Squamous cell carcinoma of the lung

Case contributed by Dr Bruno Di Muzio

Presentation

Haemoptysis.

Patient Data

Age: 45 years
Gender: Male
X-ray

Chest radiographs

PA and lateral projections, no previous imaging available for comparison. There is collapse of the right lower lobe, the remainder of the lungs appear unremarkable. There is mild deviation of the distal trachea to the right and the right paratracheal stripe appears enlarged. No pneumothorax or subphrenic free gas.

CT

CT Chest

There is evidence of the partial collapse of the right lower lobe with surrounding mass in the right hilum surrounding the bronchus which appears attenuated and compressed with enlarged subcarinal node measuring 22 mm in short axis. The bronchial irregularity suggests tumor 15mm from the carina. There is also enlarged presumed hilar node measuring 22 mm in short axis. There are enlarged prevascular nodes measuring up to 18 mm in size extending towards the anterior mediastinum. There is also enlarged right lower paratracheal node measuring approximately 12 mm in short axis and mildly prominent right upper paratracheal nodes. Subcentimetre right axillary nodes are non-specific. A left supraclavicular node measuring 11 mm could represent N3 nodal involvement. No pleural or pericardial effusion. Adrenals are not completely included on the study. Fracture of T7 greater than 20 percent loss of anterior vertebral body height. No other suspicious bony lesions in the area encompassed by this scan.

Mammography

FDG PET-CT

FDG PET confirms increased uptake in the bronchial mass, ipsilateral mediastinal lymph nodes, and within contralateral and left supraclavicular nodes, as the suspect on CT, which make this an N3 disease. No distant metastasis was identified (M0). 

Case Discussion

The findings are compatible with primary bronchogenic carcinoma with obstruction of the right lower lobe bronchus, with contralateral mediastinal and supraclavicular nodal involvement, and no signs of distant metastatic disease (T2N3M0).

Tissues should be accessible through bronchoscopy. The left supraclavicular nodes may be technically difficult to access via ultrasound. Completion staging of the upper abdomen and/or FDG PET should be performed.

Bronchoscopy lavage and biopsy were performed: 
1. TBNA sub carina: 3 wet-fixed and 3 air-dried smears prepared. Also received in formalin, multiple small cores of blood clot processed as a cell block. Adequacy statement: Small amount diagnostic material.
2. Bronchial washings: 15 ml of heavily blood-stained fluid.

MICROSCOPIC DESCRIPTION: 1&2. The smears and cell block section show very occasional groups of malignant epithelial cells. The tumor cells have high N/C ratio with enlarged hyperchromatic nuclei, granular chromatin, nuclear moulding, occasional conspicuous nucleoli and scant cytoplasm. There are occasional mitoses and apoptotic debris in the background. Immunostains on the cell block from specimen one show the tumor cells are positive for AE1/3, p40 and CK5/6 and negative for CD45 CK7, TTF-1, chromogranin, CD56, synaptophysin and TTF-1. This profile is consistent with a poorly differentiated squamous cell carcinoma.

DIAGNOSIS: 1. TBNA sub carina: Carcinoma, immunohistochemistry consistent with poorly differentiated squamous cell carcinoma. 
2. Bronchial washings: Carcinoma.

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Case information

rID: 56617
Published: 30th Dec 2017
Last edited: 30th Dec 2017
System: Chest
Inclusion in quiz mode: Included

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