Medical Challenge Question 7

A 72 year-old man visits your office after being diagnosed with non–small cell lung cancer 2 weeks ago. For the last 3 months he has suffered from worsening shortness of breath, fatigue, and reduced appetite. He has lost over 40 pounds in the last 2 months. The patient has a medical history of COPD with baseline shortness of breath upon exertion, but he does not need supplemental oxygen at home. His medications include tiotropium and as-needed albuterol metered dose inhalers which he is using regularly without significant improvement.

When the patient was diagnosed, examination revealed decreased breath sounds in the left lung field. A chest radiograph was done and showed almost commplete obliteration of the left lung field. CT scan of the chest was done next and it confirmed a large left-sided pleural effusion. The same CT scan showed evidence of multiple liver and bone metastatic lesions. The patient says after the CT scan he had fluid removed from the left-sided. The large volume thoracentesis was analyzed and cytology confirmed squamous cell carcinoma.

Even though the fluid was drained, the patient says his breathing has not any better and he is now needs home oxygen at rest. He feels generally weak and spends most of his time in bed. He needs assistance in performing most of his daily self-care activities.

Upon examination of the chest, auscultation reveals a improvement in left-sided breath sounds. A follow up chest radiograph done today shows a small amount of residual pleural fluid on the left.

Which of the following is the most appropriate management?

A. Repeat the thoracocentesis
B. Start the patient on platinum-based chemotherapy
C. Refer the patient for palliative care assessment
D. Perform a pleurodesis
E. Start radiation therapy for the bone metastases

Reference:

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. PMID: 20818875