Oral Board Case: Lung Cancer

How do you approach this patient with a newly discovered pulmonary nodule?

Expected answer

Start with a complete history and physical, focusing on risk factors — smoking history, occupational/environmental exposures (asbestos, radon), family history, and constitutional symptoms. Note pulmonary symptoms and signs of advanced disease (weight loss, hoarseness, bone pain, neurologic symptoms). Obtain a dedicated CT chest to characterize the lesion. Features concerning for malignancy include spiculation, lack of calcification, upper lobe location, larger size, and interval growth. Always compare with any prior imaging.

The CT shows a spiculated, non-calcified 3 cm RUL mass. Is any nodule risk stratification appropriate here, or do you proceed straight to staging?

Expected answer

In a 65-year-old heavy smoker with a spiculated, non-calcified mass and weight loss, pretest probability of malignancy is high, so I proceed to formal staging rather than Fleischner surveillance. Fleischner/observation applies only to low-suspicion incidental nodules. The next step is a whole-body PET/CT to evaluate nodal and metastatic disease, plus dedicated brain imaging (MRI or CT) given the constitutional symptoms.

What is the role of PET/CT in this workup?

Expected answer

PET/CT assesses metabolic activity of the primary lesion, evaluates mediastinal and hilar nodes, and screens for distant metastatic disease. FDG-avid nodes or distant foci guide the next steps. However, PET is not tissue diagnosis — suspicious mediastinal nodes must be confirmed pathologically because false positives (inflammation/infection) and false negatives (small or low-avidity tumors) occur.

PET shows FDG-avid mediastinal (station 7) nodes. How do you stage the mediastinum?

Expected answer

Suspicious mediastinal nodes require tissue confirmation before deciding on resection. EBUS-guided transbronchial needle aspiration is the preferred first-line, minimally invasive modality and samples paratracheal, subcarinal, and hilar stations. Mediastinoscopy is used when EBUS is nondiagnostic or inaccessible stations must be sampled. This distinguishes N1 from N2/N3 disease and dictates whether the patient goes directly to surgery or to multimodality therapy.

What preoperative assessment determines whether this patient can tolerate a lobectomy?

Expected answer

Cardiac risk assessment with EKG (and further cardiac workup as indicated) plus pulmonary function testing. Calculate predicted postoperative FEV1 and DLCO. ppo FEV1 and ppo DLCO >60% predict tolerance of major resection. Values 30–60% warrant cardiopulmonary exercise testing. Values <30% are high risk and require VO2max testing; a VO2max <10 mL/kg/min indicates the patient is not a surgical candidate.

Node biopsy confirms N1 disease only, and PFTs are adequate. What operation do you offer?

Expected answer

An anatomic resection — lobectomy (right upper lobectomy here) is the standard of care — with systematic mediastinal lymph node dissection or sampling for accurate pathologic staging. Perform it minimally invasively (VATS or robotic) when feasible. Pneumonectomy is reserved for centrally located tumors not amenable to lobectomy. A limited resection (segmentectomy/wedge) is reserved for patients who cannot tolerate lobectomy or for small peripheral tumors.

If biopsy had confirmed N2 disease, how would management change?

Expected answer

N2 disease should be discussed at a multidisciplinary tumor board including surgery, medical oncology, and radiation oncology. Single-level, resectable N2 disease may be treated with induction (neoadjuvant) chemotherapy followed by surgery, or definitive chemoradiation. Multilevel or bulky N2 disease is generally treated as unresectable with definitive chemoradiation. The key point is that N2 disease is not a straightforward operative case and requires multimodality planning.

The patient's ppoFEV1 is 25% predicted and VO2max is 8 mL/kg/min. What do you offer?

Expected answer

He is not a candidate for major resection. Offer stereotactic body radiation therapy (SBRT) for the primary lesion if early-stage, or definitive chemoradiation depending on stage. Refer to medical and radiation oncology. Do not proceed with lobectomy in a patient who cannot survive the pulmonary reserve loss.

If PET or biopsy revealed distant metastatic or clearly unresectable disease, what is the plan?

Expected answer

The patient is not a surgical candidate. Refer to medical and radiation oncology for systemic therapy and palliative measures. Obtain tissue for histology and molecular/biomarker testing (e.g., EGFR, ALK, PD-L1) to guide targeted or immunotherapy. Surgery has no curative role in metastatic NSCLC.