Respiratory medicine for MRCPI Part 2

A 67-year-old man with a 45-pack-year history is found to have a 2.4 cm spiculated right upper lobe nodule on CT, with an ipsilateral hilar node measuring 1.2 cm. PET-CT shows avidity in both the nodule and the hilar node, with no distant uptake. Lung function is adequate for resection. What is the most appropriate next step?

1. CT-guided percutaneous biopsy of the peripheral nodule alone Incomplete. It may confirm the histology but leaves the nodal stage undefined, and it is the nodal stage that determines the treatment pathway.
2. Tissue sampling of the mediastinum and hilum, typically by endobronchial ultrasound-guided aspiration correct Correct. PET avidity in a node is not proof of malignancy, inflammation and infection are avid too, and nodal stage determines whether he has resectable disease or needs chemoradiotherapy. Sampling before committing him to a thoracotomy is the standard.
3. Proceed directly to lobectomy on the basis of the PET findings Wrong. Operating on a PET-positive node without tissue risks either an unnecessary resection for reactive nodes or an incomplete operation for genuine N2 disease.
4. Repeat CT in three months to assess growth Wrong. A spiculated 2.4 cm PET-avid nodule in a heavy smoker is lung cancer until proven otherwise, and interval imaging simply allows progression.
5. Start palliative chemotherapy Wrong. There is no evidence of distant disease, and this is potentially curable.

The point: In lung cancer, staging drives treatment and the mediastinum decides resectability. PET is sensitive but not specific, so a PET-positive node needs tissue. EBUS with systematic nodal sampling has largely replaced mediastinoscopy as the first step.

Source: NICE NG122 — Lung cancer: diagnosis and management NICE · tier 1, national regulator or guidance