Trial Short Case 3 April 2023

Case Summary

A 58-year-old man is referred to your rooms by his GP with a suspected lung mass on a background of dyspnoea and cough since COVID in July 2022. He has reported 10kg of weight loss and is a lifelong non-smoker. He is on rivaroxaban for atrial fibrillation and has no other medical history.

A CT scan demonstrates a 120mm x 90mm well circumscribed right upper lobe mass, it appears to be parenchymal, however extra-pleural collection is not excluded, possible wall involvement.

A PET-CT demonstrates an intensely FDG avid right upper lobe pulmonary mass involving the right hilum and abutting the right mediastinum and anterior, lateral and apical pleural surfaces, however, whether there is direct invasion of the chest wall or mediastinum cannot be determined on this study. There is mild uptake around the lower paratracheal nodes and no distant evidence of metastasis.

A CT guided biopsy has been performed and confirms lung adenocarcinoma. CT brain is negative.

The patient’s respiratory function tests are: FEV1 3.81L (100%), FVC 4.57L (92%), Ratio 83%, TLCO 132%.

He has a normal sestimibi scan and echocardiogram.

N2 nodes were assessed via EBUS and were deemed likely inflammatory.

The case is presented at the lung MDT and the decision is made to trial neoadjuvant therapy prior to consideration of surgical resection.

The patient had a good response to neoadjuvant chemotherapy with a 70% reduction in tumour size (80mm x 40mm). MRI chest was suggestive of involvement of the 1st intercostal space anterolaterally

Questions

You are asked to consider surgery

  1. Describe the staging

  2. What evidence is there to support the neoadjuvant treatment?

  3. What risks do you explain to the patient preoperatively?

  4. Describe surgical options and pitfalls and how you would manage these?