Correct!
3. Surgical consultation for possible metastectomy
Because the patient has been adequately staged, 18FDG-PET scan would play little role in the management of this patient. Either chemotherapy or local radiotherapy are appropriate considerations, but left upper lobe resection to achieve metastectomy, give the apparently isolated nature of these metastatic lesions, may offer a survival benefit compared with either local radiotherapy or systemic treatment alone. Percutaneous radiofrequency ablation is a viable approach for local malignancy control in selected patients, although typically for primary lung malignancy and not metastatic lesions, but the spatial separation of the two lesions renders this approach untenable.
The patient was reviewed at a multidisciplinary conference attended by radiation oncology, medical oncology, radiology, pulmonary medicine, and thoracic surgery, and left upper lobe resection was recommended. Preoperative pulmonary function testing showed relative normal results, with preserved diffusion capacity and no features to suggest either restrictive lung disease or significant air flow obstruction. The patient underwent left upper lobe resection without difficulty.
The plan for the patient on the first post-operative day (Figure 4) was to optimize pain management, discontinue intravenous fluids, maintain the thoracostomy tube on water seal, transition to oral medication, and ambulate the patient.
Figure 4. Frontal chest radiography immediately following left upper lobe resection shows the expected left-sided volume loss with poorly defined left base opacity. A small amount of left pleural effusion may be resent with a thoracostomy tube over the left apex, but no visible pneumothorax.
On post-operative day 2 (Figure 5), the patient was afebrile, tolerating diet well, and the thoracostomy tube was removed and the patient was transferred from surgical intensive care to the floor, with the intention to discharge the patient home later in the day.
Figure 5. Frontal chest radiography postoperative day 2 following left upper lobe resection shows the expected left-sided volume loss with increase in the poorly defined left base opacity, although left lung volume has decreased compared with the immediate post-operative study (Figure 4). No pneumothorax is visible and no enlarging pleural effusion is present. The thoracostomy tube has been removed.
Later that day the patient complained of pain and sputum production and atrial fibrillation with a rapid ventricular response (heart rate in 130s) was noted. Discharge was delayed and respiratory therapy was consulted to improve pulmonary toilet. On postoperative day 3 (Figure 6), the patient became hypotensive (mean arterial pressure in the 50’s mmHg), unresponsive to fluids.
Figure 6. Frontal chest radiography postoperative day 3 following left upper lobe resection shows worsening of left lung consolidation now with a more prominent linear component, suggesting interlobular septal thickening.
Evaluation of the patient revealed copious secretions with cough and wheezing. Laboratory data showed hyponatremia (132 mEq/L, normal 136-145 mEq/L), hypocalcemia (8.2 mg/dL, normal 8.6-10 mg/dL), mild anemia (stable), and elevated blood urea nitrogen (58 mg/dl, normal 7-22.4 mg/dl) and creatinine (2.5 mg/dL, 0.7-1.3 mg/dL; baseline pre-operative creatinine was 1.4 mg/dL). A urine culture showed Pseudomonas, and the patient’s white blood cell count was elevated at 16.9 x 109 / L (normal, 4-10 x109 /L).
Which of the following represents an appropriate next step(s) for the patient’s management? (Click on the correct answer to be directed to the ninth of fourteen pages)