A 62-year-old woman with a 40-pack-year smoking history is evaluated in the clinic for preoperative clearance prior to an elective total knee arthroplasty. She is generally healthy and reports no cough, hemoptysis, dyspnea, or weight loss. A routine preoperative chest radiograph reveals an incidental 14-mm, non-calcified, solitary nodule in the periphery of the right upper lobe. Arrange the following diagnostic modalities in the most appropriate sequential order for the evaluation of this radiographic finding, from the immediate next step to the definitive diagnostic procedure. Assume that at each step, the findings remain highly suspicious for primary pulmonary malignancy but lack definitive tissue diagnosis.
- 1Retrieval and review of the patient's prior chest imaging studies
- 2Computed tomography (CT) of the chest without intravenous contrast
- 318F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan
- 4Image-guided percutaneous transthoracic needle biopsy
Answer
The correct sequential evaluation of an incidental solid pulmonary nodule is: (1) Review of prior imaging, (2) Non-contrast chest CT, (3) FDG-PET scan, and (4) Image-guided percutaneous biopsy.
The standard evaluation of a newly identified solitary pulmonary nodule begins with a comparison to prior imaging to assess for growth. If unavailable or the lesion is new, a non-contrast chest CT is ordered to characterize the anatomy. For nodules > 8 mm that are suspicious on CT, an FDG-PET scan evaluates metabolic activity and screens for metastases. Finally, highly suspicious, metabolically active lesions require a tissue diagnosis via biopsy.
Step-by-Step Solution
Key Concept
Stepwise radiographic evaluation of an incidental solitary pulmonary nodule