Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
A 56-year-old man is evaluated for hemoptysis that has occurred daily for 7 consecutive days; he has also had a recent 5-kg (11-lb) weight loss. He smoked 1 pack of cigarettes daily for 40 years but stopped smoking 3 weeks ago. Chest radiograph shows a 4-cm irregular mass in the right upper lobe. Fiberoptic bronchoscopy shows a friable tumor in the proximal right upper lobe; biopsy reveals squamous cell carcinoma. A CT scan shows a 2.0-cm right paratracheal node in addition to the primary lesion.
Which of the following is the most appropriate next step in the patient's management?
A Chemotherapy
B Positron emission tomography (PET)
C Pneumonectomy
D Pulmonary function tests
Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
Correct Answer = D)
Key Points
* In patients with potentially operable non-small-cell lung cancer, pulmonary function tests are indicated to assess pulmonary reserve.
* Brain scan and bone scan are needed in patients with potentially operable non-small-cell lung cancer.
This patient clearly has lung cancer; the next question is whether he is a suitable candidate for curative surgery. In this instance, the patient has an enlarged mediastinal node, which suggests a more advanced clinical stage. But as no tissue specimen has been obtained from the enlarged node, his pathologic stage is indeterminate. Pulmonary function testing is indicated to assess his pulmonary reserve to help select the optimal pulmonary operation.
PET scanning may help clinically suggest the presence or absence of mediastinal metastases, but owing to false-positive and false-negative results with PET scanning, it cannot definitively establish pathologic stage. A bone scan and MRI of the brain are indicated to complete his staging work-up; it would be premature to refer him for pneumonectomy at this point. It is also inappropriate at this time to assume that the patient's disease is unresectable and refer him for chemotherapy. A full scanning profile is indicated when significant non“organ specific œclinical features suggesting metastatic spread are present, such as weight loss in this case. Organ specific and non“organ specific clinical features are associated with significant rate of positive scans. Also, from a practical standpoint, few surgeons are willing to seriously consider pneumonectomy without a full scan profile. While the enlarged node is a worrisome feature (with implications for adjuvant therapy and prognosis if proven malignant), it has no bearing on operability.
