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Management Strategies for Severe Dysplasia and Suspected Lung Cancer: A Case Analysis

This case study reviews the clinical history of a 54-year-old male patient with a significant smoking history, diagnosed with severe dysplasia in the left upper lobe region and subsequent evaluations. It explores the progression of dysplastic lesions, the unpredictability of malignant transformation, and treatment options including follow-up, intraluminal therapies, surgical resection, and stereotactic body radiotherapy. The study highlights the complexities in predicting malignancy and the implications of treatment decisions on patient outcomes in suspected lung cancer scenarios.

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Management Strategies for Severe Dysplasia and Suspected Lung Cancer: A Case Analysis

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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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