A 58 years old male presented with history of right sided chest pain and cough 2 years ago with CT Attached(1). CT guided taken outside our hospital with pathology suggestive of adenocarcinoma lung. Slide review done on our centre rejected this diagnosis and said that there are no malignant cells. Repeated CT and CT guided biopsies 4 times were not diagnostic but only necrotic tissues. Attached here is the last CT.(2-3). During these 2 years duration of hesitations, 2nd and 3rd opinions , he was complicated with right sided empyema and septic shock complicated by acute renal failure that mandated CRRT for 3 months. Now renal functions are normal. He is asking for help and not hesitant as before. What can we do for this patient as we have 3 options; 1st just VATS biopsy and that set. 2 nd is open biopsy only. My impression is thoracotomy exploration, biopsy, excision of this right lung mass through right upper lobectomy, bilobectomy or even pneumonectomy or sleeve resection,
If this patient is not in immediate critical status, I suggest a 18F-FDG PET/CT followed by biopsy of the metabolically active area local or distal, necrosis will show no FDG activity, this way we can avoid unnecessary invasive procedure. If PET/CT not helpful or patient in critical situation then maybe exploratory thoracotomy with right mass excision, since it is showing increasing in size and already quite big. but distant metastases should be excluded before invasive surgical decision.
Hi
Great case.
It all depends on the resources you have. On the second image you show us, it looks like there is an airway adjacent to the mass. I would probably attempt EBUS with TBNA and have rapid on-site pathological evaluation, if available.
If surgery is more readily available than bronchoscopy, I would do PET/CT scan followed by surgery if FGD avidity is high.
It doesn't look like VATS would be of high yield here.
Hope it helps!
Keep us posted about the results.
Hi,
Can you please show the matched CT images of lung window and mediastinum window? Thank you.
Hello,
I agree with Alice , This tumour could be biopsied and staged at the same time with EBUS but I will recommend a PET/CT prior to EBUS.
Bronchoskopy? preferred Kryobiopsy. Mikrobiologie?
The progression over time is sticking.
best regards
Janos
Hi,
Thanks for sharing your great case.
While the mass is located in the upper lobe, and the pathologic evaluations show necrosis; TB is another diagnosis. So, more information are needed:
1. Patient's nationality?
2. Family Hx?
3. Other symptoms and sign (such as weight loss, fever,...)?
4. Any Hx of FOB & BAL "Broncho-Alveolar-Lavage"(and especially testing BAL for BK "direct smear, culture & PCR for AFB" & cytologic exam)?
5. PPD?
Please let me know the results.
Thanks
Hello,
I think PET/CT scan less invasive for diagnosis than EBUS. I agree if you perform PET/CT scan before EBUS. TBNA, Forceps Biopsi, Brushing and Bronchoalveolar Lavage is mandatory during EBUS because tissue is very important for diagnosis. Therapy according to the result.
Thanks
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