For those of you with a thoracic interest, here is a decision to make:
A 65 year old man presents with an asymptomatic 5 cm LLL mass, discovered on follow-up for old TB. A second, cavitating, 2 cm mass is found in the RML on CT scan. PFT’s are good, and no mets are detected. No nodes are present on CT. Nothing is visible bronchoscopically, but washings from the LLL show probable adenocarcinoma. Needle biopsy of the RML shows probable squamous carcinoma. I assume synchronous primaries. The LLL mass is wrapped around behind the aorta, and is judged too awkward for a sternotomy approach for synchronous resection. That was Bilateral Lung Cancer.
Left lower lobectomy is performed, but is difficult because of adhesions from previous disease, presumably mostly TB, since multiple nodules are present in the LUL, which are old granulomata on frozen section. Extra-pleural dissection is required. He recovers well, and is home in 5 days.
Pathology of Bilateral Lung Cancer shows a giant cell carcinoma, with vascular and pleural invasion. Margins are clear. One of 4 interlobar nodes is positive. There were no mediastinal nodes.
What do we do with the other side? I was originally planning staged thoracotomies, but the prognosis for the resected tumor gives me pause. Do I:
1. Assume a terrible prognosis for the LLL tumor, consider chemo, but leave the other side alone?
2. Assume a bad prognosis but treat the other side anyway, using radiation to limit his disability time, since the SCC should be sensitive, and this tumor is not likely to determine his fate?
3. Forge ahead with the original plan, and resect his RML?
What is the role for chemo in this type of cancer-prone individual, with an aggressive Bilateral Lung Cancer?
My tendency is to be as realistic as possible, and avoid treatment that is of dubious value. I do not feel that I “have to do something”.