An 82-Year old woman with a palpable lymph node

An 82-year-old woman with a history of LD stage SCLC of her left upper lobe nine years earlier, had been treated with five cycles chemotherapy cyclophosphamide, doxorubicin and etoposide (CDE)) resulting in a complete response. She received prophylactic cranial irradiation. Now she presented with a palpable mass in the right supra-clavicular fossa. Her further medical history revealed coronary vascular disease, for which she underwent PTCA; mild aortic valve stenosis and a pacemaker to treat a third degree AV block. She has NYHA class II. She had a history of cigarette smoking but she stopped when SCLC was diagnosed nine years ago. She had no dyspnea Laboratory investigations were as follows: normal blood cell counts, renal and liver function. An ultrasound of the neck revealed a mass in the right supraclavicular fossa extending behind the subclavicular vasculature into the mediastinum. A computed tomography of the thorax showed an intrapulmonary leasion in the right upper lobe with extended lymph node masses until the supraclavicular fossa. A FDG-PET combined with computed tomography revealed high uptake of FDG in the rightsided hilar mass with extension into the right upper lobe laterally and into the supraclavicular fossa. A biopsy was taken and revealed SCLC, staged as T2N3M1. M1 was based on a small mass adjacent to the right adrenal. The patient was treated with carboplatin-etoposide, resulting in a partial response. Shortly after finishing chemotherapy multiple brain metastases became symptomatic for which she refused further therapy. To answer the question is this a late relapse or a new primary, tissue was analysed with array CGH and compared to the array CGH profile of tissue from the tumour diagnosed nine years earlier