f*********1
发帖数: 189 | 1 Re: 【征文活动】图文并茂，一天一个病例
响应futurehw and Aplusplus 提议
1. 70 y/o patient: incidental findings of RLL lung mass on CT during a work-
up for aortic aneurysm.
2. PET-CT:
4.0 cm consolidative mass in the lower lobe of the right lung (with SUVmax
17.4), suspicious for malignancy.
3. CT-guided biopsy: poorly differentiated NSCLC. |
n*******c
发帖数: 501 | 2 Thank you for sharing. You really have good stuff:)
It would be even better if you have pathology picture of biopsy.
btw, was it a core or fine needle biopsy?
The next question would be:
How are we gonna treat him?
What is the staging? Is he a surgical candidate? Does he need adjuvant therapy?
If it is poorly differentiated NSCLC, is further molecular analysis beneficial? If we can get the whole thing from operation. Does he likely benefit from testing EGFR mutation and having tyrosine kinase inhibitor?
抛砖引玉，请诸位尤其是icetea和池老大踊跃发言指导。 |
A*******s
发帖数: 9638 | 3 Re.
Nice comments and hope more IDs to take part in the discussion.
it
gonna
【在 n*******c 的大作中提到】
: Thank you for sharing. You really have good stuff:)
: It would be even better if you have pathology picture of biopsy.
: btw, was it a core or fine needle biopsy?
: The next question would be:
: How are we gonna treat him?
: What is the staging? Is he a surgical candidate? Does he need adjuvant therapy?
: If it is poorly differentiated NSCLC, is further molecular analysis beneficial? If we can get the whole thing from operation. Does he likely benefit from testing EGFR mutation and having tyrosine kinase inhibitor?
: 抛砖引玉，请诸位尤其是icetea和池老大踊跃发言指导。
|
R*******t
发帖数: 367 | 4 Lung biopsies are core biopsies with 18 or 20 gauge needles usually. |
n*******c
发帖数: 501 | 5 Would 池大 be happy with that?
The pathologists in our hospital are always craving for more tissue...And
they always complain we do not have enough tissue in the case conference...
【在 R*******t 的大作中提到】
: Lung biopsies are core biopsies with 18 or 20 gauge needles usually.
|
R*******t
发帖数: 367 | 6 I only do thyroid biopsies with FNA, 25 gauge. Most pathologists are okay
with 20 g cores. Some would not, like a renal transplant biopsy I did before
, he preferred 18 g core, and the patient had a hematoma after.
【在 n*******c 的大作中提到】
: Would 池大 be happy with that?
: The pathologists in our hospital are always craving for more tissue...And
: they always complain we do not have enough tissue in the case conference...
|
f*********1
发帖数: 189 | 7 Haha:)
before
【在 R*******t 的大作中提到】
: I only do thyroid biopsies with FNA, 25 gauge. Most pathologists are okay
: with 20 g cores. Some would not, like a renal transplant biopsy I did before
: , he preferred 18 g core, and the patient had a hematoma after.
|
C*****D
发帖数: 1299 | 8 benign non-neoplastic lesion usually need big core; especially
transplantation evaluation. neoplastic lesion if the the radiologist is good
and can get the right spot, 20 or even 22G will be OK.
with the new applications of molecular pathology, smaller cores might be OK
in the near future for neoplastic biopsies.
before
【在 R*******t 的大作中提到】
: I only do thyroid biopsies with FNA, 25 gauge. Most pathologists are okay
: with 20 g cores. Some would not, like a renal transplant biopsy I did before
: , he preferred 18 g core, and the patient had a hematoma after.
|
R*******t
发帖数: 367 | 9 谢谢解释。
那个renal transplant biopsy当时是个PA在场，他report to的病理医生要求18g，三
个core。我进针三次，每次组织样品都是白色的皮质，我知道没有进入肾髓质，可是第
三针拔出来后，暗红血液从co-axial needle里喷射而出。我那时才开始工作第二个月
，就慌了，用gelfoam止血后，收病人入院观察，叫transplant team consult。后来
trransplant team的人说，见那点血实在不算什么，你应该来transplant OR看看，那
才叫血流成河。病人一夜之间有了个直径四公分的hematoma，幸运的是肾功保留，正常
排尿，血象正常，，血肿也不再增大，第二天出院了。
有文献说过，针筒直径和出血的后遗症并没有正比关系。即使如此，我还是希望用小点
的，尤其是内部viscera。估计是心理作用。乳腺活检都是14g以上的，甚至mammotome
是8g 的，后遗症也很少。
good
OK
【在 C*****D 的大作中提到】
: benign non-neoplastic lesion usually need big core; especially
: transplantation evaluation. neoplastic lesion if the the radiologist is good
: and can get the right spot, 20 or even 22G will be OK.
