Correct!
4. 1 and 3
If you realized that the patient is from and was being cared for in Washington state, you can be excused for not ordering cocci serologies. However, many of us practice in the Southwest US where Valley Fever is endemic. Although the new lesion is likely metastatic cancer, a general principle is to biopsy the first metastasis. This is especially important in NSCLC, where the cancer pathobiology can change and tumors can develop resistance to therapy after an initial response. This seems likely in this patient with the development of a new lesion after her good initial response. It seems unlikely that another EGFR-tyrosine kinase inhibitor similar to erlotinib would be successful after it had failed. This new lesion was biopsied and shown to be positive for the T790M mutation which was not seen in the original tumor.
What should be done at this time? (Click on the correct answer to proceed to the seventh and final page)