Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 54-year-old woman is evaluated for shortness of breath of 3 months’ duration and a 4.5-kg (10-lb) weight loss over the preceding 2 months. She has a 35-pack-year smoking history.

On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 145/82 mm Hg, and pulse rate is 108/min. Oxygen saturation is 92% with the patient breathing ambient air. No palpable lymphadenopathy is noted. The patient has clubbing of the fingertips. The lung fields are clear on the left, with diminished breath sounds and dullness to percussion over the lower half of the right lung. The remainder of the examination is normal.

A chest radiograph reveals a large right pleural effusion. A thoracentesis demonstrates an exudate, with cytologic analysis indicating adenocarcinoma. A chest tube is placed, and talc pleurodesis is performed. A CT scan reveals a 4-cm right peripheral lung mass with no obvious lymphadenopathy. A bone scan and a brain MRI are normal.

Which of the following is the most appropriate treatment?

A: Combination chemotherapy and radiation
B: Radiation
C: Surgical resection of the lung mass
D: Systemic chemotherapy

MKSAP Answer and Critique

The correct answer is D: Systemic chemotherapy.

The most appropriate treatment is systemic chemotherapy. This patient has stage IV non-small cell lung cancer (NSCLC) as evidenced by a malignant pleural effusion. The 7th edition of the TNM staging system has reclassified malignant pleural effusion as a distant metastasis, automatically placing such patients into stage IV disease status. In patients with stage IV disease, the most appropriate treatment is chemotherapy. Because metastatic NSCLC is a systemic process, systemic chemotherapy is typically used as the primary treatment modality. Goals of therapy are symptom palliation and possible prolongation of survival.

Combination chemotherapy and radiation is offered to patients with unresectable stage III disease in which the tumor and regional lymph nodes can be encompassed in a radiation field but would not be appropriate for this patient.

Although radiation therapy can be used palliatively in the setting of superior vena cava syndrome and obstructive pneumonitis, brain metastases and spinal cord compression, and bone metastases, it is not recommended as first-line therapy for this patient with advanced-stage disease.

Surgery would not be recommended in this patient because the presence of a malignant pleural effusion confirms that this patient’s disease is not curable. Surgery will add to her morbidity without improving her survival.

Key Point

• Patients with non-small cell lung cancer and a malignant pleural effusion have, by definition, metastatic disease, and the most appropriate therapy is palliative systemic chemotherapy.

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