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Mr. B born 1942 tg,sutedja@vumc.nl

Mr. B born 1942 tg,sutedja@vumc.nl. 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: dysplasia → cancer.

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Mr. B born 1942 tg,sutedja@vumc.nl

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  1. Mr. B born 1942 tg,sutedja@vumc.nl

  2. 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

  3. Please vote: dysplasia → cancer 1. Progression of all lesions 2. Only high grade dysplasia progressive 3. Unpredicatable non-stepwise histological changes 4. Not an important finding

  4. 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 alCIS  SCC 100%

  5. Clonal 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 lesions Clinical Cancer Research 2005; 11: 537

  6. ↔

  7. 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

  8. History (3) • May 2001 repeat AFB normal respiratory epithelium UDB • June 2002 repeat AFB squamous metaplasia, RB7 mild dysplasia • July 2002: HRCT no abnormalities

  9. 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

  10. Left upper division bronchus

  11. VOTE:What to do 1. Follow up AFB and HRCT 2. Intraluminal treatment e.g. PDT, electrocautery, cryotherapy 3. Surgical resection 4. Stereotactic body radiotherapy

  12. Occult cancer: HRCT + AFB + FDG-PET   Acc(ss)essible superficial intraluminal N0 with visible borders

  13. Clinical 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!

  14. Follow-up: feb 2007 • AFB stump suspicious + RB3 • RB7 abnormal • AFB “false negatives” (Helfritszh et al genetic abnormalities – impact?)

  15. VOTE: CIS and AAH 1. Always surgical treatment 2. Treat bronchoscopically & SBRT 3. Wait and see until microinvasive SCC or GGO become partially solid

  16. 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

  17. Early intervention: con vs. pro?  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!

  18. Cost-effective “tailored” therapy

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