Tuesday, September 20, 2005

What would you do next?

This is one of my chronic cough patients. She is 55 years old, remote smoker (quit in 1978) with a previous low-stage breast Ca (>5 years ago) and had initially come in with a chronic cough. I did a flex laryngoscopy and she had what appeared to be reflux laringits and her Hx was also suggestive of post-nasal drip. CxR was clear. Very mild obstruction on spiro. She was started on IN steroids and a PPI and did remarkably well with complete resolution of her cough. She remained symptom-free for several months.
Unfortunately there were some changes to her insurance copays and she ran out of her meds and her cough came back. However, when we got her back on IN steroids, anti-histamines and PPI her cough persisted. Ct of sinus was unremarkable. CxR remains normal.
We performed a bronch and her reflux laringitis was resolved. Her vocal cords were normal and she had some subtle changes of chronic bronchitis/chronic cough and her RLL bronchus was more inflammed than the other bronchi so I took some endoBBx and TBBx (looking for inflammatory/infectious conditions). Her Bx came back as Squamous cell Ca locally invasive (the path did not look like adenoCa).
I was a bit surprised and since she had no mass I could see we did a PET-CT for localization and staging and that was negative for any masses or increased FDG uptake.
Now what?

8 comments - CLICK HERE to read & add your own!:

Mike L said...

Doug's input would be great on this case.
First, which biopsy was positive for the abnormality (the endobronchial or transbronchial)?
I imagine that there is a progression on biopsy from squamous metaplasia to in situ SCCa to frank malignancy. You may have just been "lucky" to get the specimen, or the pathologist overcalled it.
I would have the path sent out to a different pathologist (Dr. Colby or Travis?) to confirm the findings.
If they concur, I would do serial endoscopic exams with biopsies to see if it worsens. If it did, I would have the surgeons resect the affected area.

Baleeiro said...

I had the same exact concerns about the specimen so I wen and looked at the slides with a different pathologist: it is clearly a Squam (really nasty cells) with mitotic figures, large cells, large nucleii. The larger Bxs (the endoBBx) had a lot of malignant cells and were clearly the source. However, the TBBx showed similar abnormalities in some of the samples...

Arenberg said...

Unless you're sure you know exactly where the biopsy showed the SCCa I'd repeat the bronch, preferably with a fluorescent scope. She might do well with local treatment (endobronchial brachytherapy, Nd-Y-AG or CO2 laser) if this is a carcinoma in situ in the proximal bronchus. She would then need close follow-up obviously.

If the carcinoma is in the blind trans-bronchs, I'd say you have no choice but to refer her for a lobectomy if a second pathologist agrees that it is cancer (I agree with Lazar here...have seen two cases where reactive cells were read as a carcinoma).

Jeff H said...

I've also had a patient "definitively" diagnosed with lung carcinoma on specimens taken from an inflammatory area (in this case the patient had pneumonia!). So, I agree that you can't exclude carcinoma, but would remain a bit skeptical. I'd even consider treating with some antibiotics and maybe even prednisone for two weeks, then rebronching (with a fluorescant scope???) and repeating biopsies.

Jennings said...

Well, squamous is the most common cell type misinterpreted as being cancer because of the metaplasia during inflammation (as mentioned by one of you guys). However, if the squamous came from the biopsy and not the BAL, you should be able to see the cancer in situ, so that would make it more likely to be cancer instead of from nonspecific inflammatio.
It seems a bit aggressive to take out the whole lung based on this biopsy. I don't know. Repeating the bronch with fluorescence as suggested by you all would be a great next step at least.

Anonymous said...

Would an endobronchial ultrasound add value. If the ultrasound showed invasive across submucosa, rings etc that might be a different and more drastic treatment than if only submucosal localized therapy.

Anonymous said...

Jeff
I posted as anonymous as I do not have a login yet.
Rob Burke

Baleeiro said...

Thank you for all the great suggestions. I have also been very hesitatnt to suggest a lobectomy based on this random Bx result. We have given her a course of steroids and ABTx and have scheduled her for a rebronch with sampling from both sides and endo and TB Bx. We don't have an endobronchial USG at our facility but that is a great suggestion. I will post a follow up as a separate entry.