Aashi
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A 58-year-old man with no previous past medical history presents to the emergency department complaining of dizziness for one week accompanied by headache, nausea, generalized weakness, decreased appetite, and weight loss. He is a 30-pack-year smoker and denies cough, shortness of breath, or hemoptysis. The patient appears cachectic on physical examination and is in no acute distress. Vital signs are normal. Physical examination is remarkable for diminished breath sounds in all lung fields and symmetrically enlarged breasts. The neurologic examination is normal.
Chest x-ray shows hyperinflated lungs with a peripheral lesion in the right upper lobe and a central left-upper-lobe lesion. The head CT scan reveals a left posterior fossa lesion with edema and mass effect. Chest CT shows a 5-cm mass in the periphery of the right upper lobe and a 3-cm mass within 2 cm of the carina in the left middle lobe. Mediastinoscopy and biopsy are performed, and the biopsy shows large-cell cancer.
How would you best manage this patient at the present time?
(A) Preoperative pulmonary function testing (PFT)
(B) Radiation therapy to the brain and dexamethasone
(C) Radiation therapy to lung lesions
(D) Combination of chemotherapy and radiation therapy
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? radiation therapy to the brain and dexamethasone.
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| Aashi
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Answer:
(B) Radiation therapy to the brain and dexamethasone
Explanation:
The patient is presenting with large-cell cancer, which usually presents as a peripheral lesion that tends to metastasize to the central nervous system (CNS) and mediastinum. It is often associated with gynecomastia.
Preoperative pulmonary function tests (PFTs) would not be indicated because he has stage IV lung cancer and is therefore not a surgical candidate. He has contralateral lesions and metastatic disease to the brain. Stages I, II, and even III disease can be treated with surgery as long as the involved lymph nodes are on the ipsilateral side. This patient has bilateral lung lesions. Radiation to lung lesions is indicated for patients whose tumor is causing symptoms, such as bronchial obstruction with pneumonitis, upper airway obstruction, or superior vena cava syndrome. Combination therapy with chemotherapy and radiation therapy shows an objective tumor response in 30 to 40% of patients with limited small-cell cancer or unresectable stage III non-small-cell cancer. Local radiation therapy is also indicated for bone and CNS metastases as palliation only.
Radiation to the CNS metastases is the best first step in therapy, given this patient's CNS symptoms, such as headache, nausea, and dizziness. Address the chief complaint in a question first.
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