A 58-year-old man is brought to the emergency department 30 minutes after a generalized tonic-clonic seizure. His wife witnessed the event and says the patient was watching television, suddenly developed twitching of the left hand, and then lost consciousness and had generalized shaking. The event lasted approximately 1 minute. He spontaneously regained consciousness but has been confused. The patient has no history of seizure, head trauma, or other medical problems, but over the past few months he has had a persistent cough, anorexia, and fatigue and has lost 10 kg (22 lb). He has not seen a physician in 20 years and takes no medications. The patient is a current smoker with a 30-pack-year history and drinks alcohol occasionally. Temperature is 37.2 C (99 F), blood pressure is 138/86 mm Hg, and pulse is 94/min and regular. The patient is somnolent but easily arousable. Bilateral pupils are equal and briskly reactive to light. There is no focal weakness, and deep tendon reflexes are 2+ throughout. Digital clubbing is present and there are several right-sided, enlarged, nonmobile supraclavicular lymph nodes. Blood cell counts and serum chemistry studies are within normal limits, except for a serum calcium level of 10.6 mg/dL. MRI of the brain reveals a 1-cm mass in the gray-white junction of the right frontal lobe with mild surrounding edema. Imaging of the chest and abdomen reveals a 6-cm right lung mass, multiple enlarged hilar and mediastinal lymph nodes, and several liver lesions of 1-3 cm. Which of the following is the most appropriate next step in establishing the diagnosis in this patient?

Question

A 58-year-old man is brought to the emergency department 30 minutes after a generalized tonic-clonic seizure.  His wife witnessed the event and says the patient was watching television, suddenly developed twitching of the left hand, and then lost consciousness and had generalized shaking.  The event lasted approximately 1 minute.  He spontaneously regained consciousness but has been confused.  The patient has no history of seizure, head trauma, or other medical problems, but over the past few months he has had a persistent cough, anorexia, and fatigue and has lost 10 kg (22 lb).  He has not seen a physician in 20 years and takes no medications.  The patient is a current smoker with a 30-pack-year history and drinks alcohol occasionally.  Temperature is 37.2 C (99 F), blood pressure is 138/86 mm Hg, and pulse is 94/min and regular.  The patient is somnolent but easily arousable.  Bilateral pupils are equal and briskly reactive to light.  There is no focal weakness, and deep tendon reflexes are 2+ throughout.  Digital clubbing is present and there are several right-sided, enlarged, nonmobile supraclavicular lymph nodes.  Blood cell counts and serum chemistry studies are within normal limits, except for a serum calcium level of 10.6 mg/dL.  MRI of the brain reveals a 1-cm mass in the gray-white junction of the right frontal lobe with mild surrounding edema.  Imaging of the chest and abdomen reveals a 6-cm right lung mass, multiple enlarged hilar and mediastinal lymph nodes, and several liver lesions of 1-3 cm.  Which of the following is the most appropriate next step in establishing the diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: This patient who is a heavy smoker has a large lung mass with liver lesions and a brain lesion, raising strong suspicion for metastatic lung cancer. Lung cancer is the second most common cancer in men and is the leading cause of cancer-related death. Most cases present late in the disease course with pulmonary symptoms (eg, cough, hemoptysis, dyspnea, chest pain) or manifestations related to distant metastases (eg, seizure) or paraneoplastic syndromes (eg, hypercalcemia). The diagnostic evaluation of suspected lung cancer begins with staging, which uses a combination of physical examination and radiographic imaging (eg, CT scan of the chest and abdomen) to establish the extent of disease. A biopsy is then required to confirm malignancy and determine the histopathologic type of the tumor. Patients with disease limited to the lung/mediastinal lymph nodes should undergo sampling of one of these areas. Those with evidence of advanced disease (eg, supraclavicular lymph node involvement, metastases) should generally have a biopsy of the distant site of spread. Enlarged scalene or supraclavicular lymph nodes are the easiest target for initial biopsy due to their superficial location, which makes sampling low risk and minimally invasive. If these lymph nodes are not involved, biopsy of a distant metastatic site (eg, liver, adrenal gland, bone) should generally be attempted (Choice E). However, brain biopsy is rarely performed due to the highly invasive and high-risk nature of this procedure (Choice C). (Choice A) CT-guided biopsy of the lung is typically reserved for patients with suspected lung cancer who have no evidence of advanced disease and have lesions that are not amenable to endobronchial ultrasound-guided transbronchial needle aspiration. This patient with advanced disease should undergo supraclavicular lymph node biopsy, which is less invasive and associated with fewer complications. (Choice D) Transbronchial biopsy of a hilar or mediastinal node is indicated for initial biopsy when these nodes are enlarged and patients have no evidence of advanced disease (eg, supraclavicular nodes, metastases). Educational objective: Patients with suspected metastatic cancer should have an initial biopsy of a metastatic site (if possible). Enlarged scalene or supraclavicular lymph nodes are generally preferred due to their superficial location.

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