A patient's viewpoint on a current controversy.

Abstract

Editor: The recent strident debates in Radiology (1–4) on the effectiveness of computed tomography (CT) in screening for lung cancer have captured the radiologists’ attention, stirred controversy, and stimulated some much needed critical thinking. What is often missing from radiologists’ thoughts is firsthand experience with the clinical drama that follows screening or diagnostic tests. My personal anecdote is an example of the clinical aphorism that the only “normal” patient is one who has not yet undergone a complete work-up. It began innocently enough with a negative CT colonographic examination that was requested following my routine annual physical examination. Lurking outside the colon were a renal lesion, a 2-cm hepatic mass, and multiple 9–10-mm noncalcified nodules at both lung bases. Our observant radiologists saw them all. Further contrast material–enhanced CT scans of the abdomen demonstrated that the renal mass was a cyst. The nonenhancing liver lesion was not a cyst. Findings from high-spatialresolution lung CT revealed seven to eight noncalcified nodules in both lower lobes. A chest radiograph obtained in 1997 was negative. Findings from the CT-guided liver biopsy showed only necrotic tissue; but the findings were not definitive. A positron emission tomographic (PET) scan was negative. After much debate, video-aided thoracoscopy was performed with an intercostal approach. Three wedge resections were performed on the right lung after the anesthesiologists had selectively collapsed it to aid the surgeons’ palpation of the lesions. Thorough evaluation by the pathologists resulted in a definitive diagnosis of Histoplasmosis capsulatum, with areas of noncalcified granulomata in all three lesions. I awoke in the recovery room after 5 hours, with a chest tube, a Foley catheter, a subclavian central venous catheter, a nasal oxygen catheter, an epidural catheter, an arterial catheter, subcutaneously administered heparin, a constant infusion of prophylactic antibiotics, and patient-controlled analgesia with intravenously administered narcotics. During the next 4 days, the tubes and the potent drugs were slowly removed, but the excruciating pain lingered on. However, the nurses were great, the hospital staff superb, the surgeons were the best anywhere, and no untoward events or complications occurred. Most of all, the outcome was great. However, 2 weeks at home while taking prescribed narcotics were required before the pain became bearable and a modicum of strength returned. Now, 5 weeks later, things are nearly normal except for anterior intercostal pain caused by the surgical interruption of intercostal nerves. But my family and I are all happy. No malignant disease was found, and a major diagnostic evaluation of all organs indicated no major disease. Total charges are still being tabulated but will probably surpass $50,000. What are the lessons learned? 1. Despite the absolutely best care by superb practitioners and great hospital care, an extremely painful and costly major procedure was performed that resulted in a 4-week disability. 2. We as radiologists do not fully appreciate the invasive nature of pulmonary nodule resections. They are not comparable to breast biopsies or colonoscopic polyp removals. Patients who have undergone thoracotomies have such an appreciation. 3. Despite our best efforts, we cannot be very specific in diagnosing new small noncalcified pulmonary nodules; and the presence of such lesions in problematic clinical settings creates an almost irresistible urge to make a definitive diagnosis with surgical resection, thereby avoiding the anxiety of 2-year follow-up CT scans. Relatively high false-positive rates have a major negative effect. 4. There are many unanswered questions relative to lung cancer screening with CT. They include the following: (a) How do we best perform the examination? (b) Who should be screened? (c) How should the follow-up be done? (d) What is the role of PET scanning? (e) How do we best integrate the clinical picture and imaging findings in guiding therapy? (f ) What other imaging processing programs can we develop to sharpen the specificity of the CT findings? High-spatial-resolution CT of the chest is a superb imaging tool. At the moment, it is very sensitive but not specific enough. The pursuit of false-positive findings in the lungs is at best costly, anxiety producing, and involves 2 years of repeated CT scans. At worst, it will lead to painful, costly, and potentially risky major surgical procedures. Routine screening of the lungs with CT will produce more surgery and certainly more CT scans to monitor change. We as radiologists must understand the consequences to the patient. It is not nihilistic to suggest that more research is needed, and we still need to prove that searching for occult lesions will improve the length and the quality of life. After 30 years of performing minimally invasive interventions as substitutes for surgery, I realize the effort was worthwhile.