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A 62-year-old African American male presents to his primary care physician for routine health maintenance. He has diabetes mellitus (DM) controlled on oral medications and hypertension (HTN), for which he takes hydrochlorothiazide and lisinopril. He has a 50 pack-year smoking history, so his physician orders low-dose chest computed tomography (CT), which shows a 2.1-cm mass in the left upper lobe area. His laboratory work is normal. He sees a pulmonology and undergoes endobronchial ultrasound (EBUS)–guided biopsy, which shows adenocarcinoma. The patient wonders if he will need surgery, radiation, chemotherapy, or all three.

Learning Objectives

  1. How do you determine the best modality for biopsy of a lung nodule?

  2. Which lymph nodes are sampled with a mediastinoscopy?

  3. Which tests should be done prior to lung cancer resection?


Assessment of a newly found lung nodule should begin with a history and physical to determine the extent of the disease, focusing especially on areas that may imply presence of metastatic disease. Questioning should be directed toward possible symptoms within and outside of the pulmonary system, including pain within the long bones and vertebrae, new lesions of the skin, and focal neurological findings, such as headache, nausea, vomiting, or seizure. Other suggestions toward metastatic disease include constitutional symptoms such as anorexia, unintentional weight loss, and general malaise. Physical examination warrants attention to palpable lymph nodes, especially the cervical and supraclavicular basins; muscle wasting; and chest auscultation. Routine laboratory studies searching for paraneoplastic syndromes include complete blood count, basic metabolic panel, calcium, and the hepatic enzymes glutamic oxaloacetic transaminase and alkaline phosphatase.


Further assessment of a lung nodule should continue with non-invasive staging of disease using advanced imaging. The status of intrathoracic nodal disease will be the patient’s major determining factor when discussing treatment options. If disease has not spread from the primary tumor to mediastinal or subcarinal lymph nodes, surgical resection would be the preferred choice.

If a patient does not already had a thin-cut chest CT, a scan with intravenous contrast should be performed for elucidation of the primary tumor size and characteristics as well as for mediastinal lymphadenopathy or other disease burden in relation to the major structures of the thorax. Extension of CT to the liver and adrenal glands can evaluate two common sites of metastasis at this initial scan. If there is an increase in the size of lymph nodes noted on CT, positron emission tomography (PET) is useful in distinguishing malignant tissue from benign forms of lymphadenopathy. PET provides benefit in the evaluation of regional disease as well as distant sites, with the exception of visualizing disease within the brain due to baseline metabolic activity. In the PLUS multicenter randomized controlled trial, addition of PET to the preoperative workup ...

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