Correct!
1. Left pneumonectomy
The patient has a nonresectable lung cancer because of the malignant pleural effusion. Therefore, left pneumonectomy would not be appropriate and chemotherapy is indicated. A trial published in 2002 randomly assigned patients with non-small cell lung cancer to either the reference arm of cisplatin and paclitaxel or 1 of 3 experimental arms: cisplatin and gemcitabine, cisplatin and docetaxel, or carboplatin and paclitaxel (2). Without stratification by histology, there was no difference seen between the arms in terms of overall survival or response rate. However, this changed in 2008, when a randomized study showed patients with adenocarcinoma or large cell carcinoma had superior survival with cisplatin + pemetrexed whereas patients with squamous cell carcinoma had improved outcomes with cisplatin + gemcitabine (3). Some add bevacizumab, an epidermal growth factor receptor (EGFR) antibody. Patients treated with carboplatin, paclitaxel, and bevacizumab have demonstrated a significantly greater response rate (35% vs. 15%) and a modest increase in survival (12.3 vs. 10.3 months) over carboplatin and paclitaxel alone (4). However, patients with squamous cell cancer and a history of hemoptysis are at unacceptably high risk of life-threatening hemoptysis with bevacizumab (4).
The patient was treated with 4 cycles of carboplatin and paclitaxel, and had a dramatic response. A follow up CT of the chest in August 2009 showed no evidence of pleural disease or residual tumor (Figure 3).
Figure 3. Follow up CT of chest after 4 courses of chemotherapy.
She had continued surveillance chest CT scans and in March 2012 a small left pleural effusion was noted. A repeat chest CT scan in June 2012 demonstrated increased left-sided pleural fluid (Figure 4).
Figure 4. Follow up CT scan in June 2012 demonstrating a left pleural effusion.
A thoracentesis is performed which revealed recurrent adenocarcinoma.
Which of the following should be performed on the pleural fluid cells?