Case Presentation: controversial and debatable cases

Case 1.

M / 65

28 pack-year ex-smoker, quit 18 years ago

Chief Complaint: Unusual findings in routine chest X-ray screening.

Past History: Nothing specific except benign prostate hyperplasia for 5 years

Chest X-ray: increased radio-opacities in both upper lobes

Chest CT:

- 65mm well-demarcated partly solid mass in RUL: highly suggestive of NSCLC

- Multiple tiny nodules in both lungs, R/O lung-to-lung metastasis

- Multifocal pure ground-glass opacity nodules in both lungs, R/O multifocal AAH/BAC

PET-CT

- Hypermetabolic malignant mass in RUL

- Probably malignant hypermetabolic nodule in LUL

- Multiple small bilateral GGO

Bronchoscopy: No endobronchial lesion, no visible anomaly

Fine Needle Aspiration of RUL mass: suggestive of Adenocarcinoma

Preoperative PFT: normal

- FVC (L) 4.86

- FEV1 (L) 3.38

- FEV1/FVC 70%

Preoperative 2D-Echo

: Mild AR, mildly dilated aortic root and ascending aorta, diastolic dysfunction grade I

EKG: Normal sinus rhythm with 1 degree AV block

Brain MRI: No metastasis

Clinical Diagnosis

- Non-small cell lung cancer (ADC), cT2bN0M0~1a (possible lung-to-lung metastasis)

Recommendation of the discussant

What would be your plan of management? Please provide with some evidence and/or rationale.

For example, we may choose one of the following treatment, such as [Surgery ± Adjuvant

chemotherapy] OR [Neoadjuvant Tx. → Surgery ± Adjuvant chemotherapy] OR [Definitive

chemo(radiation) Therapy]. What do you prefer? Why?

AND

If you prefer to perform the surgery, what would be the extent of surgery, such as [RULobectomy

& LULobectomy] OR [RULobectomy] OR [RULobectomy + sublobar resection of LUL] OR

[Sublobar resections for both lesion + mediastinal LN dissection]? Why?