Matilda is a previously healthy 75-year old widow originally from Portugal who has rarely utilized health care resources. She does not like to take medications. She has never smoked and only occasionally drinks wine. She lives with her supportive family with no discernable social issues. Over a 3-month period Matilda has lost significant weight (10%) and energy, develops a dry cough, becomes dyspnoeic and requires admission to hospital under a respirologist. She is sent from another hospital to see you at the Cancer Centre. She is on oxygen. She has no significant fever. You hear normal air entry on the left but diffuse ‘crackles’ on the right. When you take her oxygen mask off she becomes obviously distressed and her oxygen saturation drops. Her chest X-ray on the right shows a 3 cm nodular lesion in the right lung with a small pleural effusion. Her left lung is clear. A CT scan shows the nodule and reveals a few 1 cm mediastinal lymph nodes. There are also two smaller lung lesions on the right, suspicious for metastatic disease. There are no other significant findings on your physical exam or on routine blood work.