New presentation of a 65 year old female with FDG PET avid lung nodules in contralateral lobes. Indeterminate lymph nodes on imaging. In planning for optimal workup, how do you approach these patients in biopsy and NGS testing in order to determine whether these are synchronous lesions vs metastatic picture? Would you biopsy both nodules and send for NGS in addition to performing lymph node evaluation?
If both nodules can be safely biopsied it would the best way to look for 2 primaries. Especially if no definite mediastinal involvement by ca, which would make oligomet much more likely. If you have a good IP to do bilateral multilevel EBUS bilateral, one can avoid mediastinoscopy, If the histologies are different of course one can assume 2 primaries. With similar histology it would make sense to check NGS on both, but often the insurance will not pay for both NGS tests. But you could try to get it. I normally discuss this thoroughly with the pathologist. Sometimes they see in situ ca or dysplasia next to the resected site to make a primary more likely. I hope this helped. Let me know if there are more specifics to sort this out.
