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Pulmonology Quiz

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50 yr old with history of cigarette smoking present with a 2.5 cm right upper lobe mass.  Physical exam is unremarkable.  CT guided percutaneous biopsy reveals small cell lung cancer.

CT scan of the chest and upper abdomen reveals no evidence of regional adenopathy.  PET/CT scan shows activity in the R lung with an SUV of 10.2 without evidence of metastatic disease.

Bronchoscopy reveals no involvement of the carina or trachea.  Endobronchial ultrasound with lymph node sampling reveals negative lymph nodes.  There is no vocal cord paralysis.  MRI of the brain with gadolinium is unremarkable.  PFTs reveal an FEV1 of 2.6 liters.

He undergoes right upper lobectomy and pathology shows small cell lung cancer with 5 of 23 hilar and mediastinal lymph nodes involved.

Of the following options, the next best step in the management of this patient is:

  1.  Concurrent chemoradiation with radiation to the mediastinum
  2.  Radiation to the mediastinum followed by chemotherapy
  3.  Mediastinal radiation alone
  4.  Chemotherapy followed by radiation to the mediastinum