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History

A male patient in his 60s who is a former smoker presented to thoracic surgery for evaluation of a left upper lobe 2 cm lung nodule.

The nodule had been identified incidentally during a routine cardiac workup for atrial fibrillation. He was referred to a pulmonologist near his home for a robotic bronchoscopy and mediastinal staging.

He underwent a biopsy two months after his initial radiologic diagnosis, but the biopsy was nondiagnostic. At this time, his pulmonologist referred him to Rush thoracic surgery for a second opinion.

Presentation

Upon presentation to thoracic surgery, his imaging was reviewed and was concerning for a primary lung cancer. Given his previous two-month delay in diagnosis, we reviewed his case as a multidisciplinary team of interventional pulmonology and thoracic surgery. We opted to perform a single anesthetic event with robotic bronchoscopy for definitive diagnosis followed by robotic-assisted left upper lobectomy if the diagnosis was consistent with malignancy.

Treatment

The patient underwent a robotic bronchoscopy with James Katsis, MD, from interventional pulmonology in the operating room. On-site cytology confirmed a poorly differentiated squamous cell carcinoma. Once the diagnosis was confirmed, we proceeded with a robotic-assisted left upper lobectomy for therapeutic intent. He did well with the procedure and was discharged the next day. Of note, the time from initial assessment in the thoracic surgery office to the day of discharge was 14 days.

Outcome

The patient ultimately had a stage I squamous cell carcinoma and did not require any adjuvant therapy. At his follow-up visit approximately one year after the surgery, he showed no evidence of disease, and he will continue to be surveilled per NCCN guidelines in the thoracic surgery clinic.

Analysis

One of the advantages we have at Rush is our ability to collaborate between specialists – in this case, interventional pulmonology and thoracic surgery – to give patients a diagnosis and treatment within one anesthetic event that allows us to decrease time to treatment. In other contexts, this would be done in two separate procedures under anesthesia, which ultimately can delay care by several weeks, resulting in potentially worse outcomes for patients.