. Step 25 of 41
Clinical Stem 1
Non-smoking female with a new right upper lobe lung mass and three PET-positive mediastinal lymph nodes

Answer B
Initiating chemotherapy or palliative care only without confirming progression of disease is probably undesirable. It is also noteworthy that some patients may have a granulomatous disorder which can mimic cancer. Patients may also have tumor markers, such as over expression of ERCC1, which predicts resistance to platinum-based chemotherapy. Consulting palliative care medicine is appropriate, particularly because progressive disease is a concern, but may not be the next immediate step in this patient's management because her quality of life and activities of daily living have not deteriorated.

In this patient with lung adenocarcinoma and history of EGFR mutation, repeat biopsy was done to confirm disease progression and to evaluate if secondary mutations may be present which might offer prognostic value and help guide referral towards clinical trials.

Patients with a diagnosis of cancer and evidence of mediastinal and or hilar lymphadenopathy on PET-CT should undergo a tissue sampling procedure to avoid inaccurate upstaging and inappropriate therapeutic management.
References:
  1. Sequist LV, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med 2011;3:75ra26.
  2. Kennedy M, Jimenez C, Mhatre A, et al. Clinical implications of granulomatous inflammation detected by endobronchial ultrasound transbronchial needle aspiration in patients with suspected cancer recurrence in the mediastinum. J Cardiothorac Surg. 2008; 3:8.
  3. Olaussen KA, Dunant A, Fouret P, et al. DNA repair by ERCC1 in non-small-cell lung cancer and cisplatin-based adjuvant chemotherapy. N Engl J Med. 2006;355:983-991.
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