Correct!
2. Perform mediastinoscopy
In the presence of a known metabolically active lung neoplasm, the metabolically active right paratracheal lymphadenopathy must be regarded as potentially metastatic despite the negative results at bronchoscopy with endobronchial ultrasound-guided sampling. In patients with primary lung malignancy, the prevalence of malignancy in metabolically active lymph nodes that are also enlarged at CT is very high and therefore the negative results at bronchoscopic sampling require confirmation with lymph node resection. Such resection can occur at the time of thoracotomy in properly selected patients, but this patient’s right paratracheal lymphadenopathy, if malignancy were proven at this site, would change her staging (tumor measuring 5.2 cm) from T3N0 (stage IIB) to T3N2 (Stage IIIB)- i.e., from potential surgical resection to either no surgery or initial chemoradiation followed by re-staging and reconsideration for surgical resection. Proper staging is required before initiating definitive therapy, including surgery, radiotherapy, and/or chemotherapy. Cervical mediastinoscopy, given the location of the enlarged right paratracheal lymph node, is preferrable to video-assisted thoracoscopic approach.
Thoracic surgery was consulted and performed cervical mediastinoscopy. Pathological analysis of the resected lymph nodes showed no evidence of malignancy.
What other information / testing is required before determining an appropriate course of therapy for this patient’s malignancy? (Click on the correct answer to be directed to the twelth and final page)