A 62-year-old woman presents to her physician with cough and dyspnea. She reports extreme fatigue and pain in the bones of her arms and legs for the past 3 months. She also reports a weight loss of 15 lb during this time.

Physical exam reveals use of accessory muscles during breathing, along with flaring of the nostrils and elevated jugular venous pulse on inhalation, as well as decreased breath sounds on auscultation and dullness on percussion. Heart sounds are distant. The patient appears thin and pale. Her supraclavicular and axillary lymph nodes are enlarged, and there is evidence of hepatomegaly on palpation. Her blood pressure is 120/80 mm Hg, pulse is 70 beats/min, and oxygen saturation is 90% on ambient air.

The patient has a history of hypertension, which is pharmacologically managed. She has a negative family and personal history for cancer of any kind. She has smoked a pack of cigarettes a day for 45 years. Laboratory testing — complete blood count with differential, as well as liver and kidney function tests — is performed. Results reveal:

Red blood cell count: 3.0 million/µL
White blood cell count: 20,000/L
Hemoglobin: 8 g/dL
Serum calcium: 13.0 mg/dL
Alkaline phosphatase: 1500 IU/L
Serum lactate dehydrogenase: 300 U/L
Aspartate aminotransferase: 30 U/L
Alanine aminotransferase: 100 IU/L

She is 5 ft 5 in and has a BMI of 21. Her performance status score is 1.