Tuesday, October 11, 2005

What would you do next again?

We have a few posts still in progress (JJ's pulmonary nodules below and some of the smaller follow-ups) so I will make this a shorter post.
I had posted on this 55 years old, remote smoker (quit in 1978) with a chronic cough with a negative PET but a lung Bx on bronch + for NSCLCa. One of the suggestions was to do fluorescent bronchoscopy, however those expensive machines are not available here in TN... so I gave her some steroids (systemic and inhaled) and brought her back for a re-bronch. There was still some inflammation on the take-off of the RLL bronchus but no mass. I did a repeat bronch and sistematically sampled all the main lobar bronchi and brushed the RLL bronchus. EndoBBx from the left and the RUL had some mild chronic inflammation. The RLL TBBx showed mild congestion and the EndoBBx now revealed: "Extremely scant detached cells suspicious for non-small cell carcinoma present in detached mucus and clotted blood." This was reviewed by 3 of our pathologists.
She has good lung function and the previous RLL EndoBBx revealed foci of what seemed like squamous cell Ca.
What would you next?

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

Jeff H said...

Can you link this back to the initial case? I think I remember the details, but wanted to be sure.

I'm still skeptical of carcinoma in this case, but I think you have to have a discussion with the patient. Either you can say "you have good PFT's, we should take out the LLL", or propose more short term follow up. Cytology is tricky, and in this case you may want to send the slides to an outside consulting pathologist.

I think I'd still favor short term follow up after some empiric antibiotics and continued anti-inflammatories, as it sounds like the previous abnormality resolved...but, I would offer referral for a lobectomy without hesitation if the patient was leaning that way.

This is a tough one...

Baleeiro said...

The title is hyperlinked to the initial post.

Baleeiro said...

BTW, the first findings of squam were on biopsies not on cytology.

Jeff H said...

Actually, the only hyperlink is see is to Jennings pulmonary nodule post.

In any case- I'm still skeptical of carcinoma, but we have several pathologists reading two different samples taken at different points in time. So, as long as the patient understands that we can not prove that this is benign, I guess I'd refer her for resection. That is the "safest" and most conservative approach, but we've already watched it for a few months, and we still have a reading of possible cancer...

Jennings said...

I agree with JH on the point that the slide should be reviewed by an outside pathologist (maybe even send it to the Mayo or maybe send it to Doug hehe). The reason is because there is no clear lesion. However, this could also be because you caught the cancer before it expressed as an overt lesion. But the stakes are high (i.e. resection of whole lobe) and thus that last step of sending it out would be the best approach in my humble opinion.
I disagree slightly with JH in the sense that it sure as heck smells like a real cancer.
BTW, as for the link, click on the title (what would you do next again?") and that will take you to the original post.

DKeena said...

I would be leaning toward lobectomy in this case. I agree with getting the path reviewed, but it sounds like you've got malignant cells from the same spot after Rx for bronchitis and a reasonable followup period.