American Board of Internal Medicine (ABIM) Certification Practice Exam

For patients with positive mediastinal lymph nodes, which treatment is recommended?

1. Sequential chemotherapy and radiation

2. Surgical resection

3. Only observation

4. Adjuvant chemotherapy

The correct answer is: Sequential chemotherapy and radiation

In the context of managing patients with positive mediastinal lymph nodes, sequential chemotherapy and radiation is recommended primarily due to the need to reduce tumor burden and address potential micrometastatic disease. This combined approach allows for a systemic treatment of any remaining cancer cells through chemotherapy, while simultaneously targeting the local disease through radiation therapy. Sequential chemotherapy followed by radiation has been shown to improve survival outcomes in these patients by effectively shrinking the tumor and minimizing the chances of recurrence in the lymph nodes and surrounding areas. This strategy contrasts with surgical resection, which might not be feasible or effective in cases where the lymph nodes are involved, as complete removal might not adequately address the remaining cancer in the lymphatic system or beyond. Observation alone lacks the proactive intervention needed in the presence of mediastinal node involvement; such patients are at an increased risk of disease progression and would not benefit from a wait-and-see approach. Adjuvant chemotherapy typically follows surgery to eliminate residual disease, but in the case of positive mediastinal lymph nodes without prior surgical intervention, it is not the primary recommendation since it does not confront the immediate local and systemic disease as effectively as the sequential approach. Overall, the recommendation for sequential chemotherapy and radiation in this scenario underscores the importance of a