Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old

Winston W. Tan, MD; Matthew Tan


October 16, 2020

The standard treatment for stage I and II disease is surgical resection. In stage IIIA, chemotherapy is indicated, as is surgical resection in selected patients. Standard treatment of stage IIIb is chemoradiation. Stage IV requires cisplatin-based chemotherapy or surgical resection if a solitary metastatic lesion with resectable primary tumor is present.[3,4,5]

This patient underwent resection of the cancer. Owing to her residual disease and because her lymph nodes were positive, she was treated with chemoradiation. Surgical resection is the primary modality of treatment for early stage non-small cell lung cancer.[6]

Close surveillance of patients with cancer should be the standard after completion of therapy. This patient had a contralateral hilar recurrence 6 years later. When a patient has a recurrence, it must be determined whether it is the same cancer or another primary cancer. This patient had another primary cancer, specifically small cell cancer of the lung. Biopsy must be done of a new recurrence, because it could be an entirely different cancer.

Approximately 60%-70% of patients with small cell lung cancer have clinically disseminated or extensive disease at presentation. Extensive-stage small cell lung cancer is incurable. When given combination chemotherapy, patients with extensive-stage disease have a complete response rate of more than 20% and a median survival longer than 7 months; however, only 2% are alive at 5 years.

For individuals with limited-stage disease that is treated with combination chemotherapy plus chest radiation, a complete response rate of 80% and survival of 17 months have been reported; 12%-15% of patients are alive at 5 years.[1]

Recommendations from the National Comprehensive Cancer Network (NCCN) regarding cancer surveillance in survivors of non-small cell lung cancer include the following:

  • History and physical examination, and chest CT with or without contrast, every 6-12 months for 2 years, then history and physical examination and noncontrast chest CT annually

  • Assessment of smoking status at each visit, with counseling and referral for smoking cessation as needed

Other NCCN recommendations for long-term follow-up care include the following:

  • Immunization: Annual influenza vaccination, pneumococcal vaccination with revaccination as appropriate, herpes zoster vaccination

  • Counseling regarding health promotion and wellness (eg, regular physical activity, healthy diet)

  • Routine health monitoring

Several important points should be remembered:

  • Persistent cough despite treatment should prompt further diagnostic testing for lung mass.

  • Nonsmokers can develop lung cancer.

  • Neurologic symptoms in patients with lung cancer do not always mean brain metastasis. Although brain metastasis should be ruled out, other causes could be found, such as encephalomalacia.

  • Biopsy of recurrent cancer should be redone, especially if the time to recurrence is more than a few years. A separate cancer can be found in a patient previously cured of their cancer.

  • Several factors may increase the likelihood of a primary cancer resulting in a secondary cancer. A "field effect" is noted in certain types of cancers, particularly in the areas of respiratory tract. In smokers, this is especially true in such areas as the head and neck, throat, laryngeal, esophageal area, and tongue. Because the body's immune system is vulnerable to the development of the first cancer, it may be more susceptible to the development of a second cancer.


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