Post on 16-Mar-2016
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Mr. B born 1942tg,sutedja@vumc.nl
History (1)History (1)
54-yrs old >40 pack years - slight hemoptysis
Feb. 2000: Severe dysplasia with brush cytology suspicious for cancer cells left upper lobe region
Referral for bronchoscopic evaluation
Please vote: Please vote: dysplasia dysplasia →→ cancer cancer
1. Progression of all lesions
2. Only high grade dysplasia progressive
3. Unpredicatable non-stepwise histological changes
4. Not an important finding
90,000 cells’limit <0.6 mm ???????????!Bota et al. 6.1% high grade CIS SCC 87%Moro Sibolot et al. SD/CIS persistent/CIS 63%/2 yrs Kennedy et al. SD sputum SD-malignancy 15.6%Breuer et al. SD CIS = 32% & Venmans et al CIS SCC 100%
Clonal Darwinism of carcinogenesisClonal Darwinism of carcinogenesis• Field of heterogeneous clones, “some”potentially
malignant with, each has its own time clock
• Non-stepwise histological changes (metaplasia may also become squamous cell cancer!)
• No accurate prediction for malignant development based on the initial WHO histological classification
Natural course of preneoplastic lesionsClinical Cancer Research 2005; 11: 537
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History (2)History (2) Autofluorescence bronchoscopy: upper
division bronchus (UDB between LB2-3) abnormal
Histology: severe dysplasia
Cytology revision by a panel: not suspicious!
July 2000: Repeat AFB squamous metaplasia
History (3)History (3)
May 2001 repeat AFB normal respiratory epithelium UDB
June 2002 repeat AFB squamous metaplasia, RB7 mild dysplasia
July 2002: HRCT no abnormalities
History (4)History (4)
Feb 2003: Repeat AFB squamous metaplasia; RB7 normal
Jan 2004: Repeat AFB squamous metaplasia HRCT: no abnormalities
Aug 2004: repeat AFB UDB suspicious; distal margin invisible at least severe dysplasia; brush cytology suspicious for malignant cells
Left upper division bronchusLeft upper division bronchus
VOTEVOTE:What to do:What to do
1. Follow up AFB and HRCT
2. Intraluminal treatment e.g. PDT, electrocautery, cryotherapy
3. Surgical resection
4. Stereotactic body radiotherapy
Occult cancer: HRCT + AFB + FDG-PETOccult cancer: HRCT + AFB + FDG-PET
Acc(ss)essible superficial intraluminal N0 with visible borders
Clinical decision and treatmentClinical decision and treatment
Distal microinvasion cannot be ruled out → Surgery. Pre-treated with argon plasma
Radical lobectomy and SND left upper lobe
Resected specimen: squamous metaplastic field and mild dysplasia, no residual CIS or microinvasive squamous cancer, N0 stage!
Follow-up: feb 2007Follow-up: feb 2007
AFB stump suspicious + RB3 RB7 abnormal
AFB “false negatives” (Helfritszh et al genetic abnormalities – impact?)
VOTEVOTE: CIS and AAH: CIS and AAH
1. Always surgical treatment
2. Treat bronchoscopically & SBRT
3. Wait and see until microinvasive SCC or GGO become partially solid
Early squamous: not a threat?Early squamous: not a threat? 38 patients primarily resectable,
intraluminally treated first having HRCT & FDG-PET scan occult cancer lesions
16 dead and 22 alive; med surv 20 months; Lung cancer death 5/16 = 31%; 4 metachronous occult cases due to previous tumor
Remaining 11 deaths: COPD, AMI, pancreatic ca, esoph.ca. CFA, sepsis etc
Early intervention: Early intervention: concon vs. vs. propro?? They will die from co-morbidities no
significant benefit from early intervention
Succesful early intervention allow more to suffer/die from co-morbidities
Clonal aggressive lesions incurable = CT screening interval cancer!
Cost-effective Cost-effective “tailored”“tailored” therapy therapy
Intraluminal
“Occult” Bulky
Coagulation &Recanalization
Accurate targetingof N0 tumor
Tailored i.e. local → surgery + minimal/non invasive (?)