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病例漫谈113:BMJ:轻微跌倒后肩部疼痛恶化后发现了肺癌 [复制链接]

1#
银光图片
患者为一名62岁男性,因在轻微跌倒后肩部疼痛恶化而就诊。医生要求进行X线检查,根据患者X线检查结果(如图1所示),下一步该怎么做?


图1 右肩前后位平片


答案

进行胸部和上腹部计算机断层扫描(CT)检查。肩关节X线片显示空泡肺结节,测量其大小约2厘米(如图2所示)。这最有可能是原发性肺癌,并应转诊到肺癌多学科团队就诊。

图2 右肩前后位平片,右肺有空泡肺结节(红色箭头)


学习要点
当看到一个孤立的肺结节,请肺癌多学科团队进行适当的进一步调查。

患者预后
病人进行胸部和腹部CT扫描以及随后进行的肺活检,发现为T2N0M0原发性肺腺癌。该患者接受手术切除,病人在两年内安然无恙。

原文来自:
Sharp shoulder pain, getting worse, after a fall.
BMJ 2017; 356

A 62 year old man saw his general practitioner with worsening shoulder pain after a minor fall. The GP requested a radiograph. On the basis of the radiograph alone (fig 1), what imaging would you request next?

Fig 1 Anteroposterior plain radiograph of the right shoulder

Short answer
Computed tomography (CT) of the chest and upper abdomen. The shoulder radiograph shows a cavitating lung nodule measuring approximately 2 cm (fig 2). This is most likely a primary lung carcinoma and should be investigated with referral to the lung cancer multidisciplinary team already said this in 1st line.

Fig 2 Anteroposterior plain radiograph of the right shoulder, showing a cavitating lung nodule in the right lung (red arrow)

Discussion
The occurrence of incidental findings on imaging tests depends on the modality and population group, but when cross sectional imaging is taken into account it is around 23%. It is higher in patients with a non-specific initial diagnosis. Many solitary pulmonary nodules are incidental findings on imaging performed for other reasons.

Unexpected findings, particularly in tissues that are not the primary focus, can be difficult to spot. “Framing bias” or “fixation errors” are phenomena that occur where a person does not see an obvious abnormality in one structure because they are focused on another site more relevant to the clinical picture—for example, checking for causes of pain from the shoulder joint.

In some cases, the patient has a structural cause— for example, a humeral fracture. In that case, there is a risk of a “satisfaction of search” error, where the interpreter stops looking at other tissues because they have “solved” their clinical problem.

In a care setting where not all imaging is formally reported, it is important to be aware of these potential pitfalls. A structured approach to reviewing imaging, including review areas where commonly missed pathology is excluded on a “final check,” helps protect against these errors.

Learning points
- Beware of error types when reviewing radiological images, and try to have a systematic, structured approach including review areas.
- When you see a solitary pulmonary nodule, refer urgently to the lung cancer multidisciplinary team or for appropriate further investigation as with your local protocol.

Patient outcome
The patient had a CT scan of the chest and abdomen and subsequently a lung biopsy, which revealed a T2N0M0 primary lung adenocarcinoma. This was surgically resected and the patient remains disease free at two years.
最后编辑蛋蛋JY 最后编辑于 2017-03-09 15:27:14
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