Bronchoscopy with biopsy vs. Surgical Wedge resection

[DrMetal]

Was doing a MKSAP IM board review question:
72-yo F, with every risk factor in the world, 9-mm solid pulmonary nodule in the Left upper lobe, said nodule is very PET avid (no evidence of any other distant uptake, no distant mets). What do you do next?
Correct answer was Surgical Wedge Resection (I chose the second best answer: bronchoscopy with biopsy).

Their argument for a surgical wedge resection was that the nodule is highly suspicious for cancer, to go ahead and take it out. But I've scene this scenario clinically quite a few times. It seems like if we can biopsy first (if the lesion is accessible), we typically try to do that first, to get a definitive diagnosis before surgery. Right? A surgical wedge resection has a lot of morbidity associated with it. You'd want to know that you really have a malignancy, before surgery, right? (if the node or lesion is not accessible to biopsy, then I get it, go after it surgically).

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[Hernandez]

Their answer is correct. 9mm LUL nodules are not something that are routinely accessible via bronch. I have 30% yield as data from older studies stuck in my head but am not going to dig through my files to reference that. So game plan this out, Even with nav, what are you going to do if you get a non-diagnostic result? Wait and see? No, so cut out the excessive procedure. If the patient is high risk for cancer, then pet, meds with conversion to resection. Wham bam thank you ma’am. Now there are obvious caveats to this but their answer is the fiscally responsible and expedient answer for someone who can have a curative intent. If they have suspicious nodes then tbx and ebus away.

 

[DrMetal]

Their answer is correct. 9mm LUL nodules are not something that are routinely accessible via bronch. I have 30% yield as data from older studies stuck in my head but am not going to dig through my files to reference that. So game plan this out, Even with nav, what are you going to do if you get a non-diagnostic result? Wait and see? No, so cut out the excessive procedure. If the patient is high risk for cancer, then pet, meds with conversion to resection. Wham bam thank you ma’am. Now there are obvious caveats to this but their answer is the fiscally responsible and expedient answer for someone who can have a curative intent. If they have suspicious nodes then tbx and ebus away.

Ok, so it's just a matter of location? If it were a more central/hilar lesion or LN that was accessible, you'd bronch right?

 

[gutonc]

Ok, so it's just a matter of location? If it were a more central/hilar lesion or LN that was accessible, you'd bronch right?

If it's a surgically resectable, lung limited lesion, in a patient who is a candidate for surgery, you just take it out. Since that's the correct treatment, just start there.

If it's not surgically resectable (mediastinal invasion on imaging) or a hot LN on PET, then yes, bronch/EBUS prior to treatment planning (in a multidisciplinary tumor board setting) would have been the right answer.

At least you didn't choose core needle biopsy like pretty much every IM resident and hospitalist at my primary hospital appears to do. It's gotten so bad that we got radiology to agree to not do CT guided bx of lung lesions unless ordered by pulm, thoracic surgery or oncology.

 

[Hernandez]

Ok, so it's just a matter of location? If it were a more central/hilar lesion or LN that was accessible, you'd bronch right?

Isolated 9mm module without lymphadenopathy or endobronchial diseases? No. I probably wouldn’t bronch that.

Lymph node disease. Yeah. I can schedule and get an ebus done quicker than a pet and at least where I practice few of my pts with N1 disease are going to be resectable as their underlying copd is probably prohibitive.

Ironically had the Op scenario come up in tumor board and Med Onc argued with me on my telling them Pet, pft and thoracic referral.

 

[DrMetal]

At least you didn't choose core needle biopsy like pretty much every IM resident and hospitalist at my primary hospital appears to do. It's gotten so bad that we got radiology to agree to not do CT guided bx of lung lesions unless ordered by pulm, thoracic surgery or oncology.

To be honest I didn't pick it b/c it wasn't an answer choice. In real life, I've seen this attempted many times. A lesion too distal or peripheral to bronch (we don't have IP), and CT surgery doesn't want to touch it until we really know what it is (we have a weak CT surgery dept).....hence IR-guided biopsy is the only option. But I've never made that decision alone, it's always been with Pulm and CT following.

 

[chessknt]

To be honest I didn't pick it b/c it wasn't an answer choice. In real life, I've seen this attempted many times. A lesion too distal or peripheral to bronch (we don't have IP), and CT surgery doesn't want to touch it until we really know what it is (we have a weak CT surgery dept).....hence IR-guided biopsy is the only option. But I've never made that decision alone, it's always been with Pulm and CT following.

Welcome to the fantasy land of medical boards where you provide prenatal care, manage rheum biologics, treat cancer, and manage vents all in the same day. Your 4 figure fee will go to perpetuate this nonsense.

 

[DrMetal]

Welcome to the fantasy land of medical boards where you provide prenatal care, manage rheum biologics, treat cancer, and manage vents all in the same day. Your 4 figure fee will go to perpetuate this nonsense.

It's utterly ridiculous.

 

[jdh71]

I agree that size nodule just comes out if pet positive.

I know I can’t make bass boat payments by not attempting a biopsy BUT the problem in this scenario is IF the patient has all the risk factors in this scenario (no evidence of spread on let) are you really going to believe negative biopsy? If “no” then it needs to come out as the only way to be sure. Just do the math.