Guess what this is

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tartesos

tartesos

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

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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.
 
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jdh71 said:
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.
Click to expand...

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")
 
tartesos said:
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")
Click to expand...

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.
 
jdh71 said:
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.
Click to expand...

That thing was impressive compressing every vessel and patient was surprisingly asymptomatic laying flat with no issues. Radiology called it svc syndrome even.
 
tartesos said:
ROSE said looks like lymphoma!
Click to expand...
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.
 
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gutonc said:
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.
Click to expand...

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.
 
gutonc said:
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.
Click to expand...

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!!!! :mad::rage:

;):p
 
tartesos said:
And the house team and Onc always likes to push for a preliminary diagnosis so they can d/c soon. It's a culture.
Click to expand...
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.
 
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tartesos said:
And molecular studies guided therapy and such! More sample please!!!
:)
We love you Onc docs though.
Click to expand...


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.
 
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.
 
tartesos said:
And molecular studies guided therapy and such! More sample please!!!
:)
We love you Onc docs though.
Click to expand...

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"?
 
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jdh71 said:
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.
Click to expand...

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)

jdh71 said:
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!!!! :mad::rage:

;):p
Click to expand...

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.
 
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Hernandez said:
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.
Click to expand...

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.
 
I'd damn near pay out of my own pocket for a pathologist that can recognize granuloma on a needle aspirate
 
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Hernandez said:
Why? EBUS suppose to have an equivalent yields.
Click to expand...

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 said:
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!
Click to expand...

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
 
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