S IGNIFICANCE OF AN I NCIDENTALOMA 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) (2)

Mediastinal massNumberprocedureFinal HPE Diagnosis Lymphadenopathy7Mediastinoscopy and biopsyTuberculosis- 3 Sarcoidosis- 3 Lymphoma - 1 Thymoma4VATS and total thymectomyThymoma Thymolipoma1Thoracotomy and total thymectomy Thymolipoma Morgagni hernia1VATS –thoracotomy,laparotomy and mesh repair Bronchogenic cyst2VATS- thoracotomy, partial excision and marsupialisation Bronchogenic cyst Teratoma1Thoracotomy and excisionTeratoma

Solitary lung nodule NumbersProcedureFinal HPE Diagnosis Right lung lesion3Lobectomy/ Pneumonectomy and mediastinal lymphadenectomy Non Small Cell Carcinoma – 2 Fibroma - 1 Left lung lesion4Lobectomy 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

S YMPTOMS – 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

S YMPTOMS – 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

A S PART OF P RE E MPLOYMENT MHC 32y/M with Occasional fever Large Dermoid cyst on left pericardium

R OUTINE 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

W HAT 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.

C ONCLUSION 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 ; 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): LaValley D. Incidental Finding on Routine X-ray Not Pursued By Radiologist or Ordering MD Christian S. A mediastinal mass. The Journal of Family Practice ; 59(6):

Thank you