1. NYU Medicine Grand Rounds Clinical Vignette David Altszuler, MD PGY-2 December 11, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 79 year old woman with prior tobacco use (55 pack-years, abstinent since 2009) presents for evaluation of an abnormality seen on her most recent chest CT. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Began annual surveillance chest CT in 2004 A few small (<5mm) nodules were found and remained stable on follow-up images In 2009 she began undergoing chest CT scans every two years 2011 scan showed a new left upper lobe oblong lesion likely representing a thick walled bronchiole, otherwise stable 2013 scan showed that left upper lobe lesion had progressed to a 1.9 x 1.7cm groundglass opacity with areas of solid attentuation, concerning for malignancy History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: HTN Dyslipidemia Osteoporosis Past Surgical History: Ovarian cyst removal Social History: 55 pack year tobacco use, abstinent since 2009. Denies other illicit drug use. Weekly alcohol use Denies any occupational or toxic exposures Family History: Coronary artery disease in both parents Allergies: Sulfa Medications: Aspirin 81mg daily Hydrochlorothiazide 25mg daily Simvastatin 20mg nightly Calcium and vitamin D3 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: Well appearing, ambulatory, woman appearing stated age Vital Signs: T:98.6 BP:140/90 HR:88 RR:16 and O2 sat:95% on ambient air Chest with normal AP diameter, decreased breath sounds throughout, no wheezing, rhonchi or rales Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: Hemoglobin 15.5, Hematocrit 48.3 Remainder of CBC was within normal limits Basic Metabolic panel: Potassium 3.4 Remainder of basic was within normal limits Hepatic panel: Total and indirect bilirubin 1.3 Remainder of hepatic panel was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 2013 CT scan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. 2011 CT scan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. 2011 2013

10. PET/CT U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. PET/CT obtained without evidence of metastatic disease or nodal involvement Patient was referred to thoracic surgery for evaluation Underwent left upper lobe wedge resection via video-assisted thoracoscopy and lymph node dissection April 2013, 1.7cm tumor removed Intra-operative frozen section showing invasive adenocarcinoma Clear margins, nodes negative for malignancy Treatment Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Invasive adenocarcinoma of the lung, moderately differentiated, with lepidic (60%), acinar (30%) and papillary (10%) growth. Stage 1a. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS