Guess what this is

[tartesos]

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Very simple. 4R nodule. Ebus.
Biggest I've seen so far( this is not the longest view. ).

 

[tartesos]

It's not a trick question either. The most common central ca. 😉

 

[jdh71]

That's a big lymphnode and someone is doing an EBUS. You can't tell much else from the images.

But based on your hint. It's probably a lymphnode full of cocci.

 

[tartesos]

That's a big lymphnode and someone is doing an EBUS. You can't tell much else from the images.

But based on your hint. It's probably a lymphnode full of cocci.

ROSE said looks like lymphoma! And they were all exited about it, and the final path... Small cell.
This was the biggest I've seen so far, in an angle I was able to hub the ebus needle and was nowhere close the end of it( trying to go "edge to edge")

 

[jdh71]

ROSE said looks like lymphoma! And they were all exited about it, and the final path... Small cell.
This was the biggest I've seen so far, in an angle I was able to hub the ebus needle and was nowhere close the end of it( trying to go "edge to edge")

I don't think I've seen a level 4 node that big yet. Though the big nodes with small cell CA from . . . where??? Always make me scratch my head.

 

[tartesos]

I don't think I've seen a level 4 node that big yet. Though the big nodes with small cell CA from . . . where??? Always make me scratch my head.

That thing was impressive compressing every vessel and patient was surprisingly asymptomatic laying flat with no issues. Radiology called it svc syndrome even.

 

[gutonc]

ROSE said looks like lymphoma!

Your cytopathologist needs a good beating about the head and neck.
Lymphoma = Big cells
Small cell = Small cells

FWIW, I hate when they try to give a diagnosis on the ROS path. The only thing they should say is "adequate/inadequate" and "malignant/normal/reactive/necrotic". That's it. I've seen too many cases like this where the patient hears "well, we think it might be lymphoma (curable) and then it comes back small cell (really, really not curable) and now I have to walk that back (and take them from "hey, I can cure you" to "hey, you're going to be dead in <2 years" which is always a fun conversation to have). Some of my Pulm folks are good at deferring that discussion, some are not.

 

[tartesos]

Your cytopathologist needs a good beating about the head and neck.
Lymphoma = Big cells
Small cell = Small cells

FWIW, I hate when they try to give a diagnosis on the ROS path. The only thing they should say is "adequate/inadequate" and "malignant/normal/reactive/necrotic". That's it. I've seen too many cases like this where the patient hears "well, we think it might be lymphoma (curable) and then it comes back small cell (really, really not curable) and now I have to walk that back (and take them from "hey, I can cure you" to "hey, you're going to be dead in <2 years" which is always a fun conversation to have). Some of my Pulm folks are good at deferring that discussion, some are not.

And the house team and Onc always likes to push for a preliminary diagnosis so they can d/c soon. It's a culture.

I agree with you on that. I'll try and pay more attention to that because it happened before.

 

[jdh71]

Your cytopathologist needs a good beating about the head and neck.
Lymphoma = Big cells
Small cell = Small cells

FWIW, I hate when they try to give a diagnosis on the ROS path. The only thing they should say is "adequate/inadequate" and "malignant/normal/reactive/necrotic". That's it. I've seen too many cases like this where the patient hears "well, we think it might be lymphoma (curable) and then it comes back small cell (really, really not curable) and now I have to walk that back (and take them from "hey, I can cure you" to "hey, you're going to be dead in <2 years" which is always a fun conversation to have). Some of my Pulm folks are good at deferring that discussion, some are not.

Nah. That's what you get for selling hope and then disappearing after they crash and burn with resp failure, kidney failure, and shock in my unit!!!! 😡

😉😛

 

[gutonc]

And the house team and Onc always likes to push for a preliminary diagnosis so they can d/c soon. It's a culture.

Yeah, it was the culture where I trained too. And I hate it. There's no reason a patient can't go home on Tuesday without a diagnosis and see me on Thursday when the path comes back. I've had 3 cases in the last 2 weeks (all GI but the point is still valid) where the patient was told one thing on the way out the door based on prelim path but then had a completely different diagnosis (and most importantly, prognosis) when they walked in my door a day or 2 later. Wait for the data. It makes a difference.

 

[gutonc]

Nah. That's what you get for selling hope and then disappearing after they crash and burn with resp failure, kidney failure, and shock in my unit!!!! 😡

😉😛

You're the one who sold them hope. 😉

 

[jdh71]

You're the one who sold them hope. 😉

I'm not the one with the next and newest magic bag of poison!!!!!! 😡

 

[tartesos]

I'm not the one with the next and newest magic bag of poison!!!!!! 😡

And molecular studies guided therapy and such! More sample please!!!
🙂
We love you Onc docs though.

 

[tartesos]

And molecular studies guided therapy and such! More sample please!!!
🙂
We love you Onc docs though.

On that note, I don't take pleasure in bronching a patient today with already positive pleural fluid for Adeno just to get more sample for molecular studies, since we are already placing a pleurex in, can you just get some samples of that mass....( there was not enough on the pleural fluid ).

For the future if you are ever in that situation, send the fluid from the pleurex catheter drainage( got 900cc) before saying yes to the bronchoscopy. Lesson learned, the hard way.

 

[Hernandez]

I've seen em get so large you don't see anything on u/s but the mass (they aren't nodes anymore at that point).

And lymphoma off ebus bx is hard, <50% yield. If I suspect, I'll send samples in RPMI to increase yield a little but I see very few lymphomas here.

 

[group_theory]

And molecular studies guided therapy and such! More sample please!!!
🙂
We love you Onc docs though.

Had a case where the entire lesion was already surgically resected. The pathologist wanted "more tissue" for molecular studies. Hmmm, you already have the entire lesion - where will we get "more tissue"?

 

[group_theory]

I don't think I've seen a level 4 node that big yet. Though the big nodes with small cell CA from . . . where??? Always make me scratch my head.

I have (for SCC). I've also saw a recent case where there was a large hilar mass that invaded the airway, large paratracheal and subcarinal nodes, yet the hilar nodes (on same side) were not big. After EBUS, the paratrachea/subcarinal nodes were positive, the endobronchial lesion was positive, yet the hilar node was negative (benign lymphoid tissue) ... weird (the infamous skipped metastasis)

Nah. That's what you get for selling hope and then disappearing after they crash and burn with resp failure, kidney failure, and shock in my unit!!!! 😡

😉😛

The patient could have florid endocarditis with blown valves, on 3 pressors, CRRT, and ARDS, and our oncologist will tell the patient "oh, there is good news. The molecular genetics are in his favor and he has a survivable cancer. He just needs to start chemo right away and he'll do well." ... then the family will get real confused when the intensivist gives the "prognosis is poor" talk/update.

 

[tartesos]

I've seen em get so large you don't see anything on u/s but the mass (they aren't nodes anymore at that point).

And lymphoma off ebus bx is hard, <50% yield. If I suspect, I'll send samples in RPMI to increase yield a little but I see very few lymphomas here.

It's true that lymphoma is rare but it happens once a month or so here. Usually we send flow cytometry on the younger ones... And it's 9/10 sarcoidosis, but there's that once in a while we get lucky.

 

[Hernandez]

I'd damn near pay out of my own pocket for a pathologist that can recognize granuloma on a needle aspirate

 

[tartesos]

I'd damn near pay out of my own pocket for a pathologist that can recognize granuloma on a needle aspirate

That's what Tbbx are for 🙂

 

[tartesos]

I'd damn near pay out of my own pocket for a pathologist that can recognize granuloma on a needle aspirate

http://www.ncbi.nlm.nih.gov/m/pubmed/18374764/

Not that unheard of. Hope you have lots of $

 

[Hernandez]

That's what Tbbx are for 🙂

Why? EBUS suppose to have an equivalent yields.

 

[Hernandez]

http://www.ncbi.nlm.nih.gov/m/pubmed/18374764/

Not that unheard of. Hope you have lots of $

I think you misunderstand. I know the yield data.....my pathologists tried to tell me it wasn't possible.

 

[tartesos]

Why? EBUS suppose to have an equivalent yields.

Most of those young things( I'm in the south, very prevalent) we fna and Tbbx most of the time, we have some cowboy staff that are awesome endoscopists that love mocking using ebus big nodes. Or ebusing sub Carinal nodes, calling you weak.
Lots of fun!

 

[tartesos]

I think you misunderstand. I know the yield data.....my pathologists tried to tell me it wasn't possible.

You need better pathologist's!!
A Cytology fellowship is usually required, maybe they didn't do it?

 

[Hernandez]

Most of those young things( I'm in the south, very prevalent) we fna and Tbbx most of the time, we have some cowboy staff that are awesome endoscopists that love mocking using ebus big nodes. Or ebusing sub Carinal nodes, calling you weak.
Lots of fun!

For awhile i was dong both fna & tbbx and still wouldn't get calls from path, so I sadly send my sarcoidosis for meds most the time now

 

[tartesos]

For awhile i was dong both fna & tbbx and still wouldn't get calls from path, so I sadly send my sarcoidosis for meds most the time now

Man! That sucks balls for them!!!
Sorry bro.