A 58-year-old male smoker (40 pack-years) presents with a 3-month history of persistent cough and haemoptysis. Chest X-ray reveals a 4 cm peripheral nodule in the right upper lobe with irregular margins. CT chest shows the nodule with pleural indentation and no mediastinal lymphadenopathy. Bronchoscopy with biopsy confirms adenocarcinoma. PET-CT shows FDG uptake in the primary lesion (SUVmax 8.2) but no distant metastases. Which of the following is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** This patient has a resectable stage IB–IIA non-small cell lung cancer (NSCLC) adenocarcinoma with no evidence of mediastinal involvement or distant metastases. ### Staging Interpretation - **Primary tumour:** 4 cm peripheral nodule = T2a - **Lymph nodes:** No mediastinal involvement on CT/PET = N0 - **Metastases:** No distant metastases = M0 - **Overall stage:** IB–IIA (T2aN0M0 or T1bN0M0 depending on depth of invasion) ### Why Surgical Resection is Optimal 1. **Curative intent:** Lobectomy offers the best 5-year survival for stage I–II NSCLC (60–80% for stage IB). 2. **Mediastinal staging:** Systematic lymph node dissection is mandatory to confirm N0 status and guide adjuvant therapy decisions. 3. **Adenocarcinoma biology:** Peripheral adenocarcinomas are often well-suited to surgical resection and have better prognosis than central squamous cell tumours. 4. **Performance status:** No contraindications mentioned; patient is a surgical candidate. **High-Yield:** Lobectomy with mediastinal lymph node dissection (10–12 stations) is the gold standard for resectable stage I–II NSCLC. Wedge resection or segmentectomy is inferior and reserved only for high-risk patients with limited pulmonary function. ### Adjuvant Therapy Consideration - If final pathology confirms stage II (T2aN1 or T1bN1 after lymph node dissection), adjuvant chemotherapy (cisplatin-based doublet) is indicated. - If final pathology is stage IB (T2aN0), adjuvant chemotherapy is controversial but may be considered for high-risk features (poor differentiation, vascular invasion, tumour size >4 cm). **Clinical Pearl:** PET-CT with FDG uptake (SUVmax 8.2) confirms metabolic activity but does not change the surgical indication in a resectable stage I–II patient; it rules out occult metastases. ## Why Other Options Are Incorrect **Concurrent chemoradiotherapy:** Indicated for unresectable locally advanced (stage IIIA–IIIB) NSCLC, not for resectable stage I–II disease. This patient has no contraindication to surgery. **Palliative chemotherapy:** Inappropriate; this is a potentially curable patient. Palliative intent is reserved for stage IV or unfit stage III patients. **Stereotactic body radiotherapy (SBRT):** Reserved for medically inoperable patients with stage I NSCLC (e.g., severe COPD, poor cardiac function). This patient is a surgical candidate.