From the Guidelines
For a 73-year-old male with suspected bilateral lung carcinoma, the initial step in management should be a thorough clinical evaluation, including a CT scan of the chest with contrast, to provide an initial definition of tumor stage, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.
Initial Evaluation
The patient's presentation with dyspnea and bilateral lung masses suspicious for lung carcinoma on chest X-ray necessitates a comprehensive approach to diagnosis and management.
- A CT scan of the chest with contrast is recommended to assess the extent of the disease and potential metastases, as suggested by the American College of Chest Physicians 1.
- If a PET scan is unavailable for staging, the CT of the chest should be extended to include the liver and adrenal glands to assess for metastatic disease, as recommended by the American College of Chest Physicians 1.
Diagnosis and Staging
- The diagnosis of lung cancer should be confirmed by the least invasive method, such as sputum cytology, thoracentesis, fine needle aspiration, or bronchoscopy, as recommended by the American College of Chest Physicians 1.
- A thorough clinical evaluation should be performed to provide an initial definition of tumor stage, including assessment of site-specific symptoms, as recommended by the American College of Chest Physicians 1.
Management of Dyspnea
- For patients with dyspnea, pharmacologic interventions such as opioids, with or without benzodiazepines, may be considered, as suggested by the Journal of the National Comprehensive Cancer Network 1.
- Nonpharmacologic interventions, such as the use of handheld fans directed at the face, supplemental oxygen, and mechanical ventilation, may also be effective in managing dyspnea, as suggested by the Journal of the National Comprehensive Cancer Network 1.
Communication and Support
- When communicating the diagnosis to the patient, it is essential to consider factors such as the place, family support, nurse support, and management plan, as recommended by the British Thoracic Society 1.
- The patient should have access to written information, appropriate to their case, to supplement the interview, and the essential facts of the interview should be recorded in the patient's records, as recommended by the British Thoracic Society 1.
From the FDA Drug Label
For patients with non-small cell lung carcinoma, the recommended regimen, given every 3 weeks, is paclitaxel administered intravenously over 24 hours at a dose of 135 mg/m2 followed by cisplatin, 75 mg/m2 KEYTRUDA may be used with the chemotherapy medicines pemetrexed and a platinum as your first treatment when your lung cancer: has spread (advanced NSCLC), and is a type called “nonsquamous”, and your tumor does not have an abnormal “EGFR” or “ALK” gene KEYTRUDA may be used with the chemotherapy medicines carboplatin and either paclitaxel or paclitaxel protein-bound as your first treatment when your lung cancer: has spread (advanced NSCLC), and is a type called “squamous” KEYTRUDA may be used alone as your first treatment when your lung cancer: has not spread outside your chest (Stage III) and you cannot have surgery or chemotherapy with radiation or your NSCLC has spread to other areas of your body (advanced NSCLC), and your tumor tests positive for “PD-L1”, and does not have an abnormal “EGFR” or “ALK” gene
The management plan for a 73-year-old male presenting with dyspnea and bilateral lung masses suspicious for lung carcinoma on chest X-ray may include:
- Chemotherapy: paclitaxel administered intravenously over 24 hours at a dose of 135 mg/m2 followed by cisplatin, 75 mg/m2 every 3 weeks 2
- Immunotherapy: pembrolizumab (KEYTRUDA) as first-line treatment for advanced NSCLC, either alone or in combination with chemotherapy, depending on the tumor's PD-L1 status and absence of abnormal EGFR or ALK genes 3 Key considerations:
- Tumor histology (squamous or nonsquamous)
- PD-L1 status
- Presence of abnormal EGFR or ALK genes
- Patient's overall health and ability to tolerate treatment
From the Research
Management Plan for a 73-year-old Male with Dyspnea and Bilateral Lung Masses
The management plan for a 73-year-old male presenting with dyspnea (shortness of breath) and bilateral lung masses suspicious for lung carcinoma on chest X-ray (radiograph) involves several steps:
- Initial evaluation: The patient's symptoms and chest X-ray findings suggest the need for further evaluation to confirm the diagnosis and stage the disease.
- Imaging studies:
- Tissue diagnosis: A tissue diagnosis is necessary to confirm the diagnosis of lung cancer and to determine the histological type.
- Staging: The patient's disease should be staged according to the TNM staging system to determine the extent of the disease.
- Treatment: The treatment plan will depend on the stage and histological type of the disease, as well as the patient's overall health and performance status.
Role of Contrast-Enhanced CT in Lung Cancer Staging
Contrast-enhanced CT is useful in lung cancer staging, particularly in evaluating the extent of the disease and in detecting any lymphadenopathy or metastatic disease 4, 5.
- Contrast-enhanced CT can help to accurately assess the TNM stage of the disease.
- It can also help to detect any additional clinically important findings, such as lymphadenopathy or metastatic disease.
Importance of Early Imaging in Lung Cancer Diagnosis
Early imaging is crucial in lung cancer diagnosis, as it can help to detect the disease at an early stage when it is more treatable 6, 7.
- Chest X-ray is often the initial imaging study, but it may not detect all lung masses or lymphadenopathy.
- CT scan with contrast is a more sensitive imaging study that can help to detect lung masses and lymphadenopathy, and to assess for any metastatic disease.