidental Finding on Routine X-ray Not
Pursued By Radiologist or Ordering MD. 2011.
Christian S. A mediastinal mass. The Journal of
Family Practice. 2010 ; 59(6): 347-350.
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Thank you