False Positve PET or False Negative Biopsy on Hilar Nodes - 1261122

Wed, 12/18/2013 - 18:26

84 year old mother scheduled for EVAR on AAA that had been monitored for 8 years. Smoker for 50+ years until receiving PET scan results December 3, 2013.
CT Angiogram indicated suspicious RLL nodule.
PET scan indicated stage 3a cancer per medical oncologist due to 2.26 cm nodule and 2 hilar nodes on same side lit up on PET.
December 9 - Successful EVAR on AAA
December 11 - Biopsy with Mediastinoscopy on hilar nodes negative for cancer.
December 19 - Wedge resection on 2.26 cm is scheduled with an option for lobectomy if needed and lung functioning test indicates it is safe. Mother insists on moving forward and fast on this procedure even though she just had EVAR last week and the nodes are negative.
Children are confused by why moving so fast since the nodes are negative.
Mother lives in Missouri.....county is 100% endemic for histoplasmosis
Can node biopsy indicate likelihood of infection and/or inflammation?
What questions should we ask before the procedure?
What questions should we ask if tumor is positive?
What questions should we ask if tumor is negative?

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Dr West

Those hilar nodes are probably not very easily accessible. I would say that prior to a wedge resection, the leading consideration would often be of a CT-guided biopsy if the main lesion is accessible (more peripheral, not too central).

One question I'd be interested in is who is doing the surgery. It's FAR preferable to have someone who is a trained, dedicated thoracic surgeon doing this and not someone who is a general surgeon doing gallbladders and appendectomies, and then lung surgery once every week or two, or a heart surgeon who does lung surgery when there's a dry spell in cardiac surgery. That said, the plan you've outlined sounds like it was developed by someone who knows what they're doing, so I suspect she's seeing a dedicated thoracic surgeon.

I think the main question to ask is whether an intervention other than a wedge resection is feasible to obtain the diagnosis. If so, why not do that first? If not, OK, then a wedge resection makes sense, but if it shows cancer, will this be followed by a completion lobectomy and full nodal dissection? And how confident are they that she would do OK with the required surgery?

Your question about timing is fair, but it may have more to do with her insistence on a tight time frame rather than a recommendation from the surgeon that things need to move that quickly.

Good luck.

-Dr. West