This patient with stage IV adenocarcinoma of the lung (based on the presence of a likely right adrenal metastasis) should undergo tumor testing for the presence of an epidermal growth factor receptor (EGFR) mutation. Because studies have documented improved survival in patients with EGFR mutations who are treated with an EGFR tyrosine kinase inhibitor (such as erlotinib, gefitinib, or afatinib), testing to identify this mutation is a key component of the initial evaluation of all patients diagnosed with metastatic nonsquamous non–small cell lung cancer (NSCLC). In patients with likely metastatic disease who might be candidates for therapy, ensuring that an adequate tissue sample is obtained (core needle biopsy at a minimum) is essential to allow for needed molecular testing.

Although K-ras testing can help determine the prognosis in patients with NSCLC, there are currently no approved drugs that target ras mutations. Furthermore, K-ras mutations are not negatively predictive for anti-EGFR therapies as in colon cancer.

PET scanning has a role in evaluating patients who are believed to have potentially resectable disease. However, obtaining a PET scan in a patient who clearly has metastatic disease based on CT imaging is unnecessary.

Because this patient has both a pleural effusion and a likely adrenal metastasis that would classify his disease as stage IV, he is not considered a surgical candidate.