A 66-year-old gentleman presented acutely to secondary care with acutely worsening, progressive shortness of breath. His past medical history includes congestive cardiac failure, hypertension, wheelchair bound due to previous polio and chronic obstructive pulmonary disease (ex-smoker with a 40-pack year smoking history). His chest x-ray on admission showed a left upper lobe mass lesion (Fig. 1).
A CT thorax, abdomen and pelvis was reported as showing a large lobulated soft tissue mass in the left upper lobe measuring 7.2 cm x 6.9 cm x 7.5cm which was contiguous with the soft tissue extending from the anterior left main bronchus, suggestive of a lymph node, measuring 1.4 cm x 2.9 cm. There was evidence of direct tumour extension into the left pulmonary vein, almost into the left atrium (Fig. 2).
Following discussion in the Lung Cancer Multi-Disciplinary meeting the patient underwent an EBUS. Sampling from station 4R and 7 lymph nodes showed benign lymphoid material and pigmented macrophages on ROSE, therefore the procedure continued to the area of the 10L node. Ultrasound evaluation of this area were consistent with either tumour or solid material (thought likely tumour thrombus) within the left pulmonary vein, as there was a circumferential rim of fluid that was well visualised. TBNA was performed (Fig. 3).
Direct probe contact with the endobronchial wall was maintained for several minutes looking for biopsy complications (including extravasation). There were no immediate complications as a result of the TBNA. ROSE showed blood cells only with subsequent cell block material containing scanty material suggestive of non-small cell carcinoma. During the procedure, therefore, further material was obtained from the primary left upper lobe mass which ROSE revealed to be non-small cell carcinoma. A subsequent cell block was morphologically like that obtained from the tumour thrombus, but of greater quantity, allowing immunocytochemistry. This demonstrated strong p40 and TTF1 positivity and the tumour was classified as non-small cell carcinoma, not otherwise specified (Fig. 4).
Following further discussion in the Lung Cancer Multi-Disciplinary Meeting this patient was staged as T4N0M0 non-small cell lung cancer, not otherwise specified with the plan for surgical resection.
Labelled computerised tomography showing left upper lobe lung tumour contiguous with station 10 left lymph node and left pulmonary vein.