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Question 10#

A 67-year-old man complains of progressive shortness of breath. He has a history of smoking 2 packs of cigarettes per day for 50 years and has been unable to quit despite nicotine replacement and bupropion. He has mild chronic obstructive lung disease for which he is using ipratropium. He is still able to work as a part-time store manager and play golf with his friends. Chest x-ray shows a moderate-sized left-sided effusion. Thoracentesis reveals bloody pleural fluid. Cytologic examination is consistent with bronchioalveolar adenocarcinoma.

What is the best next step in management? 

a. Refer to hospice
b. Refer to a surgeon for lobectomy
c. Refer to an oncologist for chemotherapy
d. Refer to a radiation oncologist for radiation therapy
e. Place a chest tube and observe

Correct Answer is C


This patient has a non-small cell lung cancer (NSCLC). NSCLC includes squamous cell carcinoma, adenocarcinoma, large cell carcinoma, bronchoalveolar carcinoma, and other mixed versions. In patients with NSCLC, surgery alone is not appropriate for patients with advanced disease. Advanced disease is defined as the presence of any of the following: extrathoracic metastases; superior vena cava syndrome; vocal cord paralysis (which implies phrenic nerve involvement); malignant pleural effusion; cardiac tamponade; tumor within 2 cm of the carina; metastasis to the contralateral lung; bilateral endobronchial tumor; metastasis to the supraclavicular lymph nodes; contralateral mediastinal node metastases; or tumor involvement of the main pulmonary artery. Radiotherapy also has limited usefulness in advanced NSCLC, but is an option for patients with tumors within 2 cm of the carina, bilateral endobronchial tumors, or contralateral mediastinal node involvement. This patient has advanced disease because of the presence of a malignant pleural effusion. In these patients, chemotherapy has been shown to improve progression-free survival and overall survival compared to supportive therapy alone. The role of chest tube placement in malignant pleural effusion is for symptomatic relief only. This patient has good functional status and no comorbidities that would preclude chemotherapy; hence hospice is not the best option at this time.