Clinical Decisions in Advanced Non-Small

Cell Lung Cancer: From Histology to

Maintenance CME
Jamie Chaft, MD

CME Released: 09/24/2012; Valid for credit through 09/24/2013

A 68-year-old man presented 6 weeks ago with an acute febrile illness associated with
respiratory symptoms. His pulmonologist prescribed a course of oral antibiotics for clinical
bronchiectasis with improvement in his fever, although his cough persisted. Chest radiograph
at that time showed a consolidation adjacent to the right hilum. A presumed refractory
pneumonia was treated with a second course of antibiotics, again without improvement in his
respiratory symptoms. Computed tomography (CT) of the chest revealed a 1-cm spiculated
nodule in the right upper lobe, a 3.5-cm lymph node conglomerate in the right hilum, and a
single, enlarged 1.5-cm subcarinal lymph node. Bronchoscopy was performed with washings
and brushings that revealed atypical cells suspicious for cancer, but no definitive diagnosis
was rendered by the pathologist. Results of blood and sputum cultures were negative.

The patient has a medical history of well-controlled hypertension, chronic obstructive

pulmonary disease (COPD), and gastroesophageal reflux. At age 60 he underwent a
colonoscopy, the results of which were normal. He has no surgical history and no known
drug allergies. The patient takes only losartan and tiotropium daily. He works as a bread
deliveryman and has had a pack-per-day cigarette habit since the age of 16, which he stopped
during the last month while he was ill.

The patient presents to you today for an opinion prior to a planned repeat bronchoscopy for
diagnosis. He complains of mild dyspnea on exertion and a persistent cough that is
intermittently productive of blood. He has not had recurrent fever but admits to night sweats
and a 15-pound weight loss over the past 2 months. Review of systems is otherwise negative.
His vital signs are unremarkable. Physical examination is normal, with the exception of
inspiratory wheezing in the right mid lung zone.