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 .
Definition excludes :- 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
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 –
1 in 13 – men 1 in 16 – woman
Of these between 20% and 30% will present as an Solitary Pulmonary Nodule.
Master Health Check up at patient request
Carefully studied routine investigations – probably essential to pick some life threatening conditions at early ( probably curable ) stage .
HOW WE DETECTED….
Study period :- February 2008 to July 2013
We reviewed the record of the patients retrospectively.
Asymptomatic and Routine Master Health Checkup
As part of pre employment
As part of requirement for VISA
Symptoms – non specific
TOTAL NUMBER OF PATIENTS WITH DETECTED INCIDENTALOMAS - 23
MEDIASTINAL INCIDENTALOMAS – 16
LUNG INCIDENTALOMAS – 7
RIGHT LUNG (3)
LEFT LUNG (4)
(7) (2)
(7)
(7)
(7)
(2)
Mediastinal mass
Number procedure Final HPE Diagnosis
Lymphadenopathy 7 Mediastinoscopy and biopsy
Tuberculosis- 3Sarcoidosis- 3Lymphoma - 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 – 2Fibroma - 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
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
SYMPTOMS – NON SPECIFIC 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
AS PART OF PRE EMPLOYMENT MHC32y/M with Occasional fever
Large Dermoid cyst on left pericardium
ROUTINE INVESTIGATION FOR OTHER CAUSE
SIGNIFICANCE OF DETECTING AND ??? MANAGEMENT
For Patients :- Potentially lethal conditions can be diagnosed
early. Can be treated with curative intent Decreases the morbidity Improves outcome and survival.
For Doctors :- Medico –Legal consequences
WHAT DO I MEAN ?
Medico – Legal consequences ……
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
Allegation
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 three-year 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
This case settled for more than $2 million against the hospital and the surgical resident.
CONCLUSION
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
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.
Thank you
