Dr Mekhail on a Case Study of Early-Stage, Nonmetastatic Lung Cancer

“Ideally, all cases should be presented in a multidisciplinary fashion, discussed with the physicians before we reach a final plan for patients.”

Tarek Mekhail, MD, MSc, FRCSI, FRCSEd, medical director, Thoracic Cancer Program, and associate executive director, AdventHealth Cancer Institute, discusses a case study of a patient with early-stage, nonmetastatic lung adenocarcinoma from his clinical practice.

This case involved a male patient with a history of smoking, who initially presented with mild chest pain, Mekhail begins. Imaging, including CT and PET/CT scans, revealed findings consistent with early-stage lung cancer, which appeared localized to the left lung with no evidence of distant metastasis, he says. However, suspicious lymph nodes were identified in the mediastinum and chest, he notes.

To further evaluate lymph node involvement, the patient underwent endobronchial ultrasound (EBUS)–guided lymph node sampling, which did not detect malignancy, he explains. This case highlights a critical clinical decision point regarding the reliability and limitations of EBUS in lymph node assessment, as EBUS cannot access all mediastinal lymph node stations, particularly aortopulmonary (level 5) and perivascular (level 3) lymph nodes, which remained suspicious on imaging, he states.

A clinical dilemma arose regarding whether to proceed directly with surgery based on negative EBUS findings or to consider the suspicious lymph nodes as potentially malignant and initiate neoadjuvant chemotherapy and immunotherapy, Mekhail continues. The real-world challenge in this case was that the patient was already scheduled for surgery within 2 days of their diagnosis, raising the question of whether to disrupt the surgical plan, he says.

Rather than proceeding with the surgery without further lung cancer evaluation, a multidisciplinary approach was used, Mekhail emphasizes. He explains how he engaged in shared decision-making with the patient, discussing the concerns regarding possible undetected nodal disease. The patient expressed a preference for the most appropriate treatment course, he notes. Furthermore, Mekhail initiated an ad-hoc tumor board discussion involving the patient’s surgeon and other specialists, which led to the cancellation of the scheduled surgery. Ultimately, Mekhail and his team decided to proceed with neoadjuvant chemotherapy and immunotherapy before surgical resection, he concludes.