Wednesday, June 15, 2005

Lung cancer question

This was submitted by one of our readers:
Hi, great blog by the way.
We were wondering if you would post this question so we could get different opinions on the next step.
We have recently started to follow a 52 y/o woman with very severe COPD who is still smoking. She first came to our service as an in-patient with hypercapnic respiratory failure. On further follow-up we reviewed her history: 2 years ago she had a pulmonary mass identified. At the time her pulmonologist thought it was not safe to do any procedures for diagnosis and she had empiric xRt to the area. She has since followed with her primary care and has multiple hilar and mediastinal nodes that are PET positive. The orginial mass has shrunk and is no longer seen on CAT scan.
We performed a bronch: no endobronchial lesions with non-diagnostic samples. Her FEV1 is around 22% (0.5L). What, if anything, would you offer her next? Thanks.

4 comments - CLICK HERE to read & add your own!:

Jeff H said...

First, I'm surprised that she was given XRT without any tissue diagnosis-the approach would be different for small cell and non-small cell carcinomas. Presumably, she was given "radiation with curative intent" and at the time there was no indication of mediastinal lymphadenopathy. So, now, 2 years later there are PET positive mediastinal nodes. If her pulmonary function were better, I'd be interested to see which nodes are positive (i.e. subcarinal/pretracheal, or ipsilateral hilar). However, surgery is not an option.

If the patient must know if these nodes are cancerous, I'd offer a bronch with Wang (transbronchial fine needle aspiration) if the nodes are accessible (i.e. large subcarinal or low-right pretracheal. If malignant cells are identified, the diagnosis is made. If not, than there is no good diagnostic modality.

Once a diagnosis is made, there is the question of treatment. I'm not an oncologist, but I'm sure some would offer a regimen of carboplatin/taxol. Alternatively, she could be enrolled in an experimental protocol. Finally, it is also reasonable to do nothing and treat any complications that arise in the future with palliative XRT. Her functional status will determine whether she is even a candidate for chemo.

Jennings said...

How big are the nodes on CT? It might be useful to do fine-needle aspiration, as cell type can dictate type of treatment. I agree with Jeff H that chemo may be only marginally beneficial anyway, in woman with end-stage lung disease and at least stage 3 cancer.
It would likely be more appropriate, perhaps, to forgo with further diagnostic workup and discuss with the patient and family end-of-life options including hospice. Chemo may add a month or 2, but it may decrease her quality of life. This should be weighed with the patient.

Mike L said...

This is the type of patient to present at a multidisciplinary thoracic oncology conference. Not necessarily for diagnotic purposes, but to see what differing treatment modalities would offer in terms of quality of life and prolongation of life.
If it is profound and the patient would agree to receive therapy, the diagnostic options listed above are good choices.
Philosophically, we can debate the merits of treating someone for lung cancer who continues to smoke.

Palliative therapy would also be a viable (and perhaps more appropriate) option.

Blog-reader said...

We really appreciate the suggestions.
She did indeed receive xRt without tissue diagnosis. That was before she had come to see us :)
The recent non-diagnostic bronch included Wang needle aspirates which were non-diagnostic.
Her positive nodes are pre-tracheal, subcarinal and hilar ipsilateral.
She is more inclined to just watch and wait and has no real interest in smoking cessation :(
Thank you for posting our question.