A 1 cm coin lesion is seen on chest X-ray in the right upper lobe. FNAC shows adenocarcinoma. Appropriate management is:
Ans: A (Excision and observation) Ref: Schwartzs Principles of Surgery, 9th Edition & Sabiston Textbook of Surgery, 19th EditionExplanation:"Early stage lung cancer (Stages l and II) may successfully he Heated with surgery alone and, in most patients, yields long-term survival rates." {Ref: Sabi st on)Principles of Management of Lung AdenocarcinomaTreatment options includeSurgery for localized diseaseChemotherapy for metastatic diseaseRadiation therapy for local control in patients whose condition is not amenable to surgery.Radiation therapy and chemotherapy together are better than chemotherapy or radiation therapy alone for primary treatment of advanced stage lung cancer.Solitary Pulmonary NoduleAmong patients with lung cancer, the best survival can be expected in cases presenting with asymptomatic solitary peripheral pulmonary nodule on chest x-ray (coin lesions)The solitary pulmonary nodule (SPN) - abnormal density up to 4 cm in diameter, rounded or ovoid in appearance surrounded by a zone of lung tissue by x-ray, and free of cavitation or associated lung infiltrates.Eccentric flecks of calcium may he presentRecent analyses suggest that approximately 80 percent of all coin lesions were malignant in patients over 50 years of age.The differential diagnosis of an SPN includes many entitiesMalignant tumorsBenign tumorsPulmonary hamartomaGranulomaPulmonary arteriovenous fistulaPulmonary'' infarctionSurgery is rarely indicated for the nonmalignant lesions if diagnosis is confirmed.Where calcification is present, CT is useful in selecting the rare patient who can be observed safely.CT scans have the capacity to measure absorption coefficients, which indicate tissue density.For many years there has been a difference of opinion regarding the management of patients with SPNs, with some groups advocating early thoracotomy with resection of the lesion for all patients above 35 years of age and others urging a more conservative approach with greater emphasis on diagnostic studies and observation.Although the resection policy did result in a 50 percent frequency of removal of benign lesions, excellent cure rates could be expected if primary malignancies were found.Serial radiographs provide the data for calculation of grow th rate, and it usually is possible to detect that a lesion is grow ing within a few weeks.The doubling time of malignant nodules is usually between 37 and 4f>5 days.If the lesion is growing more slowly or more rapidly than this, the evidence is in favor of benignity.With the advent of video-assisted thoracoscopic techniques, resection of nodules in the periphery of the lung result in minimal morbidity and virtually no mortality.
Excision and observation
Excision and chemotherapy
Neoadjuvant chemotherapy followed by excision
Excision and Chemoradiation
Miscellaneous (Neoplasia)