Medicine>>>>>Pulmonary Disease
Question 27#

A 56-year-old woman presents with cough for the past 2 months and streak hemoptysis for the past 3 days. She denies dyspnea on exertion. She has smoked 2 packs of cigarettes a day for the past 35 years. She is otherwise healthy and has not lost weight. Physical examination is normal. Chest x-ray reveals a shaggy 3-cm nodule in the right mid-lung field. Transthoracic needle biopsy shows a squamous cell carcinoma. PET/CT scan confirms the hypermetabolic 3-cm nodule and shows a 1.5-cm ipsilateral hilar lymph node. Mediastinal lymphadenopathy, intraparenchymal metastases, pleural effusion and distant metastases are absent. Spirometry is normal. What is the best management option for this patient?

A) Surgical lobectomy
B) Radiation therapy
C) Combination chemotherapy
D) Endobronchial brachytherapy
E) Await development of symptoms such as pain or hemoptysis, then palliative radiation therapy or chemotherapy

Correct Answer is A


This patient has stage IIB non-small cell lung cancer (NSCLC) and should be considered for surgical resection with curative intent. As a general rule, patients with stages I and II lung cancer are surgical candidates unless other medical contraindications or severe COPD are present. Adjuvant chemotherapy is sometimes added, but surgery is the curative modality with the best track record. Patients with stage I lung cancer have tumors localized to the lung. Stage II cancers are associated with ipsilateral peribronchial or hilar lymph node involvement. Mediastinal lymph node involvement, pleural effusion, or distant metastases generally preclude curative surgery. These patients, however, may respond to radiation and/or chemotherapy. Although some patients have achieved long-term remission after radiation therapy, it is less effective than surgical resection. Combination chemotherapy can prolong life expectancy in selected patients but is not considered curative. Endobronchial radiation therapy (brachytherapy) can palliate intractable hemoptysis or bronchial obstruction but is not curative; survival in NSCLC after brachytherapy averages 6 months. “Watchful waiting” would be inappropriate in this patient with potentially curable disease.