: with the new applications of molecular pathology, smaller cores might be OK
: in the near future for neoplastic biopsies.
:
: before
|
I****a
发帖数: 407 | 10 The fact that the pathology report reads poorly differentiated NSCLC makes
me think the quality of the biopsy was probably not adequate.
For this case, it is not relevant because patient will most likely go for
surgery which will provide the ultimate whole block of the tumor.
But I would request a repeat biopsy if this patient presents with metastatic
disease and you get this poorly differentiated histology . The emergence of
new targeted therapies and clinical trials demonstrating differing efficacy
and toxicity of treatments according to specific histological subtypes of
NSCLC, has resulted in an increasing need for improvements in pathological
diagnosis. Accurate distinction between adenocarcinoma and squamous cell
carcinoma is now critical as histological subtyping has the potential to
influence clinical decision making and impact on patient outcome.
Down to management, he has clinical T2N0 stage IB non small cell lung cancer
. The standard of care is to perform mediastinum staging by EBUS/EUS. If he
has no lymph node involvement by above techniques as suggested by PET CT. The surgery would be
right lower lobe lobectomy. If he is not a candidate for this surgery. The
alternative would be stereotactic radiotherapy which in some series yielded
the similar outcome as surgery.
Regarding the adjuvant chemotherapy, CALGB 9633 trial specifically asked
this question, it studied T2N0 tumor size between 3-7 cm. As a group, there
is no survival benefit but the subgroup analysis with tumor >= 4cm, there is
a survival advantage with use of adjuvant chemotherapy with carboplatin and
Paclitaxel. In this subgroup, there were significant advantages in overall
survival and DFS for adjuvant chemotherapy. There was a 31% reduction in
risk of death. Median survival times were 99 months and 77 months in
chemotherapy and control groups, respectively. Quoted from JCO paper http://jco.ascopubs.org/content/26/31/5043.full
However, this trial has been criticized by many. The subgroup analysis was
not pre-planned. The p-value calculation was one sided blah blah. |
R*******t
发帖数: 367 | 11 太赞了！能说说为什么poorly differentiated NSCLC让你觉得活检样品不足吗？还有
什么样的病例结果让你觉得需要重新活检的，除了病理说,inadequate specimen以外？
谢谢。
metastatic
of
efficacy
【在 I****a 的大作中提到】
: The fact that the pathology report reads poorly differentiated NSCLC makes
: me think the quality of the biopsy was probably not adequate.
: For this case, it is not relevant because patient will most likely go for
: surgery which will provide the ultimate whole block of the tumor.
: But I would request a repeat biopsy if this patient presents with metastatic
: disease and you get this poorly differentiated histology . The emergence of
: new targeted therapies and clinical trials demonstrating differing efficacy
: and toxicity of treatments according to specific histological subtypes of
: NSCLC, has resulted in an increasing need for improvements in pathological
: diagnosis. Accurate distinction between adenocarcinoma and squamous cell
|
I****a
发帖数: 407 | 12 It is very important to know the right histology to guide the treatment. In
general, the major histology classification of NSCLC include 40% of
adenocarcinoma, 20% of squamous carcinoma, 15% of large cell carcinoma and
most of the rest are lumped into NOS(not otherwise specified). NOS are
largely due to the fact there isn’t enough pathology material to review. In
this case, it is a little different as it reads as poorly differentiated.
You would have to talk to the pathologist to find out why they make such
conclusion, whether it is really due to the poor differentiation with ample
material or it is from the limitation of the sample size.
The better understanding of the histology will promote using correct life
extending therapy as well as decrease the incidence of potential life
threatening side effect. A good example is Avastin. It could lead to fatal
pulmonary hemorrhage in squamous histology but in adenocarcinoma it extends
the life span. |
f*********1
发帖数: 189 | 13 Co-太赞了！:), Icetea, 能说说 why Avastin could lead to fatal
pulmonary hemorrhage in squamous histology but in adenocarcinoma it extends
the life span? I mean, the underlying mechanisms and why it makes such
differences. Thank you. |
I****a
发帖数: 407 | 14 It actually causes pulmonary hemorrhage on both squamous and adenocarcinoma
but the incidence in squamous histology is quite high on phase 2 study, it
happened in 4 of 13 patient which is kind of make sense because squamous
carcinoma is more centrally located in contrast to adenocarcinoma, therefore
the bleeding side effect will be more pronounced and more fatal. |
